Medication therapy management by pharmacists in a kidney transplant ambulatory clinic

Introduction: Pharmacists play an essential role as part of the multidisciplinary transplant team in providing comprehensive pharmaceutical care for kidney transplant recipients. Methods: A prospective, observational, single-centre study evaluated the clinical pharmacy service in a kidney transplant ambulatory clinic. At each visit, pharmacists reviewed and optimised the medication regimens of transplant recipients, which include the medication therapy management of immunosuppression, infective and non-infective complications commonly seen post-transplantation. Pharmacists also performed medication reconciliation and provided medication education during each visit. Any drug-related problems or discrepancies identified were communicated to the physicians in the clinic. Results: Between September 2013 and March 2015, a total of 3581 cases were reviewed. Pharmacists identified 663 drug-related problems involving 319 recipients. Most of the pharmacists' clinical recommendations (93%) were accepted by physicians. The common drug-related problems identified were 'inappropriate dosage regimen' (38%), 'omission of drug therapy' (28%) and 'monitoring parameters recommendation' (9%). Common drug classes involved were immunosuppressive agents (25%), anti-infectives (14%) and anti-hypertensive agents (12%). During medication reconciliation, pharmacists identified 180 medication discrepancies. Common medication discrepancies identified include 'incorrect dose' (68%), 'incorrect duration' (17%) and 'incorrect drug' (13%). All drug-related problems and medication discrepancies were resolved or addressed at the same clinic visit. Conclusions: Pharmacists play a pivotal role in the provision of medication therapy management to ensure safe and effective use of medications in kidney transplant recipients with complex medication regimens. This was achieved through identification and resolution of drug-related problems from medication review and medication discrepancies from medication reconciliation.