CAJ | 학술논문

1例77岁女性患者，因反复胸闷、心悸15年，加重1个月入院。入院诊断为：冠状动脉粥样硬化性心脏病，急性冠脉综合征，阵发性心房颤动；高血压3级（很高危），高血压性心脏病；类风湿关节炎；胃窦溃疡。入院给予抗炎、抗血小板、调节血脂、止痛、房颤转复、降血压、保护胃黏膜等治疗。患者长期应用糖皮质激素会导致血糖代谢紊乱、胃黏膜损伤、骨质疏松等症状，对甲泼尼龙片、盐酸胺碘酮、他汀类药物不良反应进行监测，考虑到埃索美拉唑可能与氯吡格雷存在代谢酶竞争，从而导致氯吡格雷抗栓效果不充分，临床药师建议将埃索美拉唑调整为泮托拉唑。同时，对患者进行用药教育，保障患者用药安全、有效。
1례77세녀성환자，인반복흉민、심계15년，가중1개월입원。입원진단위：관상동맥죽양경화성심장병，급성관맥종합정，진발성심방전동；고혈압3급（흔고위），고혈압성심장병；류풍습관절염；위두궤양。입원급여항염、항혈소판、조절혈지、지통、방전전복、강혈압、보호위점막등치료。환자장기응용당피질격소회도치혈당대사문란、위점막손상、골질소송등증상，대갑발니룡편、염산알전동、타정류약물불량반응진행감측，고필도애색미랍서가능여록필격뢰존재대사매경쟁，종이도치록필격뢰항전효과불충분，림상약사건의장애색미랍서조정위반탁랍서。동시，대환자진행용약교육，보장환자용약안전、유효。
One 77-year-old female patient with chest tightness and palpitations for 15 years, aggravation for one month was hospitalized. The patient was diagnosed as coronary heart disease, acute coronary syndrome, paroxysmal atrial fibrillation, hypertension, hypertensive heart disease, rheumatoid arthritis and antral ulcer. The patient received anti-inlfammatory, antiplatelet, regulating blood lipid, relieving pain, cardioversion of atrial fibrillation, reducing blood pressure, protection of gastric mucosa therapy. Clinical pharmacist paid close attention to disorder of glucose metabolism, gastric mucosal injury, osteoporosis caused by long term use of corticosteroids, monitored the potential adverse drug reactions caused by methylprednisolone, amiodarone and statins. Considering the competition of metabolic enzyme CYP2C19 between esomeprazole and clopidogrel which may lead to inadequate antithrombotic effect of clopidogrel, clinical pharmacist suggested that esomeprazole should be replaced by pantoprazole. Clinical pharmacists provided education on the medication for the patient and played an important role in the safety as well as effectiveness of drug use.