Medication adherence and telehealth interventions after liver transplantation: A systematic review and meta-analysis

Medication adherence is critical to long-term graft and patient survival after liver transplantation (LT), yet the effectiveness of adherence-promoting interventions across the post-transplant survivorship continuum remains uncertain. We systematically reviewed interventions to improve medication adherence including immunosuppressive regimen simplification, pharmacist-led or counseling strategies, behavioral and multicomponent programs, and technology-based interventions. We identified 33 studies: immunosuppressive regimen simplification (n=8), pharmacist-led or counseling strategies (n=6), behavioral or multicomponent programs (n=3), virtual visits/remote monitoring (n=9) and mobile or text-based tools (n=7). In pooled analyses of randomized trials, active interventions improved adherence versus usual care (OR 4.04, 95% CI 1.94-8.41), although heterogeneity was substantial. A higher prevalence of alcohol-associated liver disease was associated with weaker intervention effects. Regimen simplification, especially conversion from twice-daily to once-daily tacrolimus, showed consistent improvement in adherence while maintaining acceptable graft outcomes. Pharmacist-led interventions improved medication knowledge, dosing compliance, and drug monitoring. Telehealth interventions reduced travel burden and, in some studies, early readmissions and hospital stay. Overall, regimen simplification and structured multidisciplinary support appear most effective, but larger longitudinal trials with standardized adherence measures are needed.