Tacrolimus Therapeutic Drug Monitoring in Kidney Transplant Patients Before and After Pharmacist Post-transplant Consults.

Objectives: This quality improvement project sought to determine if clinical pharmacist office visits, or consults, had an impact on therapeutic tacrolimus levels in patients after kidney transplant through analysis of tacrolimus serum concentrations before versus after a pharmacist visit. Methods: A retrospective chart review was conducted for all patients that attended a clinical pharmacist office visit, also known as a consult, after kidney transplantation for a four month period. Pharmacists during the post-transplant consult reviewed adherence but also educated patients in detail about timing and logging of tacrolimus dosing, dosing with regard to labs to assure trough dosing, dosing with or without food in the stomach, what to do with a dose is taken late or if a dose is missed and foods, herbal supplements to avoid that may inhibit CYP3A4 to elevate tacrolimus levels. Results: After the post-transplant visit with a clinical pharmacist there was a 46% increase in the number of tacrolimus trough levels in therapeutic range versus before the pharmacist visit. Sixty-four percent of kidney transplant patients experienced an increase in the number of therapeutic drug levels in range after the pharmacist visit versus before the pharmacist visit. Conclusions: An increase in the quantity of therapeutic tacrolimus trough levels and the number of patients with therapeutic drug levels in range was observed after patients received pharmacist provided medication education post-transplant with emphasis on proper immunosuppressant medication administration, adherence and potential drug and food interactions. This finding demonstrates the importance of pharmacist clinical services in producing improved therapeutic drug levels in post-transplant kidney patients.

Pharmacist Impact on Tacrolimus Serum Concentrations in Liver Transplant Patients.

Objective The purpose of this quality-improvement project was to determine if a pharmacist consultation following a liver transplant is associated with an increased percentage of drug levels in range after the patient sees the pharmacist. Setting Tertiary care, multispecialty medical clinic, and hospital providing solid-organ transplant. Practice Description Pharmacist consult service in a tertiary care, multispecialty medical clinic and hospital providing solid-organ transplant. Practice InnovationProvision of liver post-transplant consultations, not required by the Centers for Medicare & Medicaid Services, that results in therapeutic drug level improvement. Main Outcome MeasureTacrolimus therapeutic drug levels in range. Results A 96% improvement in quantity of therapeutic tacrolimus levels was seen in liver post-transplant patients after pharmacist post-transplant consultation. Results revealed 59 out of 74 (79.7%) post-liver transplant patients, 25 to 77 years of age (average 59.7 years), had an increased number of therapeutic tacrolimus levels after pharmacist post-transplant consultation. ConclusionWithout a pharmacist consultation following a liver transplant, patients may have a higher number of tacrolimus levels out of therapeutic range, placing them at increased risk for possible graft loss from low tacrolimus levels or toxicity resulting from high tacrolimus levels. Improvement in therapeutic tacrolimus levels after liver transplant was observed after patients received consultation and education from a clinical pharmacist. This finding creates an opportunity for pharmacists to implement services for patients after liver transplants to improve therapeutic tacrolimus levels.