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There was a real buzz after the pharmacy symposium at the International Society of Heart and Lung Transplant (ISHLT) annual conference this year in Montreal, with the audience and speakers breaking into groups to discuss aspects of the challenging real life case that had been presented as part of the Pharmacy and Pharmacology council's ‘Lifecycle Journey’ series. This series uses a developing case to create a panel-facilitated and audience-supported best practice-based discussion at predefined key ‘journey intervals.’ This year the session was titled: A Lifecycle Journey in Cystic Fibrosis and Lung Transplantation. In this session, members of the Pharmacy and Pharmacology and the Pulmonary Transplantation Councils focused on four ‘journey points,’ which include: (1) listing considerations and pretransplant infections, (2) perioperative and immediate postoperative management issues, (3) metabolic and interaction considerations to drug dosing and (4) immunomodulation strategies for the management of bronchiolitis obliterans syndrome. The first journey point proved thought-provoking, hearing the expert panel of pharmacists and physicians discuss their practice in managing a complex patient with resistant infections in order to ensure that the patient was in optimal condition at transplant. Unfortunately, need for suppression of Burkholderia cepacia complex and Mycobacterium abscessus prior to transplant is becoming all too common. The participants had a lively discussion about antibiotic strategies, and the role of the pharmacist in balancing toxicity and efficacy was clearly evident.
The second journey point addressed the challenging postoperative management of the patient post transplant, focusing on the difficult balance between immunosuppression and the risk of sepsis. The expert panel provided consensus that the high risk of death from sepsis immediately postop requires an individualised antibiotic cocktail for success.
Having successfully negotiated the lung transplant, the patient's case moved to a third journey point, the post-transplant outpatient clinic and a scenario that transplant pharmacists are extremely familiar with—subtherapeutic tacrolimus levels. Ms Haifa Lyster, a transplant pharmacist from the Royal Brompton Hospital in London, elegantly guided us through the myriad of possible explanations for subtherapeutic tacrolimus levels. This situation is one which pharmacists are often asked to explain and solve. She discussed food/medication and medications/medication interactions, gut dysmotility, constipation, poor absorption and, of course, compliance.
The fourth and final journey point tapped into the expertise of Professor Peter Hopkins from Brisbane who discussed the nomenclature and the current strategies to treat bronchiolitis obliterans syndrome. The optimum strategy is currently unknown but current approaches include azithromycin, doxycycline, total lymphoid irradiation and photophoresis, depending on local centre preferences.
Practice research by pharmacists
Pharmacist research at the meeting was robust with plenty to interest the pharmacist. Studies from the USA and from Newcastle in the UK highlighted the risks of mycophenolate in pregnancy and the importance of preconception care in transplant patients. Pharmacists were very well represented among presenters, particularly in the area of immunosuppression. Interesting research by Dr J L Stuckey, a pharmacist from the USA, showed higher-than-expected pulmonary toxicity with use of sirolimus, highlighting the difficulty of using this agent, and Dr J A Iuppa bravely presented her centre's very poor experience with the use of proteasome inhibitors for antibody-mediated rejection following lung transplant. The importance of the pharmacist's input was also demonstrated by research from Tel Aviv showing that chronic renal failure following lung transplant is directly predicted by the number of times that tacrolimus levels are above 20 ng/dL. Dr J-B Woillard from the University Hospital Limoges, France presented very interesting work about the variability of mycophenolic acid exposure in heart transplant recipients. He has developed a web tool to help professionals clarify the pharmacokinetic exposure of this widely used and poorly understood drug.
The ISHLT also encompasses practice in artificial hearts and ventricular assist devices (VAD), an area where pharmacists are making their mark and adding to the literature particularly in the area of coagulation management, which is increasingly recognised as the key to patient survival. Dr Alexa Schmitt presented data showing that patients on VAD had international normalised ratios in the target range only 51% of the time. Dr Mary Bradbury presented a small patient cohort treated with eptifibatide for VAD thrombosis after failure of warfarin. Approximately 50% of the patients had a successful outcome but unfortunately no predictors of success were elucidated.
An ISHLT and thoracic professionals
The ISHLT represents professionals practising in all areas of thoracic medicine and pharmacy, encompassing the fields of heart and lung transplantation, end-stage heart and lung disease, and related sciences. Many of these areas of practice are very young and small specialities with no established gold standard approach for many of the aspects of care. This can make the pharmacist's role challenging in finding evidence on which to base practice and solve complex individual patient problems. It was evident that the pharmacist's skills in diabetes management, antimicrobial use and patient education as well as the obvious skills in detecting and managing drug interactions were valued by the multidisciplinary international audience.
This meeting was the culmination of an exciting first year for the Pharmacy and Pharmacology council, which will soon launch a competency statement designed to highlight the skills and abilities that pharmacists practising in thoracic transplantation should be held accountable for at an international level. It will provide our medical colleagues with a greater understanding of our role or potential roles in patient care. Speaking at the pharmacy and pharmacology council meeting, the incoming council chair spoke of his desire to grow the group internationally, to develop communications between all pharmacists working in heart and lung transplantation, mechanical heart support and pulmonary hypertension so that all members can be a resource for each other.
The esteem in which pharmacists are held by their medical and surgical colleagues, particularly for their knowledge in immunosuppression and antibody management, was evident throughout the congress. The upcoming competency statement for pharmacists working in thoracic transplant is likely to increase the demand from clinicians for pharmacists to become involved in this specialism in Europe. This provides a real opportunity for pharmacists to develop clinical roles in a rewarding and challenging field of practice.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.