"Keep looking for knowledge. Keep researching..."


"My name's Kati (she/her), I'm in my sixth year of school, which is my fourth year of pharmacy school – since there's a two-year pre-pharmacy requirement. Right now I'm on my 9th rotation, and I've accepted an offer at CVS! I'm studying to be a Doctor of pharmacy with Medical Spanish concentration. I've double minored in Chemistry and Spanish. And I'm a big fat lesbian!


In second grade, I knew I was gay. I was very masc-presenting with basketball shorts and short hair. I didn't focus on relationships all too much in high school. During my freshman year of college, there was this girl that lived across the hall...we became best friends, and we did everything together. People thought we were dating. I was happy that they did, but she transferred out later that year. I found my community that next semester: they were all gay, they were funny, and they were true to who they were. I was inspired by my friends, all these people who were living so recklessly raw. It was then that I came out again, for the second time, to my mother. My mother’s a boomer, she grew up in a different time, and she originally refused my sexuality.


In my professional years, I’ve had to dress up more – we had to look presentable towards the later years of pharmacy. My institution had a whole professional statement in the syllabus, saying no tank-tops, no jeans, etc. Of course, I was always in sweatpants. I wore my tank-tops and converse. No one really said anything. I did what I wanted, haha! One day, my mother and I went shopping for new clothes so I could dress up for my labs. I said that I didn’t feel comfortable in women's clothes, it just felt weird on my body being so skin tight. I was struggling with my body image too at that time. So I said, maybe let's go shopping for men's slacks or men's blouses. She said, 'I don't want you looking like a dyke.' It was a very stressful shopping experience, especially since I was so far away from campus and I didn’t realistically have another way of leaving and safely getting back.


My junior year, I fell in love with another woman who was in the pharmacy program, but due to mental health issues she dropped out and we also stopped dating. All the while, my mom starting becoming slightly more comfortable with me being gay, just dipping her toe in the water. More recently, I found my girlfriend on Tinder, because there aren't many gay people at Butler, or people that I relate to. We have been living together and have been exclusive since the beginning of the pandemic. My mom now treats her like her own daughter and got her more this last Christmas than me lol. She loves how my girlfriend takes care of me as I fell apart my first two years of college and my mother hated to see me struggle like that.

 

I’ve worked in community pharmacy (retail) for 5 years now and have had many trans patients who are on testosterone or estrogen and HRT (spironolactone, bicalutamide, finasteride etc). The only thing I knew at the beginning of my career about trans healthcare and medicine were the types of needles to inject hormones – that was basic. You draw up with an 18 gauge, and maybe you inject with a 25, because that's the smallest you can inject for an intramuscular injection.


In my 5th year of school, I attended a lecture by Dr. Veronica Vernon, an exceptional professor that works at a VA Center in Indy for Ambulatory Care. She’s an absolute powerhouse fighting for contraceptive prescribing rights for pharmacists and has also just become the president of IPA (Indiana pharmacists association). She's all about trans-medicine as she has a lot of veterans who are transgender who specifically come to her because she knows how to help them and manage hormone replacement therapy. She teaches a few things on campus like pharmacy law and therapeutic lectures on women's health, menopause, osteoporosis, and infertility. She also had an extra credit activity/lecture about transgender healthcare. Looking back, I wonder why this information wasn’t shared with us sooner or integrated into our regular coursework. It's niche, but it's very important.


In her supplemental transgender activity/lecture she talked about what types of tests patients needed to have (like prostate exams/mammograms) and emphasized being sensitize to your patients. The most important part of her lecture was talking about estrogen therapy and testosterone therapy and drug interactions with those therapies. She further went into depth as to when to expect different things – like when menstruation ceases, or how to bring that on early with the Depo-Provera, or when to expect certain hair growth, voice changes, muscle growth, or body fat redistribution. We learned about drugs like 5-alpha reductase inhibitors and spironolactone in other lectures about Hypertension or BPH but it wasn’t brought up how they could be added for feminizing therapy. I wondered why we didn't learn that this was an off-label usage when we learned about the drugs. No one ever brought up anything about transgender healthcare in any of the lectures until Dr. Vernon did that one side lecture. I think I have 5-6 transgender patients at the current pharmacy I'm at. It's a 24-hour pharmacy. I had patients asking me, when will my voice turn a certain way or when would I expect this or that. I thought to myself...no normal doctor or pharmacist knows that because they don't learn it in school. So I would pull up Vernon’s lecture notes and tell them what timeframes they should expect certain things to happen.


