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Published on 11 August 2010

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Top tips checklist launched for immunosuppressant prescribing


A new checklist has been launched today to help pharmacists dispensing immunosuppressants for transplant patients.

The checklist, launched by Astellas Pharma Ltd, has been developed in consultation with Jane Moffatt, Head of Medicines Management, Brighton & Hove PCT.

It is hoped that the checklist will help to improve best practice in pharmacy dispensing and reduce the number of inadvertent prescribing and dispensing errors seen in the area of transplantation.

The checklist has been launched as a result of ongoing prescribing and dispensing errors for patients receiving tacrolimus – an immunosuppressant with a narrow therapeutic index, given orally to prevent or treat organ transplant rejection. Tacrolimus is currently available in three different formulations – these formulations are not interchangeable5.  These reported errors have led to significant consequences for patients, including increased drug levels and cases of acute rejection of the transplanted organ.

By December 2008, the MHRA had received 55 case reports in seven EU countries, mostly from the UK, involving prescribing/dispensing errors in association with oral tacrolimus. These included: Six cases of prescribing errors by hospital doctor or GP, forty-one cases of dispensing errors by pharmacist related to generic or brand prescribing, and eight cases of administration errors by doctor, nurse or patient6.  These inadvertent medication errors for transplant patients continue to occur in the UK, and remain an ongoing source of concern.

The checklist calls for pharmacists to:

  • Check to identify whether prescriptions for tacrolimus are clearly written with the formulation or brand specified along with clear guidance on dosing frequency
  • Call the patient’s GP or pharmacist from the transplantation unit to clarify which formulation or brand should be prescribed if this is not clear from the prescription.  This is particularly important as different formulations are not interchangeable
  • Ask the patient which formulation/brand they are usually prescribed and ask them to check that this is the formulation/brand that they receive when collecting from their pharmacist

Jane Moffatt, Head of Medicines Management, Brighton & Hove PCT commented: “It is essential that we work together to do all that we can to prevent inadvertent prescribing and dispensing errors from occurring. From the case reports seen to date, we know that pharmacists may find themselves in situations where prescriptions have not been clearly written or simply state ‘tacrolimus’ – despite there being different formulations which are not interchangeable.

The pharmacist has a key role to play in contacting the GP when prescriptions are received that do not clearly state the formulation or brand of oral tacrolimus with clear guidance on dosing frequency. In addition, calling the transplantation unit pharmacist and checking with the patient will help to eliminate the significant consequences that have been reported and help to protect our transplant patients. I would urge every pharmacist to familiarise themselves with this simple checklist, and adhere to these steps to ensure they are doing the best for their transplant patients.”

There are over 22,000 patients in the UK receiving immunosuppressant medicines after a kidney transplant.  Given the average waiting time for a kidney transplant in the UK is around 3 years for an adult, it is of absolute importance that all healthcare professionals and patients are aware of the potential serious consequences of any medication errors.

Speaking on behalf of the ESPRIT Group, an independent group of experts with the aim to ensure the continued, effective and safe treatment of transplant patients, Professor Atholl Johnston, a leading expert in pharmacokinetics from Barts and The London, Queen Mary’s School of Medicine and Dentistry, commented: “It is of paramount importance that pharmacists recognise the responsibility they have for the management of transplant patients, and are aware of the serious implications that an unintentional medicine change can have.  Checking that all prescriptions for immunosuppressant medicines are written by brand, and where necessary phoning the GP to check, will help to avoid these potentially fatal medication errors we have seen.”

Over 80% of immunosuppressants for transplant patients are repeat-prescribed in primary care after the patient has been accurately dosed and stabilised on their medicines in a secondary care setting by a transplant specialist.


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