Although patient characteristics and types of solid organs vary, and resources differ between centres, this document aims to outline the general scope of activities that HPs can perform in the SOT process.

The SOT care process comprises 3 main stages: the pretransplant stage (from inclusion on the waiting list to surgery), the perioperative stage (from surgery to hospital discharge), and the posttransplant stage, which includes follow-up in outpatient clinics.

The FarmaTrasplante group recommends that HPs participate in the SOT process, adding value to the care team through fundamental activities spanning all stages of the transplant process, essential tasks specific to each stage of recipient care, and the management of particular patient populations.

To carry out all the functions described below, HPs should have specialised training15,16 and a proactive and innovative attitude. Their inclusion in multidisciplinary teams should be facilitated to ensure recipients receive appropriate, comprehensive pharmaceutical care.

To ensure continuity of care and a comprehensive approach for patients, it is important to emphasise that all functions conducted by HPs within the scope of SOT should be coordinated with the other healthcare professionals involved in the transplant process.

The following functions stand out among those that span all stages in which HPs may participate (Fig. 1).

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  Medication management and pharmacotherapy optimisation: HPs should participate in reviewing, assessing, and optimising pharmacotherapy at all stages of the SOT process, including identifying changes in pharmacotherapy, reconciling medicines, managing adverse effects and drug interactions, simplifying treatment regimens, and handling hazardous medicines under special conditions.

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  Periodic long-term pharmacokinetic and pharmacodynamic monitoring: given the narrow therapeutic margin of immunosuppressants and the high potential for drug interactions, HPs, as specialists and experts in therapeutics, should participate in selecting and adjusting the immunosuppressive regimen. This activity should be based on an evaluation of the pharmacodynamic response, alongside pharmacokinetic behaviour and pharmacogenetic analysis.

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  Management of adherence to pharmacological and non-pharmacological treatment: in coordination with the transplant teams, HPs contribute to the optimal monitoring, assessment, counselling, and comprehensive management of treatment adherence, including designing innovative intervention programmes. These aspects are crucial for ensuring the appropriate management of patients both before and after transplantation.

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  Management of comorbidities: HPs must participate in multidisciplinary teams to assess comorbidities, monitor and review therapy alongside therapeutic adherence, adjust therapy as required, and develop prevention programmes. Hospital pharmacists should conduct individualised interviews to collect the relevant clinical data.

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  Continuing education for patients and carers/family members: educating transplant patients is a fundamental pillar of their care, requiring ongoing and continuous efforts. The participation of HPs in this process is highly valuable, particularly in providing comprehensive patient education on treatment and adherence, healthy lifestyle habits, and hygiene and dietary measures (Table 1). Furthermore, HPs must have training in behavioural techniques (such as motivational interviewing) to enhance patient engagement (Fig. 2).

  Table 1.

  Healthy lifestyle habits, hygiene measures, and dietary guidelines that multidisciplinary teams can recommend to transplant patients, which can be reinforced by HPs.

  Healthy lifestyle habits	A relaxed lifestyleRegular monitoring of body temperature, weight, and blood pressure. Periodic laboratory testsExercise tailored to the clinical situationRegular use of a maskaLimit exposure to direct sunlight
  Hygiene practices	Strict adherence to personal hygiene measures, including showering, handwashing, and oral hygieneMaintenance of hygiene in the patients' environmentStrict disinfection measures should be implemented if wounds or sores appear
  Dietary measures	Provide a varied diet tailored to the patient's individual situationAvoid obesityLimit salt and fat intakeAvoid raw foods, alcohol, and stimulant beveragesEat foods aligned with the Mediterranean diet

  Source: Own compilation based on Monte Boquet (2020).

  a

  When this document was written, it was thought that immunocompromised patients would benefit from wearing a face mask. This recommendation should be adjusted to the type of organ, patients' clinical conditions, or current institutional guidelines.
  
  

  Figure 2.

  Principles of motivational interviewing.