I assume that some people thought that learning this was useless given the number of trans people there are. That being said, I think a lot of people had my sentiment too, that this was very important and questioning why this wasn't in the curriculum already. This was all very new, we were the first class to have this lecture as an option... and it was 2020.


I want people to learn about healthcare for queer individuals, specifically transgender individuals. It should've been in the curriculum already, not only at my school but every school that teaches future health care providers. It's excellent that we're having this in the curriculum at all, but I know that it was something that Dr. Vernon had to push for. She had to talk to someone higher up and say: they need to learn this.


____


One fantastic resource is Outcare (https://www.outcarehealth.org/). Outcare is a platform that helps patients find medical providers that are well versed in LGBTQ+ healthcare. These providers do modules, they have specific training required to become Outcare-certified. It's the nation's first comprehensive resource for LGBTQ healthcare; offering a multitude of resources! I'm not sure if it extends to community pharmacists but I'll definitely look into it once I'm licensed come May. It's something that I've told my brother about, he's a Doctor of Osteopathic Medicine in Chicago, and is interested in being a family medicine doctor. He was all about it, he said he wants to be Outcare-certified – it was awesome that he was so on-board with it, because he's a straight, white man! Primary care is an important place to help LGBTQ patients with PrEP and/or HRT.


For the future of queer medicine... There's a drug called Apretude, or cabotegravir, that was just approved in Dec 2021 for Pre-exposure prophylaxis (PrEP) of HIV. There were two trials conducted, one with MSM and transgender women and the other with only woman. The results of the trial showed that cabotegravir was vastly more beneficial than the oral daily Truvada. The only thing about it is that it's a booty shot, because of the quantity of the injection. You need to do gluteal administration with injections of larger quantities. After the month of oral lead in, you get an injection monthly for two months and then it’s every other month. Right now with Truvada just becoming generic, it’s definitely cheaper and the preferred option on insurance, even though it can cause GI upset, bone mineral density loss, and is not for those with decreased kidney functioning; and if you don’t take Truvada every day, as prescribed, you are at risk for infection. In trials comparing cabotegravir to Truvada, results showed the injection to be about 3x as effective.



Note from Dx:Q team: Learn more here https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention



The biggest barrier for patients to get Apretude is cost. It will require a prior authorization with insurance and a lot of Doctor’s offices hate doing those since they take so much time. It will also most likely require a failed trial of Truvada or Descovy. There are a lot of opportunities out there for payment assistance, but it's very hard to find them as a patient. You need to talk to a pharmacist, or someone who's in it. A provider must be at the top of their game in order to help their patients with access to this type of medication. I'm excited for what’s to come.

 

From a patient-perspective... There are so many drugs and you don't know how much they should cost. I see people coming in for Prozac or Zoloft, forking over $200 for them... I'm like '...what are you doing? Go to Walmart, go to Kroger; use GoodRX, it'll be like $20 or $30 for a three-months supply.' Pharmacists can really help. I see some patients have Medicaid and don’t have their insurance on file with us or don’t know who’s in-network and are paying for their medications when they shouldn’t. In theory it is very easy to be that support system for patients, but in the retail world it can be hard to do that, especially at a 24-hour store pharmacists nowadays are overwhelmed with vaccinations, technician shortages, increased expectations, the closing of other pharmacies, and increased patient load. A lot of pharmacists are not taking the time to help and advocate for the patients – they're just filling the drugs and giving them to the patient. It is not a lack of wanting to help, but a lack of resources, time, and institutional support.


I feel like I have a more active role as a practitioner in the retail setting. I’m able to target those at risk for opioid overdose by having access to their medication list and further checking INSPECT to see fill history and Morphine Millequivalents (MME). In Indiana, we can prescribe Narcan (naloxone) to at-risk patients or their caregivers by Standing Order (the same thing that allows us to administer vaccinations or smoking cessation therapy without consulting a physician, NP, or PA). I also target lots of patients who I think are paying too much for their drugs. I try to find whatever 'blockades' there are or try to figure out why they are prescribed overpriced medications that are either almost identical to other generically available ones or not on their formulary. A lot of medical providers are easily swayed by the drug companies with shiny manufacturer coupons that only last a month or two, and then the coupons stop and the patient is overwhelmed with cost… The challenge of accessing reasonably priced medications leads to adherence problems. It's easy to find information online about replacements and costs, but some people just don’t have the time or understand the information.

