Key to a successful transplant program

Transplant pharmacists: key to a successful transplant program

Ohler, Linda

Twenty years ago, the primary focus of immunosuppressant regimens was prevention of acute rejection using either 2 or 3 drug combinations that, in retrospect, seem simplistic. Recent advances in immunosuppressant regimens have dramatically reduced acute rejection rates, but concurrently increased the complexity of immunosuppressant regimens. The more drugs we use to manipulate the immune system, the more complex patient care becomes. We are now faced with new challenges in transplantation when patients are exposed to variable drug interactions and long-term drug toxicities.

What we have learned about immunosuppression in the past remains basically the same: too little immunosuppression may lead to rejection whereas too much often leads to serious complications including renal failure, infections, and malignancies. Finding the balance varies from one individual to the next. That balance is easily disturbed with the addition of drugs to counteract complications of transplantation and adverse effects of immunosuppressive agents, leading to polypharmacy and predisposing patients to drug interactions and drug toxicities.

The Expanding Role of Transplant Pharmacists

Initially, most pharmacists made rounds with the transplant team and offered basic pharmacy services such as therapeutic drug monitoring, providing drug information about potential side effects and drug interaction. In recent years the role of the pharmacist has expanded to include designing, implementing, and counseling patients on individualized drug regimens. Pharmacists now play an active role in the care of the transplant recipients alongside other transplant team members. Pharmacists are asked to design and implement therapeutic plans for the complex medical regimen of transplant recipients. Educating healthcare professionals and conducting clinical research also became important roles for transplant pharmacists.

A study in France demonstrated that patients’ knowledge about antirejection medications increased from 53% to 75% after counseling by pharmacists. Knowledge level about other drugs such as antimicrobial and antihypertensive agents was 15% before pharmacist counseling and increased to 50% to 60% following counseling.1 In a prospective, randomized controlled study compliance with transplant medications was improved when pharmacists counseled patients during routine clinic visits compared with clinic visits that did not include counseling by a pharmacist.2 A substantial cost savings was realized when clinical pharmacists managed a medication assistance program in a kidney transplant clinic.3

Transplant Pharmacists Are Integral to a Multidisciplinary Team

Every transplant program should include a dedicated clinical pharmacist with specialized knowledge about transplantation to optimize patient outcomes. Although their role in transplantation is often understated, transplant pharmacists fill a tremendous void on a multidisciplinary transplant team. They work with other healthcare professionals to review medication profiles, identify and solve drug-related problems, and provide information on therapeutic drug monitoring.4 Clinical pharmacists collaborate with nurses and transplant coordinators to provide discharge teaching and serve as liaisons to patients and their families regarding medication issues.

To reduce medication errors, the Institute of Medicine has recommended that pharmacists participate in daily rounds and be available on nursing units to improve patient safety,5 underscoring the importance of clinical pharmacists as members of a multidisciplinary team. Physicians are prepared to manage medical conditions and select the appropriate medications whereas pharmacists are specifically trained to evaluate not only the efficacy and safety profile of the medications, but also the pharmacokinetic and pharmacodynamic profile of each medication. The contribution of the pharmacist enables the transplant team to have a more in-depth and comprehensive perspective when designing and implementing drug regimens for each transplant recipient. With today’s complex immunosuppressant regimens, making clinical rounds without a transplant pharmacist could be equated to navigating the high seas without a compass.

References

1. Monnier G, Charpiat B, Serratrice F, Bossaert S, Fourcade N, Duceff C. Evaluation of drug therapy knowledge in liver transplant patients after pharmacy counseling. Therapie. 2003;58:305-311.

2. Chisholm MA, Mtilloy LL, Jagadeesan M, DiPiro JT. Impact of clinical pharmacy services on renal transplant patients’ compliance with immunosuppressive medications. Clin Transplant. 2001;15:330-336.

3. Chisholm MA, Vollenweider LJ, Mulloy LL, Wynn JJ, Wade WE, DiPiro JT. Cost benefit analysis of a clinical pharmacist-managed medication assistance program in a renal transplant clinic. Clin Transplant. 2000;14(4pt 1):304-307.

4. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267-270

5. Kohn LT, Coorigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

Thank You to the Transplant Pharmacists

In developing this special issue on Transplant Pharmacy, the Editor has worked with more than 20 pharmacists who have demonstrated the dedication and high standards we have come to expect from this profession.

Thank You to the Guest Editors

Meredith Aull, PharmD

Steve Gabardi, PharmD

Agnes Lo, PharmD

Jamie Park, PharmD

Paula Phongsamran, PharmD

Jennifer Trofe, PharmD

Thank You to the Pharmacists Who Reviewed the Manuscripts

Robyn Boardman, PharmD

Dean Collier, PharmD

Steve Gabardi, PharmD

Kathleen Lake, PharmD

Agnes Lo, PharmD

Sherry Milford Laforest, PharmD

Ali Oylaei, PharmD

Christin Rogers, PharmD

Kristin Schonder, PharmD

Linda Ohler, RN, MSN, CCTC, Editor in Chief, and Agnes Lo, PharmD

Copyright North American Transplant Coordinators Organization Jun 2004

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