  Source: own work based on Huarte, J. (2013).
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  Care transitions: HPs should participate in medicine reconciliation at all care transitions, particularly when moving patients from medical/surgical intensive care units to wards, on hospital admission and discharge, during interhospital transfers, and in collaboration with the community pharmacy. Hospital pharmacists can add value to the care team and patients by preventing adverse medication-related outcomes, optimising treatment, and ensuring continuity of pharmaceutical care once patients return home.

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  Monitoring, developing, and reviewing protocols: HPs must be able to interpret and manage hospital protocols related to transplantation. They should also proactively identify needs and opportunities to improve existing protocols and participate in the development of SOT-related protocols whenever practicable.

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  Research and clinical trials: HPs should participate in this area to enhance the development of pharmacological and clinical research and to support its integration into the SOT team.

Figure 1.

Key roles in which hospital pharmacists may participate in the care pathway of solid organ transplant patients.

During the pretransplant stage, HPs should participate actively with the multidisciplinary team in reviewing patients' pharmacotherapy, including the objective assessment of pharmacological risk and adherence behaviour. The HPs should also contribute to the non-pharmacological assessment, evaluating personal and socio-economic factors and identifying risk factors for non-adherence, both pharmacological and non-pharmacological. Finally, HPs should support the development of a risk management plan, based on a comprehensive review of the medical history and data collected from an individualised interview (Fig. 1).

Hospital pharmacists provide support during the perioperative stage, delivering pharmaceutical care from the early stages of the transplant process onwards. Thus, their involvement in comprehensive pharmacotherapy management and discharge planning is essential. It is recommended that HPs participate proactively in daily bedside rounds throughout patients' hospital stay. Furthermore, HPs should routinely participate in reviewing medicines, planning and managing access to medicines, and reinforcing education for patients and carers/family members (Fig. 1).

Access to medicines at discharge is considered a key factor in the transplant process.

Despite the presence of a National Health System with universal coverage, the involvement of HPs in multidisciplinary teams remains essential in Spain to assess potential barriers to accessing certain drugs and to provide information that facilitates this process. In countries such as the United States and the United Kingdom, HPs coordinate the initial supply of all necessary medicines at discharge. In these countries, delivering medicines directly to the patients' homes is a recognised clinical practice, as it provides an opportunity to educate patients and carers/families on correct use and reinforce knowledge of therapy management. Given that this practice is not widespread in Spain, HPs must take several considerations into account to ensure proper planning of medicine access at discharge:

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  Deliver medicines and explain to patients and carers the agreed treatment plan.

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  Identify potential challenges related to patients' financial contribution, and coordinate with social workers when necessary to explore potential solutions. Ideally, this assessment should be conducted during the pretransplant stage; consequently, at discharge, HPs must ensure that appropriate measures have been taken to address such challenges.

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  Identify needs and provide tools to improve treatment management and adherence:

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    Develop patient-managed systems for organising medicines using pill dispensers.

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    Utilise a personalised dosing system (PDS). These systems are useful for patients who have difficulties understanding their treatment regimen and lack the autonomy or ability to manage their dosing schedule. Hospital pharmacists should identify patients who could benefit from a PDS and coordinate with community pharmacists; in such cases, it would be helpful to provide the complete medication plan at discharge.

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    Promote the use of additional tools, such as mobile apps for tracking medicines and setting reminders.

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  Manage the roles in which hospital pharmacists may participate procurement of medicines at discharge:

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    Consider providing medicines to patients in advance. This aspect is particularly relevant when dispensing may be delayed, such as during weekend discharges, while awaiting approvals, or because patients have been referred from other autonomous communities.

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    In recent years, telepharmacy programmes have been developed to support home delivery of hospital medicines, accompanied by appropriate individualised pharmacotherapeutic monitoring for each patient. These programmes may benefit patients who have mobility issues, are at risk of social exclusion, or have difficulty adhering to treatment.

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    To streamline access to hospital-dispensed medicines, it is essential to ensure effective coordination with the outpatient unit responsible for their supply.

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    Hospital pharmacists must ensure that patients collect their medicines from the community pharmacy. To this end, medicines should be authorised in the electronic prescription system a few days before discharge to facilitate their collection.

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  Prior to discharge, inform patients and carers/family members about the medicines to be collected from the community pharmacy, those dispensed by the hospital pharmacy, and those that are not publicly funded or are subject to regulatory requirements, such as an inspection stamp.

