Introduction: Drug therapy problem (DTP) is an undesirable event experienced by a patient that involves drug therapy, interferes with achieving goals of therapy and requires professional judgement to resolve. Providing a medication management service, a pharmacist can ensure that all medications are the most appropriate and effective, the safest possible and taken as intended (1).The aim of this research was to determine the prevalence of DTPs, interventions of clinical pharmacist and follow-up which includes clinical outcomes.

Patients and Methods: We included 150 patients in the research, of which 57 patients were in HTx (heart transplant) group, 19 in LVAD (left ventricular assist device) group, 64 in CMP (cardiomyopathy) group and 10 were classified as Others. At the initial assessment patients, DTPs were grouped into 4 categories: indication, effectiveness, safety and adherence. Follow-up was conducted on next following visit. Clinical parameters and number of hospital admission were assessed at the baseline and following visits for all patients, while parameters such as international normalized ratio or tacrolimus concentration were appointed to specific group of patients.

Results: On average, patients were 57 years old, majority were men (80.00%). The number of prescribed medications was 1734 with an average of 11.5 per patient. Analysis revealed 484 DTP and their distribution overall and among 4 patient groups is shown in Table 1. In HTx group most frequent intervention included immunosuppressants; 85.96% had immunosuppressant values within the therapeutic levels range, compared to 61.40% prior intervention. In the CMP group 82.70% patients had 4 pillars of heart failure therapy at baseline, compared to 89.13% after follow-up. Details about target doses are shown in Table 2. High percentage of four pillars is not surprising considering that prescribers are adopting a guideline-directed medical therapy for heart failure with reduced ejection fraction. Achieving target doses of medications was limited by symptomatic hypotension and bradycardia, renal impairment and hyperkalemia. Long-term anticoagulation with warfarin is required after LVAD implantation; 68.42% patients in LVAD group were in the INR range comparable to 89.00% after follow-up. According to the percentage of drug interactions, the narrow therapeutic width of warfarin is predisposing factor for clinically significant interactions.

Conclusion: As a part of multidisciplinary team, clinical pharmacists have essential role in identifying and resolving DTPs, simplifying complex regimens and providing individualized education thus ensuring patient safety and having positive impact on clinical outcomes.