Clinical 21
Pharmacy Practice News • December 2009
Transplant Pharmacy are at least six makers of mycophenolate mofetil, “so the potential for confusion here is not something to overlook.” He added that although “we haven’t seen this occur yet, because these generic formulations have only been around for a few months, it’s been a problem with the other transplant-related drugs and will be an issue with the immunosuppressives as time goes on if you don’t educate patients about this.” Dr. Marfo and his colleagues have developed several strategies for avoiding such problems. “When we counsel patients, one of the things we tell them is that if you go to the pharmacy and there is ever a change in the color of your meds, you have to ask to speak with the pharmacist or call us first before
taking it,” he said. “That can avoid a lot of problems.” His team also counsels patients to obtain their medications from independent pharmacies that have expertise dealing with transplant medicines. “We’ve asked these pharmacies not to switch patients to generics without telling us. This way, we can prepare the patients and make sure they understand what they’re getting and how to take it safety.” About once a month, Dr. Marfo added, he visits the retail pharmacies in his community that service transplant
patients and asks for a list of patients who are being dispensed generic drugs. “It’s a great counseling tool,” he said. (For other counseling tips, see sidebar.)
A Lasting Contribution Dr. Smith said the practice of organ transplant pharmacy is rewarding on several fronts. One of its major attractions, he noted, is the ability to help patients at every stage of therapy. “I’ve had residents who counseled patients when they were first admitted to the hospital, helped care for them throughout their hospital stay, and then
provided detailed discharge counseling,” he said. “Months later, if any of these patients get readmitted—and trust me, many of them will come back to your clinic with complications—you have pharmacists in place who know them and can drop right back into providing a high level of clinical care.” That continuity of care “is something that the pharmacy profession has been striving to provide,” Dr. Smith said. “It doesn’t really happen in many practice settings, but when it does, it is a beautiful thing to see.” —David Bronstein
Patient Counseling Tips Don’t overlook food-drug interactions. Something as simple as grapefruit juice, for example, can interfere with the absorption of tacrolimus and cause problems, Dr. Marfo noted. Focus on side effects. Many transplant drugs cause significant side effects that can lead to noncompliance. Certain forms of cyclosporine, for example, can cause gingival hyperplasia, which is an overgrowth of gum tissue. In females, the drug can cause an overgrowth of facial hair. “These side effects are both especially troubling to younger patients, because they raise cosmetic issues,” Dr. Marfo said. “You need to work with the patients and parents to make sure these side effects don’t become reasons not to take their medications.” Stress the dangers of nonadherence. Many patients only come into the clinic once a month, Dr. Marfo said. “They may miss a dose for three weeks before you see them,” he said. “Then you do blood work, their creatinine has gone from 1.0 to 4 or 5, you suspect rejection, do a biopsy, and lo and behold, they’ve rejected their organ. It could really happen that quickly.” Warning patients about such outcomes, he said, can help boost compliance. Document discharge counseling. At discharge, pharmacists have “a wonderful opportunity” to counsel patients and family members about how to manage their medications and disease long after they leave the hospital, Dr. Smith said. But the counseling also has a compliance benefit. “CMS surveyors will look for documentation in the medical record that a pharmacist was an integral part of developing the discharge plan for your transplant patients.” —D. B.
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