作者:Laura L. Hardwick、Thomas D. Batiuk
DOI:10.1592/phco.22.12.1063.33604
日期:2002.8
A 59-year-old man inadvertently received a 10-fold increase in his twice-daily oral dose of tacrolimus 1 mg that resulted in trough blood levels above 90 ng/ml for over a week. The patient had end-stage renal disease secondary to diabetes mellitus and had received a kidney transplant from his daughter 3 months earlier. Despite the numerous adverse effects commonly reported with tacrolimus, such as mild nephrotoxicity, nausea, tremors, and elevated liver enzyme levels, our patient's acute but prolonged overdose resulted in minimal signs and symptoms of toxicity. Nevertheless, education regarding the importance of accurate dosing, close monitoring, potential drug interactions, and the various capsule colors should be provided to all patients who receive tacrolimus, as well as their physicians, nurses, and pharmacists, in order to prevent as many errors as possible.
一名59岁的男性偶然间将每日两次口服的他克莫司剂量从1毫克增加到了10倍,导致其血药浓度在一周内超过90 ng/ml。该患者因糖尿病导致终末期肾病,并在3个月前接受了来自女儿的肾脏移植。尽管他克莫司常见的不良反应包括轻度肾毒性、恶心、震颤和肝酶水平升高,但我们的患者在急性但长期的过量情况下,仅出现了轻微的毒性迹象和症状。然而,应该向所有接受他克莫司治疗的患者及其医生、护士和药剂师提供关于准确剂量、密切监测、潜在药物相互作用以及各种胶囊颜色的重要性教育,以尽量减少错误的发生。