In this report, we described a case of a clinical practice, in which the clinical pharmacists was involved in the treatment of a soft tissue sarcoma patient, who was diagnosed with mental disorders induced by regorafenib. The patient was complicated with hypoproteinemia, hepatic insufficiency, leukoencephalopathy and other diseases. Before the treatment, the patient's mental was normal. After continuous administration of regorafenib(40 mg, po, qd) for 5 days, the patient has a sudden loss of consciousness. Clinical pharmacists excluded the possibility of mental disorders caused by tumor brain metastases, exacerbation of leucoencephalopathy or hepatic encephalopathy and the drugs used together. They determined that mental disorders were likely to be related to the use of regorafenib through the association evaluation of adverse reactions. It was considered to be an adverse reaction induced by regorafenib. Therefore, regorafenib treatment was temporarily suspended and symptomatic treatment was given. After 5 days, the patient's mental state improved. In addition, clinical pharmacists monitored the patient for symptomatic treatment, and provided appropriate antitumor drug treatment recommendations based on evidence-based evidence. This case suggests that the clinical use of regorafenib should be vigilant against mental disorders adverse reactions, do a good job of pharmaceutical care, and timely drug analysis and symptomatic treatment after adverse reactions.

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