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Pharm II- Exam 1 > Thyroid Disorders and Parathyroid Disorders > Flashcards

Thyroid Disorders and Parathyroid Disorders Flashcards

1
Q

What is a goiter?

A

Enlargement of the thyroid gland

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2
Q

What is Grave’s disease?

A

Autoimmune disorder that results in hyperthyroidism during the early phase and can progress to hypothyroidism if there is destruction of the gland in later phases

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3
Q

What is thyroglobulin?

A

A protein synthesized in the thyroid gland; its tyrosine residues are used to synthesize thyroid hormones

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4
Q

What is TSH?

A

The anterior pituitary hormone that regulates thyroid gland growth, uptake of iodine and synthesis of thyroid hormone

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5
Q

What is a thyroid storm?

A

Severe thyrotoxicosis

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6
Q

What is thyrotoxicosis?

A

Medical syndrome caused by an excess of thyroid hormone

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7
Q

If a pt comes in with a goiter. do they have hyper or hypo thyroidism?

A

we DONT know yet, need to do more testing to determine

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8
Q

What is thyroxine-binding globulin (TBG)?

A

Protein synthesized in the liver that transports thyroid hormone in the blood

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9
Q

Role of thyroid in child? adult?

A

normal growth/development

maintain metabolic stability

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10
Q

TSH is under the control of…

A

the hypothalamic hormone thyrotropin-releasing hormone

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11
Q

What hormones are release by the thyroid?

A

Thyroxine, Triiodothyronine

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12
Q

What are the 2 ways that the thyroid func. is regulated?

A

TSH secreted by the anterior pituitary > secretion of TSH under negative feedback

Extrathyroidal deiodination of T4 to T3

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13
Q

What regulates conversion of T4 to T3?

A 
nutrition
nonthyroidal hormones
ambient temperatures
drugs
illness
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14
Q

What is required for thyroid hormone synthesis?

A

Iodine

Thyroglobulin

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15
Q

Which thyroid hormone is predominantly secreted from the thyroid gland?

A

T4

T4 is then converted to T3

they are highly protein bound, only the unbound is active

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16
Q

Where are thyroid hormone receptors found?

A

in the most hormone responsive tissues: pituitary, liver, kidney, heart, skeletal muscle, etc.

(# of receptors may be altered to preserve body homeostasis)

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17
Q

Besides T3 and T4, the thyroid also releases…

A

calcitonin

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18
Q

Key features of thyrotoxicosis?

A

warm/moist skin, sweating, heat intolerance, tachycardia, dyspnea, increased appetite, nervousness, weight loss, exophthalmos

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19
Q

Key features of hypothyroidism?

A

pale/cool/puffy skin, sensation of being cold, bradycardia, reduced appetite, lethargy weight gain

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20
Q

What are some causes for hypothyroidism?

A

hashimoto’s, drug induced, dyshormonogenesis, radiation, congenital, secondary (TSH deficit)

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21
Q

Labs of pts with hypothyroidism?

A

primary: elevated TSH, decreased serum free T4
secondary: assess only free T4 –> free T4 and T3 low , antithyroid peroxidase abs in autoimmune thyroiditis

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22
Q

TSH of … is concerning for hypothyroidism. TSH of ….is concerning for subclinical hypothyroidism

A

10

> 4.5

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23
Q

When do you need to carefully monitor hypothyroidism lab studies?

A

during pregnancy

may need to increased dosage

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24
Q

In hyperthyroidism TSH is?

In hypothyroidism?

A

low

high

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25
Q

Besides hypothyroid, what can cause low serum T4 and T3?

A

LOTS of drugs

i.e. Salicylates, NSAIDS, Octreotide

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26
Q

Drug of choice for tx of hypothyroidism?

A

Levothyroxine (synthetic T4)

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27
Q

Half life of levothyroxine? What is unique about its dosing?

A

7 days (so can dose daily)

color represents a tablet strength

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28
Q

Which levothyroxine dose does not contain any dye?

A

50 mcg

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29
Q

When do you change a dose of levothyroxine, when do you recheck a TSH?

