Department of Pharmacy, Tufts Medical Center, Boston, MA 02111, USA.
Am J Health Syst Pharm. 2013 Mar 15;70(6):511-3. doi: 10.2146/ajhp120529.
A case illustrating multiple considerations in choosing safe and effective dual antiplatelet therapy for a patient with a history of clopidogrel allergy-including concerns relating to a national drug shortage-is described.
A 75-year-old woman required dual antiplatelet therapy (aspirin plus a thienopyridine) after a cardiac catheterization procedure; during a prior emergency department visit for acute coronary syndrome, she had experienced an allergic reaction within 24 hours of receiving dual therapy including clopidogrel. A team of pharmacy and allergy staff determined that challenging the patient with prasugrel was the best treatment option. Key considerations in the decision-making process included (1) concerns that an alternative thienopyridine, ticlopidine, might be unavailable for long-term outpatient use due to an ongoing national drug shortage, (2) the patient's concomitant use of metoprolol (cessation of β-blocker use is recommended for four days before attempted clopidogrel desensitization), and (3) recent reports of the safe use of prasugrel in three patients with a history of clopidogrel allergy. In the case described here, prasugrel administration was effective and did not result in adverse effects; however, the risk of cross-reactivity of clopidogrel and ticlopidine or prasugrel remains largely unknown. The case highlights the importance of careful consideration of a number of patient- and drug-specific factors in the selection of the most appropriate antiplatelet dual therapy for patients with a history of allergic reactions to clopidogrel.
A shortage of ticlopidine prompted the use of prasugrel in a clopidogrel-allergic patient requiring dual antiplatelet therapy. Prasugrel therapy was well tolerated, with no evidence of allergic reaction.
本文通过一个病例说明了在选择安全有效的氯吡格雷过敏患者双联抗血小板治疗方案时需要考虑多种因素，包括与全国药物短缺相关的问题。
一位 75 岁的女性在接受心脏导管检查后需要双联抗血小板治疗（阿司匹林加噻吩吡啶）；在因急性冠脉综合征到急诊科就诊时，她在接受包括氯吡格雷在内的双联治疗后 24 小时内发生过敏反应。一组药剂师和过敏专家团队认为，用普拉格雷挑战该患者是最佳治疗选择。决策过程中的关键考虑因素包括：（1）由于全国性药物短缺，替代噻吩吡啶（噻氯匹定）可能无法长期用于门诊患者；（2）患者同时使用美托洛尔（建议在尝试氯吡格雷脱敏前停止使用β受体阻滞剂 4 天）；（3）最近有报道称普拉格雷在 3 例氯吡格雷过敏史患者中安全使用。在本文描述的病例中，普拉格雷的使用是有效的，且没有产生不良反应；然而，氯吡格雷和噻氯匹定或普拉格雷之间交叉反应的风险仍很大程度上未知。该病例强调了在选择最适合有氯吡格雷过敏史的患者的双联抗血小板治疗方案时，需要仔细考虑患者和药物的多种因素。
由于噻氯匹定短缺，需要对双联抗血小板治疗的氯吡格雷过敏患者使用普拉格雷。普拉格雷治疗耐受性良好，无过敏反应证据。
