Transplant group calls for pharmacists on team

Pharmacists are gaining new support in the organ transplantation world. UNOS, the United Network for Organ Sharing, is encouraging all transplant centers to include at least one clinical R.Ph. on each transplant team. UNOS coordinates organ donation and transplantation specialists nationwide.

The impact on hospitals varies. Institutions with active transplantation centers have transplant pharmacists already and will likely see no change, said Lisa McDevitt, Pharm.D., clinical pharmacy specialist in solid organ transplantation at Tufts-New England Medical Center (Tufts-NEMC), Boston. "But if your transplant center has not had a dedicated transplant pharmacist, you are thinking about the issue be-cause of UNOS' position," she said. UNOS' pharmacist endorsement came in June 2004. Lobbying by transplant R.Ph.s and transplant administrators brought a change in UNOS bylaws. The amendment was sponsored by UNOS' Transplant Administrators Committee.

"We felt it important that transplant pharmacists be recognized for the vital role they play," said committee chair Ian Jamieson, MBA, MHA. "It can be hard to justify a dedicated pharmacist when you're doing only 35 renal transplants a year. Now smaller centers are under the gun to develop a transplant pharmacist or hire someone." New language advises transplant centers to "identify one or more pharmacists who will be responsible for providing pharmaceutical care to organ transplant recipients. The clinical transplant pharmacist shall be a designated member of the transplant team and will be assigned primary responsibility for providing comprehensive pharmaceutical care to transplant recipients."

There was at least one prior attempt to encourage the addition of pharmacists to the transplant team, McDevitt said, but there were not enough transplant R.Ph.s to meet the projected need. UNOS already requires that every team include a transplant surgeon and a primary care physician with specific experience. The group also recommends the inclusion of a nurse coordinator and a clinical pharmacist. "It would be inappropriate to require transplant pharmacists on every team," McDevitt said. "There are not enough trained transplant pharmacists to go around."

The American College of Clinical Pharmacy counts about 200 working transplant pharmacists among its members, McDevitt said. However, there may be many full- or part-time transplant specialists who are not ACCP members.

There is plenty for transplant pharmacists to do. Drug therapy is a constant question for transplant recipients and their physicians. "Our transplant patients have to check with the team before starting or stopping any drug, including OTCs," said Jill Martin, Pharm.D., president-elect of ASHP and director of transplant outcomes at University Hospital in Cincinnati. "We have patients get into trouble with something as simple as aspirin when they don't call us first." Immunosuppressive drugs can impair renal function, thus increasing the potential risk of kidney damage from nonsteroidal anti-inflammatory drugs, even at OTC dosages. Instead, "we have to be very cautious about NSAIDs. We move patients to analgesics that do not affect the kidneys, such as Tylenol."

In addition, antibiotics such as Biaxin (clarithromycin, Abbott) and erythromycin can double, even triple, serum levels of immunosuppressants with quick and potentially disastrous results. "It takes significant time to review a total drug regimen with just one product added or removed. An R.Ph. on the team significantly reduces the incidence and severity of interactions and helps reduce adverse drug reactions."

Already complex drug regimens are further complicated by age and a growing number of comorbidities. "Recipients have to take two big bags of pills every day for the rest of their lives," Jamieson said. "We are not here to create jobs for pharmacists; we are here to optimize outcomes for our patients. It's not tough to see pharmacists' value, given the complexity and the cost of drug regimens in this field."