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Endocrine 2 > Pharm - tx of thyroid disorders > Flashcards

Pharm - tx of thyroid disorders Flashcards

1
Q

indication for beta blockers

A
  • adjunctive tx during thyroid storm
  • to prep pts for surgery
  • to manage pregnant pts w/ thyrotoxicosis in the short term
  • primary therapy for thyroiditis or iodine-induced hyperthyroidism
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2
Q

beta blocker dosing

A
  • propanolol 20-40 mg QID
  • younger pts and severely toxic pts may require 240-280 mg/day in divided doses
  • atenolol start w/ 25-50 mg/day and titrate up to 200 mg daily
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3
Q

contraindications to use of beta blockers

A
  • decompensated heart failure
  • asthma
  • COPD
  • concomitant MAOi or tricyclic antidepressant use
  • 2nd or 3rd degree heart block
  • bradycardia
  • severe peripheral vascular dz
  • Raynaud’s
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4
Q

goals of therapy of beta blockers

A

-decrease the sx of Grave’s

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5
Q

what are the 3 treatment options for Graves?

A
  • antithyroid drugs (thioamides)
  • radioidodine
  • surgery
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6
Q

best tx options for pts w/ mild hyperthyroidism, minimal thyroid enlargement, and NO orbitopathy

A
  • radioiodine (w/o thioamide pretreatment or glucocorticoids) OR
  • 1-2 year course of thioamides
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7
Q

best tx options for pts w/ mild hyperthyroidism, minimal thyroid enlargement, and mild orbitopathy

A
  • radioiodine (w/0 thioamide pretreatment but w/ glucocorticoids) OR
  • 1-2 year course of thioamides
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8
Q

best tx options for pts w/ more severe hyperthyroidism

A
  • consider definitive therapy w/ radioiodine or surgery OR
  • 1-2 year course of thioamides OR
  • long term thioamide therapy
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9
Q

best tx options for pts w/ moderate to severe orbitopathy

A

surgery rather than radioiodine w/ glucorcorticoids for definitive therapy

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10
Q

thioamide agents

A
  • methimazole

- PTU (propylthiouracil)

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11
Q

goals of therapy for thioamide agents

A
  • render the pt euthyroid as quickly and safely as possible

- usually within 3-8 weeks

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12
Q

Indication for thioamide agents

A
  • preferred tx for children, pregnant women, and young adults with uncomplicated Grave’s disease
  • to control hyperthyroidism (not a cure)
  • can be given before surgery or RAI to deplete the thyroid gland of stored hormone to prevent thyroid storm
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13
Q

what are the two phases of dosing for thioamides

A
  • initial therapy: achieve eurthyroidism

- maintenance therapy: continued until remission is achieved

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14
Q

methimazole dosing

A
  • initial dose is based on the severity of the hyperthyroidism, size of goiter and free T4 level
  • small goiter and mild disease (T4 1-1.5 ULN) can be started on 5-10 mg daily
  • free T4 1.5 -2 times ULN can be started on 10-20 mg daily
  • larger goiters and T4 2-3 times ULN should be started on 20-40 mg daily
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15
Q

monitoring parameters of methimazole

A

-monitor T3 and T4 for response to therapy

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16
Q

contraindications to methimazole

A

-first trimester of pregnancy (category D)

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17
Q

initial dosing of PTU

A

-300-600 mg in divided doses usually 3-4 times per day

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18
Q

monitoring parameters of PTU

A

monitor T3 and T4 for response to therapy

19
Q

major adverse reactions to thioamides

A
  • benign transient leukopenia
  • agranulocytosis
  • drug induced hepatotoxicity
20
Q

indication for RAIU

A
  • may be considered first choice given lower cost and lower risk of complication that surgery
  • Poor surgical candidates, people who don’t response to drug therapy/had ADRs
  • those who develop recurrent hyperthyroidism after surg
21
Q

monitoring paramters for RAIU

A

measure free T4, total T3 and TSH 4-6 weeks after treatment and then at 4-6 week intervals for 6 months

22
Q

goals of therapy for RAIU

A

to deplete thyroid hormone from gland→decreases risk of hyperthyroidism post-RAI administration and thyroid storm

23
Q

Contraindications to RAIU

A
  • pregnancy/lactating women
  • severe/active Grave’s ophthalmopathy
  • discouraged/prohibited in patients who can’t follow radiation precautions
24
Q

Given a patient taking thioamides, select the appropriate monitoring for liver toxicity

A
  • baseline CBC/liver enzymes
  • routine liver function monitoring not recommended unless patient has hx of liver dz or is at increased risk for hepatitis
  • question pt about sx of hepatitis during first few months of therapy
25
Q

Given a patient taking thioamides, select the appropriate monitoring for agranulocytosis

