Purpose: Tacrolimus (TAC) is the most frequently used immunosuppressant in the USA today, with a narrow therapeutic index that requires frequent 12-hour trough monitoring and dose adjustments. Randomly drawn TAC levels are of little value outside of one specific indication – confirming non-adherence in the setting of suspected rejection. Cost of TAC trough analysis can range between $250-450 per level. Earlier study of emergency department (ED) visits established that transplants patients average one ED visit per year. Purpose of this study is to characterize TAC levels in the ED in terms of timing and cost implications.

Methods: Retrospective chart review of all TAC levels ordered/completed in the ED from January 2010 to December 2014. As previously described, appropriately drawn TAC levels were defined as 2 hours +/- anticipated 12-hour trough (7AM-11AM or 7PM-11PM). Data collected included patient demographics, transplant information, time since last clinic follow up, TAC level and timing during ED visit.

Results: Query of the electronic medical records revealed that 107 levels were drawn in the ED during the study period. According to the definition, 61 (56%) levels were drawn inappropriately, outside the desired time range. Moreover, 4 (3.7%) patients had undetectable TAC levels and were not currently taking TAC. Patients with inappropriately drawn TAC levels averaged 36 days since last clinic visit – all with TAC levels drawn during that visit. Most patients were in ED for gastrointestinal problems, dehydration and urinary tract infections. No patient was seen in ED with suspected acute rejection due to non-adherence.

Conclusion: Considerable cost associated with TAC level analysis warrants careful temporal consideration. The random levels in ED are often futile and result in repeat true trough in case of admission – doubling the cost of analysis. Increasing ED and transplant staff education may result in considerable cost saving

CITATION INFORMATION: Lee B, Jain D, Campara M. Are Random Tacrolimus Levels in the Emergency Department Costing You Money? Am J Transplant. 2016;16 (suppl 3).

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