 

It's very hard to get a hold of a provider. You go through so many roadblocks, and we can only do so much on our end... we can prescribe a few things as a pharmacist, but a lot of insurances don't cover pharmacist-prescribed medications, which sucks. It's an ongoing fight for prescribing-rights for pharmacists. In Indiana, oral contraceptives are already very loosely restricted online so pharmacists should have that prescribing right. All it requires pretty much is a blood pressure and to ask if they have a history of blood clots or smoking. Being the one who works directly in the pharmacy and communicates with insurance, it’s easy to find replacements based on what they are actually experiencing; for example, their estrogen is too low in their birth control so they are having a lot of continuous bleeding, or maybe they are having cystic acne on an androgenic progestin, or maybe the one prescribed isn’t covered by their insurance. It would be amazing to just be able to use the clinical I’ve learned to switch them. We are the doctors of drugs, it’s so silly to not have the scope of prescribing rights that we should have at this point.


Med students have a lot less time learning about medications, around a couple semesters. Whereas, pharmacy students have 4 years and an extra professional year on campus versus MD/DOs... almost all drug-focused. We need to collaborate as practitioners, but there's still this doctor-God mentality, where it's like, 'I prescribe it, you fill it.' It's very stressful when doctors do this. When doctors mis-prescribe medicines, pharmacists can be legally at fault as we are filling the order and by law have a corresponding responsibility to protect the patient. In Indiana, you can deny a prescription for 4 different reasons – if it's against the law, if it's against the best interest of the patient, if it's going to cause harm, or if it will aid/abet and addiction/habit... People don't understand that pharmacists are healthcare providers and they have the right to do this. They'll just say, 'Here's my drug... fill it.' But the dose might be too high or the duration may be wrong. It's very hard to tell a patient, 'no', because they see us as a McDonald's giving them french fries. But this is your medication that interacts with everything else you're taking, and it might kill you. Patients don't understand that medicine can be very dangerous, if improperly prescribed. There's always so much going on, and it's hard to monitor everything. A lot of patients don’t listen to me when I tell them that their medication is not appropriate for them or the wrong dose. I ask sometimes what they are taking it for as the indication can alter the dose, for example how you need a higher dose of Eliquis after a blood clot versus using it for Atrial Fibrillation, and they think I’m violating HIPAA…which is ridiculous. It’s a pharmacists’ job and duty to verify medications are appropriate and don’t interact with their other medications.


It's so stressful sometimes, but there are a lot of good patients who are grateful for the extra information that I give them that they otherwise aren’t getting from their medical providers. I will tell them important things that prevent hospital visits and adherence problems. They'll say 'Oh, my doctor didn't tell me that!'... when it may be the main counseling point with the drug.

 

I want Dx:Q readers to always be critical thinkers. I want you guys to be open to learning, I want you to be hesitant about certain things – questions things. It's very easy to be like, 'my doctor gave me this, he told me to take this,' but read about it! Read what it does. Read what it's for. There's a lot of mis-prescribing, duplicate therapy, a lot of unnecessary medications that people are taking, as well as medications that patients should probably be on but aren’t. Always be skeptical about what you're getting because doctors make errors, they do. Pharmacies also make errors, we can dispense the wrong drug to the wrong patient or put the wrong pills in a bottle. Be proactive, make sure your name is on that label. Make sure that drug looks like what you've been taking, or read the side of the bottle to make sure it's what it's supposed to look like (there’s usually a description of the pill on the bottle or pamphlet). There's so much going on, it's very easy to take something that you're not supposed to be taking. Always ask your pharmacists, that's another thing. If you're questioning your medications, call your pharmacists or go to your pharmacy. We're the drug experts and we can help! We'll give our recommendation and then maybe talk to your provider, say: 'Hey, I talked to a pharmacist, and they said this side effect is actually coming from this med... could we switch to something else?' Be proactive.

 

I don't know if I have any advice for my past self because I feel like everything happened in the timeframe that it needed to happen. I've always been a proactive learner, I've always been curious about everything, I've always been questioning everything. So, keep questioning. Keep looking for knowledge. Keep researching. Everything is fluid, nothing is stagnant. Guidelines change, new information comes out – see who's funding the research, see who's funding the trials. See why those drugs withdrawn from the market. Dive in deeper and try to figure things out. I don't have any core recommendations for my past self, just... keep going." -Kati Forbes, Indianapolis, IN (she/her)


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