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:
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
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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