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Endocrinology > Hyperthyroidism Pharmacology > Flashcards

Hyperthyroidism Pharmacology Flashcards

1
Q

Drugs that inhibit TRH or TSH secretion without hypo/hyper thyroidism

A

bromocriptine, cabergoline, levodopa, corticosteroids, somatostatin, octreotide, metformin, interleukin-6, bexarotene

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2
Q

Drugs that inhibit thyroid hormone synthesis with hypothyroidism

A

iodides, amiodarone, lithium, thioamides, tyrosine, kinase inhibitors, HIV protease inhibitors

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3
Q

How can Amiodarone induce hypothyroidism?

A

blocks peripheral conversion of T4 to T3

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4
Q

How can Amiodarone induce hyperthyroidism?

A

iodine induced mechanism (pt. with underlying thyroid disease)
inflammatory mechanism - leakage of thyroid hormone

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5
Q

How do you treat Amiodarone induced hypothyroidism?

A

replace with levothyroxine

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6
Q

How do you treat Amiodarone induced hyperthyroidism in patients with underlying thyroid disease (multinodular goiter)?

A

antithyroid medications

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7
Q

How do you treat Amiodarone induced hyperthyroidism due to inflammatory mechanisms?

A

corticosteroids

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8
Q

How does Warfarin affect a patient with hyperthyroidism? What do you do to compensate?

A

increases catabolism of clotting factors

lower the Warfarin dose

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9
Q

Most common cause of hyperthyroidism?

A

Graves Disease

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10
Q

What lab value can you detect in a patient with Graves Disease?

A

thyrotropin receptor antibodies (TRAb)

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11
Q

Two types of Thioamides

A

methimazole and propylthiouracil

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12
Q

How do thioamides prevent thyroid hormone synthesis?

A

inhibit thyroid peroxidase-catalyzed reactions

block iodine organification that leads to synthesis of T3 and T4

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13
Q

What is special about propylthiouracil (PTU)?

A

blocks conversion of T4 to T3 in peripheral tissue

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14
Q

Preferred pharmacotherapy treatment for hyperthyroidism

A

methimazole (MMI)

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15
Q

How long does it take for thioamides to become effective?

A

3-4 weeks

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16
Q

Which thioamide is preferred in the first trimester during pregnancy?
Why?

A

propylthiouracil (PTU)

high protein bound (75-85%) so less effect on the fetus

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17
Q

When starting antithyroid medication what tests do you want to order at baseline?

A

CBC and LFT

[low WBC count and abnormal LFT most likely]

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18
Q

What do you measure every 2-4 months in a patient on antithyroid medication?

A

free T4 and total T3

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19
Q

When prescribing an antithyroid medication when can you expect symptom improvement?

A

within 3-8 weeks

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20
Q

When do you reduce the antithyroid dose?

A

as soon as signs of HYPOthyroidism develop

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21
Q

What are the most favorable outcomes for remission in a patient with hyperthyroidism?

A

> 40 years old, small goiter, short duration of disease, no prior relapse with antithyroid drugs, duration of therapy 1-2 years, low TSAb titers at baselie or a reduction with treatment

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22
Q

At the end of antithyroid drug therapy what would qualify the patient as being in remission?

A

low or undetectable levels of TRAb

normal seurm TSH, FT4, amd TT3 for 1 year after discontinuing the drugs

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23
Q

If your patient relapses after being treated with antithyroid drugs, what is the next line of therapy?

A

radioactive iodine (RAI)

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24
Q

What are some rare adverse effects in antithyroid medications?

A

agranulocytosis
vasculitis
hepatic damage

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25
Q

What is the black box warning for propylthiouracil?

A

hepatic damage [severe liver injury and acute liver failure]

26
Q

Common side effects of antithyroid medications

A

mild uticarial papular rash
arthralgias
GI intolerance

27
Q

In a patient with hyperthyroidism who is taking Warfarin what lab value will be increased?
Why?

A

INR

increased catabolism of vitamin K dependent clotting factors

28
Q

MOA of radioactive iodine (RAI) treatment

A

taken up and concentrated in the thyroid gland - damages thyroid gland without affecting other tissues

29
Q

Who is RAI treatment contraindicated in?

A

pregnancy/nursing [planning pregnancy in 4-6 mo]

thyroid cancer

30
Q

How well is RAI absorbed?

A

rapidly after oral administrations - 90% in 60 min

31
Q

How is RAI excreted?

A

renally (37-75%)

feces (~10%)

32
Q

How long is the half life of RAI?

