Laboratory’s Role in Transplantation Success

May 2024 - Vol.13 No. 5 - Page #16
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Category: Laboratory Information Systems

This past April, the Institute for Safe Medication Practices (ISMP) issued a report on reducing medication errors in transplant recipients.1 Among the longstanding concerns involved with solid organ transplantation is the open-ended use of immunosuppressant agents necessary to combat transplant rejection and graft-versus-host disease, among other potential complications.

Immunosuppressive regimens generally consist of a combination of several agents from different therapeutic classes. A typical regimen example might comprise a calcineurin inhibitor, an anti-proliferative agent, and a corticosteroid. Given the vulnerability of transplant patients, it is essential to be aware that with as little as a two-fold change in blood concentrations with some of these agents, patients can experience toxicity or an episode of acute rejection.2

With these general concepts in mind, the laboratory plays a critical role in helping to maintain both the patient benefit and the financial stability of transplantation programs.

Impact of Narrow Therapeutic Index Drugs

As is common throughout healthcare, a tendency toward use of generic medication formulations has proliferated transplant medicine. Key to this tendency is the process of therapeutic drug monitoring (TDM), which may be common in some institutions for a variety of drug analytes, including antimicrobials, antiepileptics, and, per this discussion, immunosuppressive agents.

Immunosuppressants often have a narrow therapeutic index (NTI), meaning small differences in dose or blood concentration may lead to serious therapeutic failures or adverse drug reactions (ADRs). Dosages need to be individualized to the type of transplant, target blood concentration, body weight, drug-drug and drug-food interactions, and the risk of rejection or toxicity.1

For the laboratory running a TDM program for transplant patients, drug-drug interactions may be of particular concern given that NTI immunosuppressants are metabolized through common pathways. Thus, laboratory-involved operations related to specimen timing and transport play a vital role in this continuum of care.3

A Study of Medication-related Errors

ISMP analyzed 520 transplant medication-related errors reported to the ECRI and the Institute for Safe Medication Practices Patient Safety Organization (ECRI/ISMP PSO) between January 2020 and September 2023 to identify common themes and capture reports classified as mild or above, according to the Agency for Healthcare Research and Quality (AHRQ) harm scale. In 10% of these events, errors associated with coordination between laboratory specimen collection and dose administration were found to be contributing factors. Errors in this phase can lead to inaccurate laboratory values or results interpretations that contribute to inappropriate doses, and/or prolonged hospitalizations. See the SIDEBAR for an example complication provided by ISMP.1

ISMP goes on to make several recommendations to help improve care team collaboration for transplant success, including, but not limited, to the following:

  • Develop transplant order sets. Transplant medication order sets can help guide prescribers to select the appropriate immunosuppressant doses, routes, frequencies, and formulations in accordance with the patient’s clinical state. These order sets should include standard times for laboratory monitoring, including the timing for measuring target blood concentrations.
  • Incorporate clinical decision support. Dose range checking based on patient parameters, drug-drug and drug-disease interaction screening, and prescriber alerts for when laboratory results are out of range all help increase the efficacy of treatment.
  • Conduct interdisciplinary rounding. Per the recommendation of current laboratory leaders, inclusion of laboratory staff on clinical rounding teams can substantially improve the lab’s contribution as well as the patient experience.4 Daily review of immunosuppressant medication orders, laboratory monitoring (eg, trough level, dose adjustment based on level, etc), and assessment of side effects is also key.
  • Educate both practitioners and patients. As part of regular assessments, emphasize the risks associated with inappropriately timed laboratory levels, missed/duplicate doses, and wrong formulations, and continue to seek best case workflows. Likewise, educate patients on the benefits of proactive maintenance of current medications. This is particularly important during transitions in care.

Conclusion

As the number of patients receiving transplants has been increasing, hospitals must be prepared to address these nuances. Fortunately, there are numerous resources available to assist the laboratory and collaborative care teams in formulating a combined approach to perioperative care. As always, be sure to learn from mistakes and errors that arise in this complicated area of healthcare.


References

  1. Institute for Safe Medication Practices (ISMP). Guardians of grafts: reducing medication errors in transplant recipients. ISMP Medication Safety Alert! Acute Care. 2024;29(7):1-4.
  2. Tichy E, Morris G. Generic immunosuppressant use at a major transplant center. Pharm Purch Prod. Supplement. 2012;9(9):S2-S4.
  3. Hall CL, Fominaya CE, Gebregziabher M, et al. 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.
  4. Radke T. Advantages of Lab Participation in Clinical Rounds. MedLabMag. 2024;13(4):8-10.

David McCormick is managing editor at Ridgewood Medical Media, publisher of MedicalLab Management and Pharmacy Purchasing & Products. He can be reached at davidm@ridgewoodmedia.com.



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