early detection and adequate management of DRPs in autoimmune disease , improving patient adherence to therapy . ⁸

Blood monitoring is an essential part of monitoring medication safety , especially for DMARDs which are known to be nephrotoxic , hepatoxic and cause bone marrow suppression , and can result in cessation of therapy if not managed early on . In addition , drug levels can be taken to determine if the medication has reached a therapeutic range for optimal efficacy . For DMARDs like azathioprine , analysis of the active thiopurine metabolites ( 6TGN and 6MMPN ) are typically carried out following initiation of treatment or a dose increase , or if patients continue to show symptoms , this can determine if patients require any dose adjustment . ⁹ Pharmacists are ideally placed to advise on dose changes to optimise therapy , and , in turn , reduce disease activity and further increase adherence . On another note , undetectable levels may indicate non-compliance , prompting a discussion with the patient . Specialist pharmacists can explore reasons for non-adherance with the patient and provide education or even advise more appropriate alternative options if necessary . ⁹

Hospital pharmacists routinely perform medication reconciliation for inpatients and are able to advise the wider team on drug interactions , intolerance , formulation changes , medication dosing to optimise therapy and enhance the patient ’ s experience with their medication . By undertaking a thorough drug history with the patient , pharmacists are able to discuss their usual medication routine , potential DRPs and missed doses . ⁶ They can also access the patient ’ s general practitioner record to view the last prescription issue date , which may highlight compliance issues if dated from a long time ago . This is a good opportunity for pharmacists to explore patients ’ thoughts and understandings towards their medications , provide education and also to raise awareness to the destructive nature of autoimmune disorders . ^{1 , 2} This , in turn , will make patients keen to adhere to their medications to avoid consequences such as surgery in uncontrolled IBD , or deformities in rheumatoid arthritis .

Psychological impact of treatment can also play a role in non-compliance . The complexity of the regimens and potentially poor outcomes are often associated with high levels of frustration , anxiety and depression which further decrease adherence and worsens disease , due to both a direct effect of stress in the immune pathway and the decrease in treatment adherence . ^{10 , 11} Psoriasis is a good example here ; the condition can increase the levels of stress and anxiety which , in turn , lead to worsening in the clinical course of the disease . ¹¹ Therefore early evaluation and treatment of the psychological impact in patients with autoimmune / immune-mediated conditions is crucial to implement methods to improve adherence to treatment . Pharmacists are in a good position to provide a basic level of psychological advice and referral to appropriate mental health team for tailored support . They can also provide links to self-help schemes and forums to allow patients to reach out to individuals suffering from similar conditions . ⁵ Alcohol intake is also linked with poor adherence . Therefore , screening for alcohol misuse at each patient admission , or visit to a pharmacy clinic can be carried out to screen for harmful alcohol use . Heavy alcohol use can also increase the risk of fatty liver disease which may limit the use of certain drugs and increases the risk of mortality . ¹¹ Overall , pharmacists are well placed to detect these issues early on and prompt early referral to a psychologist or psychiatrist in order to support patients to improve adherence and screen for psychological comorbidities . ⁵

Benefits of continued education for the healthcare team Successful treatment of these complex disorders requires a multifaceted approach to improve outcomes . Specialist pharmacists can provide training to other pharmacist colleagues or health care professionals to ensure that the wider team is aware of normal practices with disease management and also routinely implement MO . This learning can be shared , for example , through general teaching sessions , accompanied ward visits and reviewing case studies .

Conclusion Pharmacists can have a major impact on improving the clinical outcomes of patients with autoimmune / immune-mediated diseases . By delivering a patient-centred approach and targeted communication , pharmacists can support medication adherence , reinforce patient education and improve health outcomes of the patients in their care .