Avoiding Drug Interactions

The sheer number of pills and medications makes avoiding drug interactions challenging for transplant patients with multiple comorbidities and the clinicians who provide their care. The average transplant recipient takes more than 10 medications in more than 30 doses every day, the study authors noted. Some of those have a very narrow therapeutic range and a plethora of interactions.

“Many of the drugs used in transplant patients are metabolized through the liver, as are many other drugs, such as antihypertensives and anti-infectives. Those are the two biggest classes that have interactions, and transplant patients are often prescribed both,” Taber added.

As a result of all these factors, “drug-related problems, which encompass medication errors, nonadherence and adverse drug events, are a predominant cause of deleterious clinical outcomes in solid organ transplant recipients—most notably, graft loss,” according to the researchers. Approximately two-thirds of transplant recipients experience drug-related problems, which contribute to potentially avoidable hospitalization in about 12% of these patients.

Compounding the problems, nearly two-thirds of veteran transplant recipients receive care from both VA providers and those in Medicare or private insurance networks, leading to uncoordinated care. These dual users have a greater risk of having duplicative testing, omissions in care and medication discrepancies, according to the authors.

The VA Improving Transplant Medication Safety through a Technology and Pharmacist Intervention study is exploring use of a dashboard system to reduce medication errors, adverse drug events and nonadherence and improve health outcomes compared to the usual care veterans receive following a transplant. The researchers have closed enrollment, having reached 1,900 veterans at 10 sites. They are now six months into the two-year study.

The goal of the study is to evaluate the effectiveness of a technology-enabled system featuring a dashboard that runs queries nightly. The system identifies veterans receiving care through the VA who have had transplants, then checks for any safety alerts such as lab results outside the normal thresholds, potential drug:drug interactions, change of dose in a drug that interacts with another they are taking, or non-adherence, as indicated by failure to fill a prescription or medication refills that have expired, Taber said.

The system also will flag the record of a patient who is due for lab testing but has not had any reported results. “If a patient hasn’t had labs done within the VA system in quite a while, say, six months or so, the pharmacist may reach out. If the labwork was done outside the VA, they can enter the results manually,” Taber said. Sometimes apparent nonadherence also may indicate that a veteran is getting some care outside the VA and updating the medication information can avoid medication errors, he noted.

“The system updates each night. The pharmacist can log in in the morning to see updated information. It’s a pragmatic study that enables pharmacists to incorporate use of the dashboard into their daily workflow. We wanted to make it as interactive and adaptive as possible,” Taber said.

“Pharmacists can click on an alert, get more information, then do their normal work, then contact a patient, provider or transplant center or all three. They could alter therapy, change a dose or put a plan in place to bring in a patient through usual clinical care,” he added.

Taber said he hopes the research will raise awareness that veterans who have had organ transplants are at high risk for medication-related events and help develop a solution for managing the complexity of the issues associated with dual use.

Ideally, the study will enable the VA to “provide tools to pharmacists to better monitor patients efficiently before issues impact clinical outcomes,” Taber said. “The goal is to prove this is an effective and efficient system and then disseminate it across the whole country to provide better care to these vulnerable veterans.”

  1. Hall CL, Fominaya CE, Gebregziabher M, Milfred-LaForest SK, Rife KM, Taber DJ. Improving Transplant Medication Safety Through a Technology and Pharmacist Intervention (ISTEP): Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc. 2019;8(10):e13821. Published 2019 Oct 1. doi:10.2196/13821