A
  • get baseline CBC
  • Routine serial WBC not recommended
  • Pts told to report following sx: rash, fever, sore throat, flu-like symptoms
  • Differential WBC count ordered during febrile illness and at onset of pharyngitis
26
Q

thyrotoxicosis factitia

A

Hyperthyroidism produced by the ingestion of exogenous thyroid hormone

27
Q

long-term risks of hyperthyroidism

A
  • results in negative calcium balance, reduced bone density, and increased fracture risk.
  • tell patients to take 1200-1500mg Ca2+ daily through diet/supplements
28
Q

given a pt with hypothyroidism or subclinical hypothyroidism, select the initial dose based on age, ideal body weight and concomitant conditions

A
  • levothyroxine 1.6-1.7 mcg/kg/day
  • ideal body weight is best predictor of daily requirements
  • young healthy adults: start on full dose
  • 50-60 yo w/o heart dz: start on 50 mcg/day
  • odler w/ known cardiac dz: 12.5-25 mcg/day titrated up monthly
  • subclinical: don’t need full dose: 25-75 mcg usually is enough
29
Q

given a pregnant woman with thyroid disease, select the appropriate reasons to treat the disease

A
  • Untreated maternal hypothyroidism can lead to increased rate of miscarriage, stillbirths, congenital defects, and mental retardation
  • Thyrotoxic (hyperthyroidism) women need to be euthyroid before attempting surgery
30
Q

appropriate treatment for hypothyroidism in pregnant women

A
  • If they had it before pregnancy, increase levothyroxine dose by 25-30% upon a missed menstrual cycle or positive pregnancy test and notify their provider→increase from 7 doses/week to 9 doses/week
  • All those with treated hypothyroidism who are planning a pregnancy should optimize thyroid status before conception (TSH <2.5mIU/L)
31
Q

appropriate treatment for hyperthyroidism in pregnant women

A
  • PTU is preferred for tx in first trimester
  • Those on methimazole should be switched to PTU if pregnancy confirmed in first trimester→after first trimester, consider switching to methimazole
  • Both cross the pacenta so to avoid deleterious effects on baby, maintain free T4 level at or just above the upper limits of normal→free T4 and TSH should be monitored every 2-6 weeks
32
Q

goals of therapy for for hypothyroidism in pregnant women

A
  • normalize serum TSH values within trimester-specific pregnancy range
  • First trimester: 0.1-2.5 mIU/L
  • Second trimester: 0.2-3.0 mIU/L
  • Third trimester: 0.3-3.0 mIU/L
33
Q

monitoring parameters for pregnant women

A
  • Monitor TSH and total T4 should be monitored every 4 weeks during the first half of pregnancy
  • TSH should be checked at least once between 26 and 32 weeks gestation
  • Adjust doses as needed
34
Q

Given a woman who is planning a pregnancy, select the appropriate reasons for correcting the thyroid status prior to conception

A

Untreated hypothyroidism can lead to increased rate of miscarriage, stillbirths, congenital defects and mental retardation

35
Q

drugs that can cause drug-induced thyroid dz

A
  • lithium
  • amiodarone
  • interferon-alpha
36
Q

lithium

A
  • inhibits release of thyroid hormone from gland so T4 and T3 fall, TSH rises
  • can get lithium induced goiters
  • most have family hx of thyroid dz/ positive thyroid abs
  • ck baseline thyroid fxn before starting lithium
  • ck every 6 mos
37
Q

amiodarone

A
  • has high iodine content so can get iodine induced hyperthyroidism
  • can also get hypothyroidism
38
Q

amiodarone induced hyperthyroidism

A
  • occures suddenly
  • leads to thyrotoxic sx
  • labs: high thyroid hormone and low TSH
  • type 1: related to iodine load
  • type 2: direct destruction of thyroid cells
39
Q

tx of type 1 amiodarone induced hyperthyroidism

A
  • methimazole or PTU to block hormone synthesis

- potassium perchlorate may block iodine uptake by thyroid and deplete iodine stores

40
Q

tx of type 2 amiodarone induced hyperthyroidism

A
  • beta blockers for sx

- prednisone for anti-inflammatory action

41
Q

amiodarone induced hypothyroidism

A
  • not dose related
  • lab findings: nl T4 and high TSH
  • tx: T4 replacement
42
Q

interferon alpha induced hyperthyroidism

A
  • graves dz like and hyperthyroid thyroiditis
  • d/t toxic effect on gland
  • tx: beta blocker if sx are bothersome
43
Q

interferon alpha induced hyporthyroidism

A
  • risk factors: presence of antithyroid abs before tx, female, Asians
  • more common than hyperthyroid
  • tx: start T4 if sx warrant

Endocrine 2 (15 decks)

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