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.

Pharmacists' Involvement

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 of therapy.

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.

Research Findings

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 evaluated.

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.

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