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Thyroid Therapeutics
Endocrinology
| Question | Answer |
|---|---|
| Dawn Phenomenon | hyperglycemia that happens in the morning |
| Somogyi's | Rebound hyperglycemia, can happen at any time during the day |
| Insulin and TZD onboard together increases risk for | Edema |
| Amylin secretion | Amylin is co-secreted with insulin. If no insulin is secreted, amylin is not secreted. |
| Pramlintide has a black box warning for | Type 1: insulin-induced severe hypoglycemia, typically occurs within 3 hours of dosing |
| T4 half life | 7 days, still dose daily |
| T3 half life | 1-3 days; more potent, so more CV AEs |
| Drug of Choice in Hypothyroidism | Levothyroxine (T4); 6-8 weeks to reach steady state. T4 levels will normalize much quicker than TSH b/c feedback loop takes time. Monitor 3-6 months for one year after reaching euthyroid, then yearly |
| T3 | Tri-iodothyronine (another tx for hypothyroidism). Cytomel. Increased risk for cardiotoxicity. Only use this if they fail on the t4. Cytomel is more expensive and requires more monitoring. |
| Switching brands of levothyroxine | Stay consistent with brand b/c levels are different, provider and patient must give authorization |
| Liotrix (Thyrolar, Euthyroid) | Synthetic T3 and T4 in a fixed ratio. Expensive and lacks therapeutic rationale. 3rd line. |
| Thyroid USP (Armour Thyroid) | Dessicated beef or pork thyroid gland. Red flag: allergies. Variable ratio of T3 to T4. Leave this alone or to endocrinologists |
| Thyroglobulin | Fixed 2.5:1 ratio of T4 to T3, expensive, no clinical advantage |
| General guidelines for thyroid replacement dosages are determined by | age, duration, severity of hypothyroidism, and cardiac risk factors |
| TSH long standing or severe | If greater than 15 |
| If a patient has cardiac risk (at any age) or is older than 65 | Then reduce thyroid replacement to only 25% of full dose. Watch for angina exacerbation |
| Monitoring T4 replacement therapy | monitor TSH and T4 every 4-6 weeks. T4 normalizes within a few weeks, TSH normalizes after a minimum of 6-8 weeks. Symptoms may not resolve for 3-6 months. |
| Patient education | may take without regard to food, don't double up on doses, may not see improvement for 2-3 weeks. Signs of excess dose (sx of hyperthyroidism) or lack of efficacy, anticipate life-long therapy, OTC drugs |
| Myxedema Coma in Hypothyroidism | Rare syndrome, most prevalent in the elderly in the winter. Cardinal features: hypothermia, respiratory depression, unconsciousness. Treat immediately, but not at full replacement doses. |
| Causes and tx of Hyperthyroidism | Autoimmune Graves disease, Autonomous hyperfunction, thyroiditis. Tx: Thioamides (MMI, PUT), Surgery, Radioactive Iodine |
| Propylthioracil (PTU) in hyperthyroidism | Acutely, PTU works faster than methimazole b/c it works at the conversion of T4 to T3. But in general, it takes 17 weeks to work. Compliance is an issue b/c it 3-4x/day dosing |
| PTU | It is the preferred agent in pregnancy and lactation |
| Methimazole (MMI) for hyperthyroidism | works within 6 weeks, fewer AEs. Higher compliance b/c dosage is QD or BID. Need to take for 6mos-2years |
| When is surgery indicated for hyperthyroidism treatment? | Indicated in patients wtih obstructions, malignancy, presgnancy in 2nd trimester, or those with contraindiations to RAI or thiomides |
| Radioactive Iodine | Indicated in elderly patients who are poor candidates for surgery or have cardiac disease |
| TT3 measures | total T3; useful for early detection of hyperthyroidism |
| TSH | most sensitive for detecting hypothyroid state |
| Elevations in TSH | hypothyroidism |
| Depression in TSH | hyperthyroidism |
| If a patient is less than 45 years old with no cardiac risk and mild hypothyroidism that is short in duration, what kind of thyroid replacement should they receive? | 100% full replacement. 100-125mcg/day of Levothyroxine |
| If a patient is less than 45 years old with no cardiac disease with longstanding or severe hypothyroidism, what kind of thyroid replacement should they receive? | 50% full replacement dose. Monitor/adjust every 2-3 weeks |
| If a patient is older than 45 with short or mild hypothyroidism, what kind of thyroid replacement should they receive? | 50% full replacement dose. Monitor/adjust every 2-3 weeks |
| At any age if a patient has cardiac risk factors or if they are over 65, how much thyroid replacement should they receive? | 25% full replacement dose. Monitor/adjust every 4-6 weeks. Watch for angina exacerbation |
| What is the effect of estrogen on thyroid hormone therapy in patients with nonfunctioning thyroid gland? | Decreases the response to thyroid hormone therapy |
| What is the effect of thyroid replacement hormones on anticoagulants? | Increases action of anticoagulants, may need to decrease anticoagulant dose. |
| What is the effect of thyroid replacement hormones of Beta blockers and Digitalis glycosides | Decreases the action of BB and Digitali glycosides |
| Hyperthyroidism Treatment Adjuncts | BB - decrease action of thyroid hormoneCorticosteroids - Decrease action of thyroid hormone and decreases immune response in Graves diseaseIodine - blocks release of thyroid hormones from the gland |
| Monitoring Hyperthyroidism | TT4 and FT4I: after 4-6 weeks of therapy, after a dose change, every 6-12 months thereafterRAI: monthly TSH and Ft4 to detect iatrogenic hypothyroidism |
| Common AE of Thiomides | Skin rash or itching |
| If you miss a dose of thioamides... | take it as soon as you remember, double up if necessary |
| How should a patient take Iodides? | mix with milk of juice to prevent GI distress, and administer through a straw to prevent tooth discoloration |
| Thyroid Storm Cause | Abrupt precipitation by physiologic or emotional stress. |
| Thyroid storm symptoms | Cardiovascular collapse; high fever, tachypnea, tachycardia, confusion, restless, hepatomegaly with mild jaundice, muscle wasting and weakness |
| Treatment of Thyroid storm | Propylthiourcil, propanolol, corticosteroid, iodide, supportive measures |
Created by:
ltm12