Evaluation of transplant pharmacist-led post-transplant hyperglycemia service

Introduction

Uncontrolled post-transplant hyperglycemia (PTHG) can result in post-transplant diabetes mellitus (PTDM), therefore strict control of PTHG is warranted. PTDM affects 10%–40% of transplant recipients and increases morbidity and mortality. The objective of this study was to determine if pharmacy-led management of PTHG through a collaborative practice agreement (CPA) improves glycemic control.

Methods

Retrospective review of adults ≥18 years who received a kidney or liver–kidney transplant between January 2014 and December 2015 and April 2021 and October2022 in the pre- and post-CPA groups, respectively. Inclusion criteria were patients started on any anti-hyperglycemic agent within 1 month of transplant with 12 months of follow-up. Patients with type 1 diabetes mellitus, an insulin pump, other organ transplants, or treatment with high-dose corticosteroids for rejection were excluded.

The primary outcome was a composite of hospitalizations and emergency department (ED) visits within 6 months of transplant due to PTHG. Secondary outcomes included hemoglobin A1c (HgbA1c) <7% and discontinuation of insulin at 6- and 12-month post-transplant, and time to first documented ambulatory PTHG assessment. Data were reported with descriptive statistics.

Results

Fifty-one and 53 patients in the pre- and post-CPA groups were included, respectively. Transplant pharmacists followed all patients in the post-CPA group.

The primary outcome occurred in three patients (5.9%) in the pre- and no patients in the post-CPA groups (p = 0.083), respectively. More patients in the post-CPA group achieved a HgbA1c <7% at 6 months (31.7% vs. 68.1%; p = 0.007) and 12 months (22.7% vs. 58.3%; p = 0.004) using the last HgbA1c carried forward. More patients in the post-CPA group discontinued insulin at 12 months (7.1% vs. 30%; p = 0.02) and all anti-hyperglycemic agents by 6 months (2% vs. 15.1%; p = 0.02).

Conclusion

The transplant pharmacy-led service increased access to care, numerically reduced hospitalizations and ED visits due to PTHG, achieved more HgbA1c <7%, and had less insulin use at 6- and 12-month post-transplant.