ABSTRACT
OBJECTIVE：To accumulate relevant experience of clinical pharmacists consultation ，and to promote clinical safe and rational drug use. METHODS ：From different approaches ，the clinical pharmacists analyzed and evaluated of drug use in 4 consultation cases ，i.e. a patient of pulmonary infection after liver transplantation was treated with antifungal therapy by voriconazole，which resulted in excessive blood concentration of voriconazole ；a hemoptysis patient with pulmonary infection was found fibrinogen decreased ，after treatmented with anti-infective and hemostatic drugs ；a patient with pulmonary infection after lung transplantation ，followed by the increase of urea and creatinine after anti-infective therapy ；a patient with grand mal epilepsy after kidney transplantation was treated with phenobarbital and diazepam ，the blood concentration of tacrolimus decreased significantly. The pharmaceutical consultation opinion was put forward and the treatment plan was optimized by clinical pharmacists. RESULTS ：Clinical pharmacists put forward pharmaceutical consultation suggestions for four consultation cases ， which were adopted by doctors. Case 1 was stopped voriconazole and omeprazole，and changed to pantoprazole for gastric protection. The steady-state valley concentration of voriconazole decreased from 12.38 μg/mL to 6.86 μg/mL，and the liver function of transaminase and total bilirubin were improved. Case 2 was stopped cefoperazone-sulbactam and hemocoagulase ，given vitamin K1，fibrinogen，cryoprecipitation，plasma for symptomatic treatment. The fibrinogen was gradually increased from 0.74 g/L to 2.88 g/L，and then remained within the normal range. Case 3 was adjusted the dosages of nephrotoxicity-related drugs （meropenem， levofloxacin，ganciclovir and Compound sulfamethoxazole were adjusted to 1 g q 12 h，250 mg qd ，94 mg qd and 2 tablets qd respectively）. The renal function indicators of urea decreased from 37.6 mmol/L to 7.8 mmol/L；creatinine decreased from 173 μmol/L to 68 μmol/L；the renal function returned to normal ，and the infectious indicators also improved. Case 4 adjusted the oral dose of tacrolimus increasing to 2 mg q 12 h，and oral dose of Pentaester soft capsule was increasing to 1 g bid. The blood concentration of tacrolimus increased from 0.8 ng/mL to 5.9 ng/mL，which reached the expected value ，and there was no further fluctuation during hospitalization. CONCLUSIONS ：Clinical pharmacists consultation mainly focuses on the following 66295644。 aspects， such as individual treatment p lan adjustment ， judgment and treatment of ADR ，adjustment of medicationplan for special population ，optimization of treatment plan for drug interactions ，so as to guarantee the safe use of drugs in clinic.