A

8 days

33
Q

Prior to treating a female patient with RAI what do you want to obtain ___ hours prior to administering the therapy?

A

48 hours

pregnancy test

34
Q

When treating hyperthyroidism with RAI, how long should you wait after giving the 1st dose to administer the 2nd dose?

A

6 months

35
Q

What are some predictors of success in RAI therapy?

A

higher ablative dose, female, lower FT4 at diagnosis, absense of palpable goiter

36
Q

Within first 1-2 months after RAI what lab values do you want to assess?

A

free T4, total T3, TSH

37
Q

Once RAI becomes effective the patients will appear more as ____ and you will need to start the patient on _____

A

hypothyroid

thyroid hormone replacement therapy [dose based on FT4]

38
Q

Mild adverse effects seen in RAI therapy

A

mild thyroid tenderness and dysphagia

39
Q

Rare adverse effects seen in RAI therapy

A

hypersensitivity
radiation induced thyroiditis
cardiovascular events and tachycardia

40
Q

After being treated with RAI when can men and women conceive?

A

women - stable euthyroidism is established

men - after 3-4 months

41
Q

Why do you give antithyroid drugs up to 3 days prior to starting RAI and reinstituting 4 days after RAI treatment?

A

deplete thyroid hormone content within the gland

42
Q

What do you start prior to RAI to minimize risk of hyperthyroidism and thyroid storm?

A

beta-blocker

43
Q

What do patients want to avoid in their diet when going on RAI treatment?

A

iodine - cows milk, dairy, fish, seaweed, eggs, chocolate, iodized salt

44
Q

What do you want to educate your patient on with RAI therapy?

A

adequate hydration
frequent voiding [enhance excretion]
stimulate salivary flow [gum or candy]
avoid close contact with others

45
Q

What three things do you use to pretreat a hyperthyroid patient prior to surgery?

A

methimazole
propranolol
iodide

46
Q

Why do you give a patient propranolol prior to thyroid surgery?

A

antagonizes sympathetic/adrenergic effects of thyrotoxicosis
reduces tachycardia, tremor, stare
relieves palpitations, anxiety, tension
control HTN and A-fib

47
Q

Why do you give a patient iodide prior to thyroid surgery?

A

decrease vascularity of thyroid

48
Q

Who benefits from taking propranolol prior to thyroid surgery?

A

> 60 years old
HR > 90 beats/min
CVD

49
Q

At high doses what effect might propranolol have?

A

block peripheral T4 to T3 conversion

50
Q

Preferred beta-blocker in pregnant/lactating women

A

propranolol

51
Q

Which beta-blocker is used for thyrotoxicosis in ICU setting or storm? Why?

A

Esmolol

IV infusion

52
Q

MOA of iodide salts and iodine

A

inhibits thyroid hormone biosynthesis - blocks thyroid hormone release - decrease size nad vascularity of thyroid gland

53
Q

Disadvantages of iodide salts and iodine

A

increase intraglandular stores of iodine [delays onset of thioamide therapy and prevents use of RAI for weeks]

54
Q

Two therapeutic uses for iodide salts and iodine

A

adjunctive preop prep for thyroidectomy

treatment of thyroid storm [with other therapies]

55
Q

uncommon and reversible adverse effects of iodide salts and iodine

A

acneiform rash, swollen salivary glands, mucous membrane ulcers, conjunctivitis, rhinorrhea, drug fever, metallic taste, bleeding disorders, rare anaphylatic reacitons

56
Q

What medication should be continued through RAI treatment?

A

beta-blocker

57
Q

what can precipitate a thyroid storm?

A

infection, trauma, surgery, RAI, withdrawal from antithyroid medication

58
Q

Signs and symptoms of thyroid storm

A

decompensated thyrotoxicosis, high fever, tachycardia, tachypnea, dehydration, delirium, coma, nausea, vomiting, diarrhea

59
Q

therapeutic measures of thyroid storm

A

supress thyroid hormone formation and secretion
treatment of precipitating event
supportive care

60
Q

when treating a patient with thyroid storm, what should you administer first?

A

antithyroid drug - methimazole or propylthiouracil

61
Q

In thyroid storm, after administering antithyroid drug what else does the patient need?

A

iodine
hydrocortisone
propranolol [or esmolol if need IV]

62
Q

in treating a patient with thyroid storm what is the overall goal of therapy?

A

blocking conversion of T4 to T3

Endocrinology (7 decks)

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