Question

M.E. is a 29-year-old woman with a 7-month history of heavy, irregular menses, a 5-lb weight gain, constipation, and decreased energy. Her past history is unremarkable. She takes no prescription medications but uses iron and calcium supplements. She has a family history of thyroid disease. On examination, her weight is 152 lbs, her heart rate is 64 bpm, and her blood pressure is 138/86. Her thyroid gland is mildly enlarged, without nodularity. She has trace edema in her lower extremities, and her reflexes are slow. Laboratory studies are as follows: TSH is 15.3 mIU/mL (elevated), free T4 is 0.3 mIU/mL, and total cholesterol is 276 mg/mL.

Diagnosis: Primary hypothyroidism Answer the following questions. Include two references, cited in APA style.

List specific goals of treatment for M.E. What drug therapy would you prescribe? Why?

What are the parameters for monitoring the success of the therapy?

Discuss specific patient education based on the prescribed therapy.

List one or two adverse reactions for the selected agent that would cause you to change therapy.

What would be the choice for second-line therapy?

What over-the-counter and/or alternative medications would be appropriate for M.E.?

What lifestyle changes would you recommend to M.E.?

Describe one or two drug–drug or drug–food interactions for the selected agent.

Answer 1

List specific goals of treatment for M.E. What drug therapy would you prescribe? Why?

The treatment goals for hypothyroidism :

Reverse clinical progression

Correct metabolic derangements, as evidenced by normal blood levels of thyroid-stimulating hormone (TSH) and free thyroxine (T4).

Levothyroxine is the treatment of choice for hypothyroidism. It has a 7-day half-life, allowing daily dosing.

What are the parameters for monitoring the success of the therapy?

While initiating levothyroxine therapy, serum TSH should be measured to monitor for adequate replacement.

Normalization takes up to 4 months to normalize

It is recommended to measure TSH 6–8 weeks after initiation or a change in levothyroxine dose. Physiological parameters to asses the effectiveness include heart rate, pulse wave arrival time, echocardiographic parameters of a left ventricular function, Achilles reflex time, voice fundamental frequency, and basal metabolic rate

Discuss specific patient education based on the prescribed therapy.

Store L-thyroxine as per product insert at 20°C-25°C°F) and protected from light and moisture.

Should not take the medication with substances or medications that interfere with its absorption or metabolism.

People unable to ingest L-thyroxine should initially receive 70% or less of their usual dose intravenously.

L-thyroxine can be crushed and suspended in water to give as enteral feeding.

Consume food at least one hour after the drug intake.

Dosage adjustments can be done after 4-8 weeks following initiation of therapy.

List one or two adverse reactions for the selected agent that would cause you to change therapy.

Levothyroxine sodium is a replacement for a hormone produced by the thyroid gland. It can also be used to treat or prevent goitre caused by hormone imbalances, radiation treatment, surgery, or cancer.

One of the major side effects of Levoxyl includes hair loss during the first few months of treatment. Other serious side effects include a headache, sleep problems (insomnia), nervousness, irritability, fever, hot flashes, sweating, pounding heartbeats, changes in menstrual periods, appetite or weight changes.

What would be the choice for second-line therapy?

The second line of treatment can be used when there is less tolerance to the L- thyroxin therapy.

Triiodothyronine-levothyroxine combination therapy in patients with hypothyroidism can be used. This can be used to manage subclinical hypothyroidism and myxedema coma.

There are therapeutic categories such as (i) levothyroxine therapy, (ii) non–levothyroxine-based thyroid hormone therapies, and (iii) use of thyroid hormone analogues.

The thyroid extracts, synthetic combination therapy, triiodothyronine therapy, and compounded thyroid hormones are included in the second category.

What over-the-counter and/or alternative medications would be appropriate for M.E.?

Vitamin B: B vitamins have many interactions with thyroid function and hormone regulation.

Acetaminophen can reduce muscle pain.

Fibre and laxatives can be used to alleviate constipation.

What lifestyle changes would you recommend to M.E.?

Eating high fibre diet

Limit the intake of goitrogens

Intake of coffee after one hour of medications

Increase fluid intake

Exercise regularly

Control stress

Proper iodine intake

Sleep schedule

Improve intake of complex carbohydrates

Describe one or two drug-drug or drug-food interactions for the selected agent.

Iron and calcium carbonate results in reduced levothyroxine absorption

Iodine supplements may interact with the treatment of primary hypothyroidism

Other drugs and supplements that decrease the effect of levothyroxine:

Cholestyramine, Aluminum, Cimetidine, Sucralfate, Selenium, Magnesium, Zinc

References:

1.Ali J Chakra, Simon HS Pearce and Bijay Vaidya, Treatment for primary hypothyroidism: current approaches and future possibilities, Drug Des Devel Ther. 2012; 6: 1–11.Published online 2011 Dec 22. doi:  10.2147/DDDT.S12894, PMCID: PMC3267517,PMID: 22291465

2. ‘https://emedicine.medscape.com/article/122393-questions-and-answers