Pharmacist monitoring of drug therapy in patients with abnormal serum creatinine levels.

Because of possibly drug-related adverse events that occurred in renal patients, a program was developed to routinely monitor renal patients to ensure that all prescribed drugs and dosages conformed to standard clearance-adjusted regimens. Summary laboratory reports were surveyed daily, patients with abnormally elevated serum creatinine values were noted, and reviews of patients' medication profiles and orders were performed at least daily. The pharmacist was made responsible for judging if renally-eliminated drugs were used appropriately. If the pharmacist deemed that a change was needed, the prescribing physician was contacted by telephone or in person. From January 1990 through December 1992, a total of 627 patients with renal impairment were monitored. Among these patients, 233 changes in drug therapy were implemented as a direct result of pharmacist assessment and subsequent physician contact. The most common changes were dosage decreases. Medications requiring changes most often were antimicrobial agents, accounting for 55% of all interventions. A retrospective assessment of interventional efficacy, performed through focused evaluation of 20 randomly selected cases, revealed no direct evidence of either therapeutic failure or drug toxicity in patients for whom pharmacist-directed changes were made. Pharmacist monitoring can have a beneficial influence on the care of renal patients.