When it comes to compounded medications in veterinary health, the importance is not lost on Lauren Forsythe. In fact, compounding is at the forefront of her work. As Clinical Assistant Professor and Pharmacy Service Head at the University of Illinois Urbana-Champaign, she sees firsthand the opportunities to optimize veterinary and pharmacy education around compounded medications. We sat down with Lauren to learn more about her work in veterinary pharmacy, the trends she’s seeing, and how she’s supporting veterinary students’ education.
Thanks for sharing your insights with us today, Lauren! For those who are just meeting you, what led you to veterinary pharmacy?
I chose pharmacy school because I didn’t want to go to veterinary school; I grew up too close to it. My parents were both veterinarians and owned a mixed animal practice. Had I not grown up in the field, I probably would have landed myself in vet school. But I went to pharmacy school with the intent of working in community pharmacy or local chain pharmacy. I had a friend who did that and still showed horses, so it seemed like a good balance to be part of healthcare but not be a veterinarian.
You ended up very connected to veterinary medicine though! How did your path lead to your current job?
Halfway through my schooling, one of my compounding professors found out that I showed horses and that my parents were vets. He told me I should look into veterinary pharmacy. I said, “That’s a thing?” So, I learned more about it and realized it was a perfect fit for me. I spent the rest of school working toward that.
At the time, there were only three residencies in the country for veterinary pharmacy; I think there are five spots now. I received Purdue University’s first vet pharmacy residency. Coming into Purdue, my career goal after finishing residency was to work towards being a pharmacy director at a veterinary teaching hospital. I wanted the mix of teaching, research, and clinical. Throughout my residency, I did a lot of different things and took a detour for a while thinking I wanted to actually teach at a pharmacy school. I got as far as interviewing at my alma mater for a faculty position there before I ended up in a more clinical setting at UC Davis where I worked as a veterinary pharmacist.
I did that for three years. California was a fun adventure, but I’m a Midwest girl at heart, and I have three small kids, so when I had the opportunity to move within driving distance to family, I knew it was time to move back. Plus, I had advanced well in my career and was able to step into the lead pharmacist role here at Illinois. The school was at a point where they were looking for someone to come in and sort of revamp the pharmacy and create change. And I’ve always been excited for change and willing to jump into new “What Could Bes,” so that was a fun opportunity, and I was game for the challenges.
Such an interesting path! What was it about veterinary pharmacy and compounding that clicked with you and made you realize it was a perfect fit?
I grew up with close ties to the veterinary industry, and then one of my favorite classes in pharmacy school was the compounding class. Compounding was sort of falling by the wayside, but my school was a 0-6 program and was a little less traditional than some of the big schools using different structures. Our pharmacy school had a very good compounding professor who was very active in the industry; he actually was a key witness in trials of the 2009 Polo pony deaths by Franck’s pharmacy in Florida. He did a great job of teaching us to think critically about our compounds and to always question the accuracy of information, no matter what someone’s title was. I, along with most of my classmates, I think, found that class very interesting. We made a couple of veterinary compounds as part of our class, and we always had to research ahead of time and evaluate the prescription. As I dug into some of that info, I had gotten really interested in it. So when he mentioned veterinary pharmacy, and I started to learn more about it, I saw how important compounding was in veterinary medicine.
You’ve had so many interesting experiences with veterinary pharmacy. What do you enjoy most about it?
I really like working with veterinarians. I enjoy teaching vets and doing research with them. I think they’re a fun profession to work with. I even tend to be more involved on that side of the profession. For example, I’m active in our state vet med association rather than our state pharmacy association.
I also like all the challenges of veterinary pharmacy and how it’s not straightforward. There’s no “this is what you have to do,” do it by the book structure—there usually is not even a book that tells you what to do! I’m actually co-authoring a book with the pharmacist I work with, Alexandria Gochenauer, PharmD, FSVHP. It’s about compounding and is geared toward veterinarians. The impetus to write it was the fact that we went to try to put together a full CE course, and we found there was no text to use for it. As I said before, it just doesn’t exist. So we might as well write it!
That’s a great lead-in to the next question. Where do you see the biggest gaps in veterinary pharmaceuticals? Any strategies for closing these gaps?
Definitely education. That’s one I would push to the forefront because I’m at a teaching hospital. But I notice when I go to CE, and when I answer questions for vets, it is a lot of the same questions. And I enjoy trying to answer questions, but I can’t reach everybody. That’s why I do CE talks, and I am a clinical pharmacology consultant for VIN, Veterinary Information Network, to answer questions there. I also write articles and now this book.
