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中华移植杂志(电子版) ›› 2023, Vol. 17 ›› Issue (01) : 17 -31. doi: 10.3877/cma.j.issn.1674-3903.2023.01.003

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器官移植受者新型冠状病毒感染入院治疗药物使用建议(2023版)
全国移植药师联盟, 浙江省医院药事管理质控中心   
  1. 1. 浙江大学医学院附属第一医院，杭州　310003
    2. 空军军医大学第一附属医院，西安　710032
    3. 深圳市第三人民医院　518112
  • 收稿日期:2023-01-16 出版日期:2023-02-25

Suggestions on the use of drugs for COVID-19 infection in organ transplant recipients (2023)

National Alliance of Transplant Pharmacists, Zhejiang Hospital Pharmacy Management Quality Control Center   

  • Received:2023-01-16 Published:2023-02-25
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全国移植药师联盟, 浙江省医院药事管理质控中心. 器官移植受者新型冠状病毒感染入院治疗药物使用建议(2023版)[J]. 中华移植杂志(电子版), 2023, 17(01): 17-31.

National Alliance of Transplant Pharmacists, Zhejiang Hospital Pharmacy Management Quality Control Center. Suggestions on the use of drugs for COVID-19 infection in organ transplant recipients (2023)[J]. Chinese Journal of Transplantation(Electronic Edition), 2023, 17(01): 17-31.

2022年末，国务院应对新型冠状病毒感染疫情联防联控机制综合组对新型冠状病毒(新冠病毒)疫情防控政策作出科学调整后，新冠病毒感染(COVID-19)防控进入新阶段。对于免疫抑制状态的器官移植受者，COVID-19具有感染率高、入院症状严重和病程延长等特点。同时，器官移植受者长期服用的免疫抑制剂为窄治疗窗药物，易与其他药物产生相互作用导致不良反应增加，尤其是目前对COVID-19疗效较为明确的抗新冠病毒药物奈玛特韦/利托那韦，此时免疫抑制剂如何调整，是值得关注的临床问题。此外，器官移植受者发生COVID-19时，这些常规治疗药物的疗效如何，使用时机及疗程如何，以及合并肝肾功能不全时如何合理使用等问题尚无明确共识。因此，全国移植药师联盟联合浙江省医院药事管理质控中心基于目前循证医学证据及临床实践，结合抗病毒治疗药物的药学特性，制订了《器官移植受者新型冠状病毒感染入院治疗药物使用建议(2023版)》，主要关注器官移植受者COVID-19入院治疗中的抗新冠病毒药物及免疫抑制剂，有效保障该群体临床用药安全，提升药物治疗水平。

表1 合并肾功能不全的器官移植受者奈玛特韦/利托那韦剂量调整建议
肾功能 剂量调整建议
eGFR >60～90 mL·min－1·(1.73 m2)－1 无需调整剂量：奈玛特韦300 mg＋利托那韦100 mg，每12小时1次
eGFR 30～60 mL·min－1·(1.73 m2)－1 奈玛特韦150 mg＋利托那韦100 mg，每12小时1次，连续5 d
eGFR <30 mL·min－1·(1.73 m2)－1，未透析 药品说明书不推荐使用
文献推荐：第1天，奈玛特韦300 mg＋利托那韦100 mg，1次/d；第2～5天，奈玛特韦150 mg＋利托那韦100 mg，1次/d
透析 药品说明书不推荐使用
文献推荐：第1天，奈玛特韦300 mg＋利托那韦100 mg，1次/d；第2～5天，奈玛特韦150 mg＋利托那韦100 mg，透析后给药，1次/d
体质量≤40 kg者可考虑奈玛特韦150 mg＋利托那韦100 mg，每48小时1次
表2 奈玛特韦/利托那韦用药期间免疫抑制剂调整建议
免疫抑制剂 调整建议 启用建议
他克莫司 奈玛特韦/利托那韦使用前12 h暂停使用 第6天或第7天检测他克莫司血药浓度，此后每2～4天复查；超过治疗目标浓度，继续停用；在治疗目标浓度范围内，以基线剂量的25%～50%重新启用；低于治疗目标浓度，以基线剂量的25%～75%重新启用
环孢素 剂量减至原来的20%，同时改为每日1次服用 第6天开始逐步重新启用
西罗莫司 奈玛特韦/利托那韦使用前12 h停用 可在第7天以原剂量的20%重新启用，每日剂量增加20%
霉酚酸类药物 奈玛特韦/利托那韦与麦考酚钠相互作用较小，可根据COVID-19严重程度考虑不调整、减量或停用  
糖皮质激素 奈玛特韦/利托那韦与泼尼松相互作用较小，可根据COVID-19严重程度，使用不同剂量糖皮质激素  
表3 合并肾功能不全的器官移植受者阿兹夫定剂量调整建议
肾功能 剂量和用法
eGFR >60 mL·min－1·(1.73 m2)－1 原剂量：5 mg，1次/d
eGFR 30～60 mL·min－1·(1.73 m2)－1 3 mg，1次/d
eGFR 15～<30 mL·min－1·(1.73 m2)－1 慎用
血液透析 持续6 h以上的血液透析患者，全剂量维持，建议透析后给药
CRRT 推测可按正常剂量使用
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