Development of a Discharge Counseling and Medication Reconciliation Process for Pediatric Patients Within a Large, Academic Health System.

OBJECTIVE: This study aims to characterize the impact of a pharmacist-driven discharge medication reconciliation and counseling program targeting high-risk pediatric patients to mitigate barriers in transitions of care. METHODS: This was a single-center quality improvement initiative including high-risk pediatric patients within a large academic medical center. Pharmacy, medical, and information technology team members developed a scoring system to identify patients at high risk of hospital readmission that resulted in a trigger tool built within the electronic medical record (EMR). Pharmacy workflow, the EMR documentation, and staff training were implemented. The primary end point was the number of high-risk patients with complete medication reconciliation and/or discharge counseling performed during the first 2 months after implementation. The secondary end points included quantification and qualification of the interventions conducted by a pharmacist. RESULTS: Pediatric clinical pharmacists conducted discharge medication reconciliation and/or counseling for 60 patients during the first 2 months after implementation. There were 65 interventions performed, including 60 discharge medication reconciliations and 5 discharge counseling sessions. Of these interventions, 22 were recommendations on appropriate medication dosing and frequency (37%), 12 on duration of therapy (20%), and 8 were medication additions (13%). There were 6 interventions on adherence assistance (10%), 6 involved selection of medication formulation (10%), 3 involved medication discontinuation (5%), 2 involved appropriate therapy selection (3%), and 1 involved medication stability (1%). All interventions were accepted and implemented by the prescribing providers. CONCLUSIONS: Pharmacist-driven discharge medication reconciliation and counseling programs targeting pediatric high-risk population might be an effective tool to mitigate gaps in transitions of care.

Elevated tacrolimus levels after treatment with nirmatrelvir/ritonavir (Paxlovid) for COVID-19 infection in a child with a kidney transplant.

BACKGROUND: Paxlovid (nirmatrelvir/ritonavir) is a novel drug available under emergency use authorization by the Food and Drug Administration for the treatment of COVID-19 infection. Tacrolimus, a calcineurin inhibitor, is commonly used as an immunosuppressant medication in children with kidney transplants. While tacrolimus is metabolized by the cytochrome P450 system (CYP3A4), ritonavir is a potent CYP3A4 inhibitor. There is a paucity of data regarding the drug-drug interaction between nirmatrelvir/ritonavir and tacrolimus in children with kidney transplants. CASE-DIAGNOSIS/TREATMENT: This is a case report of a 14-year-old female with a history of a kidney transplant, maintained on tacrolimus and prednisone, who starts nirmatrelvir/ritonavir for a COVID-19 infection. She subsequently develops supratherapeutic tacrolimus levels and an increase in serum creatinine. Her tacrolimus was held, and the nirmatrelvir/ritonavir was stopped. Over time, her kidney function returned to baseline, her tacrolimus levels returned to the therapeutic goal, and her tacrolimus was resumed. CONCLUSIONS: Our case report highlights the strong interaction with concomitant use of tacrolimus and nirmatrelvir/ritonavir in a pediatric kidney transplant recipient and the development of supratherapeutic tacrolimus levels. Providers should therefore be cautious when prescribing nirmatrelvir/ritonavir to a pediatric patient currently on tacrolimus.