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Key Toxicities to Watch as a clinical pharmacist: Renal: nephrotoxicity, rising creatinine Neuro: tremors,confusion, seizures Metabolic: hypertension, QT prolongation, hyperglycemia Electrolytes: K, Mg Heres how we intervene before toxicity takes over: Slash Tacrolimus doses by ~70% when starting Posaconazole TDM every 23 days (dont wait for trouble) Monitor renal function, BP, electrolytes, glucose closely Anticipate the reverse interaction when Posaconazole is stopped tacrolimus levels crash without timely adjustment Key Insight: Pharmacists arent just dose adjusters. We are the safety net that spots silent drugdrug collisions before they harm patients

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