During this stage, the multidisciplinary team should coordinate to provide patients with sufficient information to support adequate self-care after discharge. Thus, the HPs' role in educating patients and carers/family members is based on the following aspects:

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  Providing information on medicines, including the prescribed treatment regimen, potential adverse effects, interactions with other medicines, and dosing schedule, in coordination with the multidisciplinary team. Hospital pharmacists must have various tools, such as pill dispensers and PDSs, to ensure that patients possess the knowledge and skills required to manage their treatment regimen correctly at discharge.

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  Providing patients with information on the transplant stages and care pathway, with particular emphasis on explaining the post-discharge stage, managing expectations, the chronic nature of their condition, and the likelihood of polypharmacy.

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  Educating patients on the responsibilities associated with transplantation, such as reporting adverse effects and obtaining approval from the multidisciplinary transplant team before they start over-the-counter medicines, nutritional supplements, herbal remedies, or any other medicines prescribed by other physicians in an outpatient setting.

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  Assessing the patients' understanding of the information provided using validated scales. Whenever possible, HPs should participate in developing and administering a self-assessment questionnaire at discharge.

The FarmaTrasplante group recommends that HPs participate in patient follow-up visits and in monitoring and reviewing patients' complete therapeutic regimens. Furthermore, HPs can support the pharmacotherapeutic management of key posttransplant complications, including organ rejection and infection prevention and treatment.

Organ rejection poses a risk to patients even when therapeutic management and treatment adherence are optimal. Depending on the histopathological characteristics of the organ and time course, organ rejection is classically divided into 3 types: hyperacute, acute, and chronic. Each type requires the transplant team to provide individualised pharmacological management. In this context, HPs can assist with the pharmacological management of rejection. Hence, they must train to acquire the necessary knowledge of the specific complications associated with each type of organ and stay abreast of advances in the mechanisms of organ rejection. In this way, HPs can: (a) develop protocols for pharmacological management of rejection; (b) lead administration protocols for biological medicines (high-cost and potentially toxic) in transplant patients with immune-mediated complications requiring these treatments; and (c) help identify rejection by detecting symptoms or monitoring patients serologically for donor-specific human leucocyte antigen antibodies.

Although rejection is a major complication following transplantation, the development of increasingly potent immunosuppressants has improved its control. However, intensive immunosuppression carries a risk of infectious complications and the development of neoplasms. The risk of infection changes over the course of the posttransplant period and is particularly associated with changes in the immunosuppression regimen and dosage. Strategies for preventing infectious diseases are based on exposure risk, donor and recipient serology, epidemiological history, and the time since transplantation. Depending on exposure, infections are categorised as donor-derived, recipient-derived, nosocomial, and community-acquired. Transplant HPs can add value to the multidisciplinary approach to preventing and treating infectious diseases after transplantation. Hospital pharmacists can collaborate with multidisciplinary teams on infectious disease management through the following activities, among others: reviewing pretransplant immunisation status and implementing posttransplant vaccination recommendations; screening for colonisation with multidrug-resistant microorganisms; detecting antimicrobial allergies and intolerances; reconciling treatments during care transitions; developing prophylaxis and treatment protocols and monitoring adherence; assisting with antimicrobial selection, dosing, dose adjustment, and monitoring; reviewing and managing interactions between antimicrobials and immunosuppressive therapy; educating patients on treatment; assessing adherence, particularly during readmissions; and participating in quality improvement, evaluation of antimicrobial use, and clinical research.

Furthermore, the implementation of telemedicine care models in transplant centres in Spain should be promoted, given that telepharmacy tools can improve the individualised and comprehensive follow-up of posttransplant outpatients (Fig. 1).

Certain populations may face additional risks during the SOT process, including paediatric and elderly patients, women of childbearing age wishing to conceive, and patients with multiple comorbidities or taking multiple medicines. These patients require more comprehensive and individualised pharmacotherapy monitoring by the multidisciplinary team, with support for HP involvement (Fig. 1). Table 2 shows these activities, classified as either essential or complementary.