CLINICAL PHARMACISTS' IMPACT ON TRANSPLANT PATIENTS
By Carol Milano
For renal transplant patients, following a complicated
regimen of antisuppressant medications is crucial. "We know compliance
is the leading cause of preventable kidney rejection," explains
Marie Chisholm, PharmD, associate professor of pharmacy at University
of Georgia College of Pharmacy, and associate professor of medicine
at Medical College of Georgia (MCG).
Since 1997, Dr. Chisholm has explored whether clinical
pharmacists can improve compliance rates at MCG Hospital and Clinics
in Augusta, which performs 60 to 80 kidney transplants each year. So
far, her program has served over 750 patients.
Causes of improper medication use include patient confusion,
lack of appropriate instructions, complicated regimens, or failure to
fill a prescription. Now, clinical pharmacists at MCG's busy out-patient
renal transplant clinic interview patients and review medications to
recommend and monitor therapy.
Transplant pharmacist Gene McGinty, BSRPH, usually begins
seeing patients one or two days after their release. "I love it,"
he exclaims. "I like the patients and enjoy talking with them.
Once they hear I'm a pharmacist, they seem to open up more and talk
about their meds. We develop a relationship with patients, especially
while seeing them twice a week for a short time after the transplant,"
when rejection possibility is greatest.
He discusses new patients' medications to ensure they
know exactly how to take them. "We have to avoid information overload,"
McGinty's learned. "Sometimes we can bombard them with details
about their condition and the way their life will be after a transplant."
For the first three months, while susceptible to infection, patients
need careful monitoring during antibiotic prophylaxis.
When McGinty feels a long-time patient knows how to take
the medications and is in compliance, he may spend a minute or less.
However, his greatest satisfaction is time to talk long enough to spot
a problem. One patient was prescribed 30 milligrams of prednisone each
day, in six 5-milligram tablets. Her pharmacist filled the prescription
with 10-milligram tablets. The patient didn't read instructions on the
bottle and was taking six tablets instead of three. "In a short
conversation, I could discover that she was overdosing," recounts
McGinty. Drug interactions are another frequent difficulty.
Dr. Chisholm supervises PharmD students on five-week clinical
clerkships during their final year at U Ga College of Pharmacy. "The
students talk to patients, getting to see some of them multiple times.
They see where they can really make a difference in someone's care -
and they love it," says Dr. Chisholm.
The out-patient team includes nursing staff, physicians,
pharmacists and students who do interviews and follow-up care. Each
visit includes a full patient work-up with lab tests, as well as blood
pressure measurements. A clinical pharmacist reviews the new test results
and current medication regimen, to identify problems and increase efficacy
Laura Mulloy, MD, Chief of Nephrology, Hypertension and
Transplant Medicine at MCG, feels Pharm Ds provide a double-check on
whether the patient is taking every drug exactly as she prescribed.
She's found the RN may simply repeat a previous prescription, but the
Pharm Ds investigate carefully.
Mulloy often seeks their opinions about different medications,
since they may have more knowledge of side effects and interactions
for non-transplant drugs. "Compliance is a big problem with transplant
patients, who may stop taking a medication, thinking it won't make a
difference. Even a telephone reminder from a Pharm D helps patients
get a refill when they should, or comply with instructions," says
Dr. Mulloy. "Absolutely, compliance is better when the Pharm Ds
intervene," she adds.
Dr. Chisholm's research proves Dr. Mulloy's observation.
For two years, renal transplant patients were randomized into either
a control group given only routine out-patient clinical services at
each visit, or an intervention group which also received clinical pharmacy
services. In addition to patient counseling, reviews of medication histories,
and instructions for optimizing therapy, the clinical pharmacists' interventions
included recommendations to the nephrologists.
Both pharmacy refill records and compliance rates (CR)
were studied. Calculating the CR included assessing how many patients
were compliant each month, and the mean time patients were compliant
in each group. The difference in frequency of patients achieving "target"
immunosuppressive blood levels in both control and study groups was
The mean CR for patients seeing a clinical pharmacist
(n=12) was statistically higher than the control group's (n=12) mean
CR (p< 0.001). During a 12-month post-transplant study period, patients
in the intervention group were in compliance longer than those in the
control group (p< 0.05). Patients having clinical pharmacy intervention
achieved "target" levels more often than patients who did
not (p< 0.05).
While the main focus of the study was the CR, the researchers
also found that clinical pharmacist intervention decreased adverse drug
reactions and improved blood pressure control. In addition, subjects
in the control group reported higher overall satisfaction levels with
the out-patient clinic's health care.
Clinical pharmacist care has become an ongoing, valuable
addition to treatment for patients at MCG's renal transplant clinic.