The biggest thing is most vets use compounds so much in their everyday practice, besides maybe food animal doctors. My pharmacist Alex and I did a study a few years ago that polled 1,500 veterinarians and found that about 65% of them are compounding in-house to some extent, and largely they haven’t had formal education on compounding. Vets aren’t taught to write prescriptions well in vet school, let alone how to make the medication. I think it’s a fun area to close the gaps, and I think it’s an important area.
Here at Illinois, we have a really strong zoo med department, and that’s one population that uses compounds a lot. We have an opportunity to say to students who have an interest in this field—which a lot of our students do—”Hey, you might need to compound in practice, or you might use compounds, so let’s learn something about them.” And then we’re developing opportunities to help teach that. For example, we have what we call professional development rotations where veterinary students basically have six weeks of electives at the end of their clinical year when they can take anything they want. They have the option to retake any of the normal rotations, but they also can take oddball things. We developed a pharmacy elective, and it involves hands-on work—they can compound, fill meds, do other things they don’t really get to do in the teaching hospital, but they’ll have to do in practice. It’s great experience.
We also do some compounding information for our primary care and zoo med students that are on rotations, and we teach it during some of their lower-level coursework. We’ve started to get them informed on compounding at a number of different levels.
Additionally, we have a newsletter that goes out monthly to referring veterinarians, and we’ve started having a pharmacist write a short column every month for the Pharmacist Corner to help educate on different topics. We’ve done 503B facilities versus 503As, we’ve done beyond-use dates, we’ve done all sorts of different compounding tidbits to help get some more of this information out and address those questions we get over and over. And with this textbook we’re writing, it will be one big reference that can be used for CE courses, a source for more reading, and to keep on hand with all the information we recommend having.
It sounds like you’re taking a lot of action in educating students and veterinarians! What about clarity on the differences between 503A pharmacies and 503B manufacturers? At Epicur, we know there are a lot of questions surrounding that topic, and we’re working to help audiences gain a better understanding. What has your experience been?
My internal doctors have been trained that we want 503B when possible. But I don’t know that there’s a ton of traction outside in the broader audience yet. The biggest issue that I see, as far as a nationwide thing, is the fact that depending on the different states, 503B concepts in animal med is questioned. It’s so confusing on a regulatory standpoint; I think that adds a lot of uncertainty to all of it because you have that extra narrative. You get different stories—some say, “It is best, and it’s not illegal, so why wouldn’t you do it?” Then you get a 503A pharmacy saying, “This isn’t legal” or, “This isn’t right.” It’s adding that extra gray area and layer of doubt.
How do you clear up that confusion and reinforce the importance of 503B manufacturing?
I like to look at it by asking: What are the risks we have with a compounded medication? Why do we limit the use and recommend you should use an approved product first? Then I explain the risks in general with a compounded medication:
- It may not contain potency
- It may not contain what it says it contains
- It may not be stable, even if it does contain the right amount to start with
- It may not work
- It may not be safe
- It may not contain the right ingredients because of human error
There are different studies to support all of that. Then I explain those are the general risks with compounds, but when we’re talking compounding in a traditional sense, we’re talking 503A where you don’t have required endpoint testing to eliminate any of those concerns. When we’re talking about compounding with 503B, we are manufacturing compounded products which means we have required endpoint testing. They’re still not FDA-approved drugs, so there is still some uncertainty. And we don’t have a guarantee of efficacy because that’s not required to be proven. We don’t have requirements that they prove that this drug is safe in animals because that’s part of FDA approval.
However, we do check off the fact that we have to prove it contains what it says it contains. We have to prove that it’s stable in patients. So I say that we can check off some of those concerns as being proven to not be an issue with each specific lot that comes out of a 503B facility by the virtue of it being manufactured in an FDA-regulated facility.
What are the top things you still want to see students educated on before they enter the veterinary field?
Well, we’re working on exposing them to compounding—there’s so much to teach them on it, you just can’t cover everything! Client education or client counseling on medications is another big one; it’s starting to get legislated as required in some states. California has legislation on it, and I know a few other states have considered it. It’s being modeled after the requirements for pharmacists to counsel, and I don’t think vets are prepared for it.
I watched the implementation in California and all of the stress that it caused in the veterinary profession. I don’t think we’ve educated them enough to be prepared to do that. That’s a gap I’m hoping to help alleviate. I have an elective that I’m hopefully going to be able to offer next Fall to the vet students. I’m also working with some of our faculty here to do some research on the current knowledge level in this area with students, and then see if we can improve that from an educational sense.
Any trends that are catching your eye as something to watch in veterinary medicine?
Definitely keep an eye on that medication counseling topic. I watched it go through our legislature here in Illinois this year. It got withdrawn, but I think it’s going to keep coming up in states going forward. The controlled substances handling and management with USP 800 is another big thing. I think it will come into play even more. It’s just not quite there yet.