Partnering with a Renal Pharmacy
Chronic kidney disease (CKD) clinical care teams are redesigning coordinated services to meet the continuous and complex needs of this special patient population. Medication-related problems due to complex medication regimens and multiple comorbid disease states create substantial burdens in delivering patient-centered CKD care. Pharmacists focused on renal disease are being utilized to support a multitude of services, from medication reconciliation to comprehensive medication review for high-risk CKD patients. Partnerships with pharmacies or pharmacists who specialize in renal disease offer innovative support to multidisciplinary healthcare teams and are gaining new attention with promising outcomes.
Patients with CKD have clinical challenges and gaps in medication-related care that place them at increased risk of mortality, hospitalization, and cardiovascular events compared to patients without CKD. Condition and care needs are routinely changing, resulting in frequent care transitions that leave patients susceptible to adverse events and unfavorable health outcomes. As kidney disease progresses, secondary complications such as hyperphosphatemia, anemia, secondary hyperparathyroidism, and cardiovascular disease often develop, further complicating treatment plans. Pill burden and polypharmacy are well-documented problems in CKD, with dialysis patients taking an average of 10–12 medications entailing 19 pills per day from four to five different prescribers.1-2 Combined, these factors may lead to unintended medication-related problems (MRPs) that compromise therapeutic goals.
An MRP is an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes.3 There are several categories of MRPs, with significance ranging from poor medication adherence to life-threatening adverse drug events. The incidence of MRPs increases as CKD progresses and is estimated at about four MRPs per patient upon initial evaluation by a pharmacist.2 A common MRP is drug accumulation and toxicity for drugs dependent on renal elimination. For example, a patient with CKD receiving high-dose gabapentin or a high-dose oral hypoglycemic agent is at risk for an MRP. These supratherapeutic doses may cause sedation and dizziness leading to a fall or life-threatening hypoglycemia, each resulting in preventable healthcare utilization (e.g., emergency room visit, hospitalization, urgent care, etc.).
Drug dialyzability, or drug removal due to dialysis, is an important consideration in end stage renal disease (ESRD) patient care. Many drugs require dosage adjustment, supplemental dosing, or alternative timing of administration, while others should be avoided altogether due to dialytic clearance. Another important consideration is that standard treatment guidelines may not apply directly to the ESRD population, as many clinical trials that influence guideline recommendations often exclude patients with ESRD. Pharmacists trained in the pharmacology of CKD and ESRD understand the many deviations from standard treatment in the general population.
Several studies have evaluated the benefit of partnering with pharmacists who specialize in renal disease to combat MRPs. Intervention by pharmacists who specialize in renal disease has shown to be effective in reducing MRPs in CKD and ESRD, with benefits in therapeutic and financial outcomes.4-9 Potential therapeutic benefits include prevention of acute kidney injury (AKI), delayed progression of CKD, cost savings, reduced morbidity and mortality, and improved medication adherence.4-9 In addition to improving therapeutic and financial outcomes, pharmacists are positioned to articulate patient preferences in medication-related decisions and are sensitive to the social, economic, and physical implications of CKD and ESRD.
Medication management services offered in partnership with pharmacist who specialize in renal disease present an important opportunity to bridge medication gaps and improve patient-centered care for those with CKD.
| PHARMACY MEDICATION THERAPY MANAGEMENT SERVICESa | DEFINITION | CLINICAL APPLICATIONS |
| Comprehensive medication review10 | A systematic process collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with the patient, caregiver, and/or prescriber. Performed by pharmacist. |
May be focused on high-risk groups:
Interventions may include:
|
Collaborative practice agreement11 |
Legal document that creates formal relationships between pharmacists and physicians or other providers. Collaborative practice agreements define certain patient care functions that a pharmacist can autonomously provide under specified situations and conditions. |
May include:
|
Medication reconciliation |
The process of creating the most accurate list possible of all medications a patient is taking—including drug name, dosage, frequency, and route. May be conducted by a pharmacist or pharmacy technician. |
Performed at each care transition or at a recurring interval. |
| Targeted medication review | Medication-specific review or consultation based on claims or electronic health record. |
Often based on high-risk or contraindicated medication(s). May include:
|
aDefinitions of medication therapy management or medication management services may vary based on determinations made by the Centers for Medicare & Medicaid Services, payors, professional pharmacy organizations, and others. |
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References
- St. Peter WL. Management of Polypharmacy in Dialysis Patients. Semin Dial 2015;28:427-432.
- Manley HJ, Cannella CA, Bailie GR, St. Peter WL. Medication-related problems in ambulatory hemodialysis patients: a pooled analysis. Am J Kidney Dis 2005;46:669-680.
- Helper CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533-543.
- Salgado TM, Moles R, Benrimoj SI, Fernandez-Llimos F. Pharmacists' interventions in the management of patients with chronic kidney disease: a systematic review. Nephrol Dial Transplant 2012;27:276-292.
- Lalonde L, Normandeau M, Lamarre D, et al. Evaluation of a training and communication-network nephrology program for community pharmacists. Pharm World Sci 2008;30(6):924-33.
- Quintana-Bárcena P, Lord A, Lizotte A, Berbiche D, Lalonde L. Prevalence and management of drug-related problems in chronic kidney disease patients by severity level: a subanalysis of a cluster randomized controlled trial in community pharmacies. J Manag Care Spec Pharm 2018;24(2):173-181.
- Jang SM, Cerulli J, Grabe DW, et al. NSAID-avoidance education in community pharmacies for patients at high risk for acute kidney injury, upstate New York, 2011. Prev Chronic Dis 2014;11:E220.
- Pai AB. Keeping kidneys safe: the pharmacist's role in NSAID avoidance in high-risk patients. J Am Pharm Assoc 2015;55:e15-23.
- Burnier M, Pruijm M, Wuerzner G, et al. Drug adherence in chronic kidney diseases and dialysis. Nephrol Dial Transplant 2015;30(1):39-44.
- Centers for Medicare & Medicaid services. CY 2019 Medication Therapy Management Program Guidance and Submission Instructions. 2018. Accessed June 7, 2019: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Memo-Contract-Year-2019-Medication-Therapy-Management-MTM-Program-Submission-v-040618.pdf
- APhA Foundation. Collaborative Practice Agreements (CPA) and Pharmacists’ Patient Care Services. Accessed June 7, 2019: https://www.aphafoundation.org/collaborative-practice-agreements.
