When thinking of an organ transplantation procedure, what comes to mind? Is it a visceral image of blue-gowned surgeons huddled over a brightly lit operating table, performing impossibly complex and intricate surgery? You’re not wrong. But did you also know there is an extensive team of multidisciplinary healthcare professionals co-ordinating to ensure that any solid-organ, tissue, or blood that is transplanted or transfused is matched from donor to recipient, that it isn’t rejected, and that the patients involved are well informed and mentally prepared for such a procedure.
A pharmacist is one such professional that is vital in this process, and we ask Dr. Ravina Barrett, Senior Lecturer in Pharmacy at the University of Brighton, exactly what the role entails and where in the process a pharmacist might become involved.
Are there areas of specialism within transplantation pharmacy, or will the same pharmacist stay with an organ recipient from beginning to end?
No, there will be more than one pharmacist dependent upon the specific case. Using renal transplantation as an example, the duty pharmacist would usually be a specialist in renal care. During a hospital stay within the NHS, there are different bandings of pharmacists; a band 8 consultant devises the overall patient treatment plan and prescription, and a band 7 specialist will check the patient’s charts each day and perform the more direct patient care.
Once a transplant patient is discharged, a community pharmacist will be given the prescription list and use their professional judgement if there is something they think the hospital pharmacist needs to know, such as any adverse reactions or any conflicting over-the-counter bought herbal preparations, that may interact with the prescribed medication.
At what stage does a pharmacist come into the organ transplantation process, and what type of work and medications are involved?
A pharmacist will be involved with all stages of the transplantation pathway; before, during and after the procedure, and in the long term. The types of medications prescribed will be carefully balanced and unique in each case, and the pharmacist will take a holistic view of each case individually, considering factors such as the patient’s age, any existing morbidities and subsequent medicine taken, any bacterial or fungal infections, the carefully monitored response of the patient’s immune system, and any future family planning needs, to name but a few. You need to think about it not only from a drugs and planning perspective, but also from an emotional perspective of a person, will they cope with the stress of all the monitoring and the clinic visits? Due to long waiting times for transplants, unfortunately some older patients die waiting for an organ, so it is sometimes worth considering and discussing other options such as palliative care.
Another factor considered by the pharmacist is the bioavailability of anti-rejection drugs, as this varies between different brand and formulation. For example, the absorption rate of a liquid is much higher and gets into the system much faster than a solid capsule or tablet, so this too will be tailored to each patient.
The role of a transplant pharmacist is extremely dynamic as there is an on-going counterbalance between immunosuppressants, other medications and patient response. Dr. Barrett explains how sometimes pharmacists change course halfway through treatment plan to accommodate for something that may not have been anticipated.
There is clearly a very carefully thought-out drug repertoire for each transplant patient, how is this managed and are there problems in terms of patient adherence?
During a hospital stay, the pharmacist will be working closely with the various pathology laboratories so that a patient’s treatment can be managed, and any medications can be tweaked. For example, haematology will provide data on how the patient’s immune system is doing, microbiology will establish any culture sensitivities so that the correct antibiotic can be prescribed, if needed, and the histocompatibility & immunogenetics laboratory will help match any solid organ between donor/recipient, the pharmacist tailoring the immunosuppressants and all other medications based on these results.
When the patient is discharged from hospital, it’s vital they have enough support and education to recognise any problems themselves so they can self-care, and it’s the hospital pharmacist’s job to provide this information and support. A community pharmacist will now dispense medications and be the main point of contact for the patient until their next hospital appointment.
Usually, only one week’s supply of drugs is given initially, and the patient is invited back to see the hospital pharmacist so that any side effects or problems can be reported. After this, and dependent on where the patient lives, prescriptions are normally dispensed monthly by arrangement with a local community pharmacy provider that delivers directly to their home. This continuity of care is absolutely essential so that people continue with their drug therapy.
Transplant patients are usually very good at drug compliance as they have gone through a lot in order to get a donated organ and are extremely committed to the process that gives them a new lease of life. To be a good candidate for a transplantation, patients can’t have the types of problems so common in ill health, such as obesity or hypertension, so they are generally aware of looking after themselves, and very much invested in their health. That personal thing that goes on in their head is so powerful, you really can’t underestimate it.
Do you have any advice for any undergraduates wanting to specialise as a transplant pharmacist?
Go and get experience of working in a hospital, see if that’s OK with you, because that is a huge learning curve in itself. Then, go and work in the specialist area you are interested in, for example with the renal team. They’re crying out for specialist renal pharmacists across the country because of the level of complexity involved in the job. This is not your average pharmacist role dealing with patients on a cardiology ward, this is not your pregnancy and breastfeeding, this is not rheumatoid arthritis or surgery, these are complex, multidimensional cases. Emotionally it can be a learning curve as well, and you need to make sure how you feel about that before you go and make your decision.