A

in 4-6 weeks because it has reached steady state after 4-5 half lives

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30
Q

Relationship btwn T4 and concentration and TSH…

A

is not linear, small change in T4 can lead to big change in TSH

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31
Q

What can impair absorption of Levothyroxine (T4)?

A

food, mucosal diseases, GI tract

-needs to be taken on any empty stomach with water only

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32
Q

What drugs can increase T4 clearance?

A

rifampin
carbamazepine
possibly phenytoin

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33
Q

What other drugs can be used for the tx of hypothyroidism?

A

Lipthyronine

Liotix

Thyroid USP

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34
Q

Why do people like taking T3 (Liothyronine)?

A

has a short half life and gives them a burst of energy

BUT gives more than the body would have normally

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35
Q

Content of Thyroid USP (Armour Thyroid)?

A

desiccated pork thyroid gland

High T3: T4 ratio

not really recommended

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36
Q

dose requirement for thyroid replacement may be better estimated by….rather than on actual body weight

A

ideal body weight

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37
Q

Average thyroid replacement dose requirement

A

1.7mcg/kg/day

once they reach steady state

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38
Q

Levothyroxine dose for Young patients with long-standing disease and patients over age 45 without known cardiac disease?

A

start on 50 mcg Levothyroxine daily

then increase to 100 mcg daily after 1 months

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39
Q

How should levothyroxine dose be adjusted in older pts?

A

initial daily dose for older patients or those with known cardiac disease is 25 mcg per day

then titrate upward in increments of 25 mcg at monthly intervals to prevent stress on the cardiovascular system

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40
Q

What can accelerate thyroxine disposal?

A

nephritic syndrome

other severe systemic illness

several antiseizure meds and Rifampin

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41
Q

Levothyroxine dosage in pregnant women?

what about for postmenopausal women on hormone replacement therapy?

A

Pregnancy increases the thyroxine dose requirement for 75% of women

increases dose need in 85% of women

42
Q

What drugs can be effected by hypothyroidism?

A

Digoxin > higher serum levels

might decrease sensitivity to Warfarin, restoration of euthyroidism can increase the warfarin dose requirement

43
Q

Excessive doses of thyroid hormone may lead to…

A

heart failure

angina pectoris

MI

44
Q

Which Levothyroxine tablet is the least allergenic?

A

0.05 mg (50 mg)

white tablet - no dye

45
Q

Hyperremodeling of cortical and trabecular bone due to hyperthyroidism, may lead to…

A

reduced bone density and may increase the risk of fracture

46
Q

Besides hypothyroid, TSH-suppressive Levothyroxine therapy may also be used for…

A

nodule thyroid disease and diffuse goiter

hx of thyroid irradiation

thyroid CA

47
Q

When should Levothyroxine be taken?

A

on any empty stomach, ideally an hour before breakfast

48
Q

What meds may interfere with Levothyroxine absorption? When should they be taken?

A

ferrous sulfate

PPIs

calcium carbonate

bile acid resins

4 hrs after levothyroxine dose

49
Q

Sxs of hyperthyrodisim?

A

Cardinal sign is loss of weight concurrent with an increased appetite

Nervousness
Anxiety
Palpitations
Emotional lability
Easy fatigability
Menstrual disturbances
Heat intolerance
50
Q

PE findings in hyperthyroidism?

findings specific to Graves’s disease?

A

Warm, smooth, moist skin
Unusually fine hair

exophthalmos
pretibial myxedema

51
Q

What are the treatment options for hyperthyroidism??

A

antithyroid drugs

RAI

surg

52
Q

Advantages of antithyroid drugs? disadvantages?

A

(+) noninvasive, low initial cost, low risk of permanent hypothyroidism

(-) low cure rate, ADEs, drug compliance

53
Q

antithyroid drugs are considered first line for which pts?

A

children, adolescents, and in pregnancy

54
Q

Examples of antithyroid drugs?

A

Thiourea drugs

  • Propthyouracil (PTU)
  • Methimazole (MMI)
55
Q

MOA of PTU and Methimazole?

A

serve as preferential substrates for the iodinating intermediate of thyroid peroxidase and divert iodine away from potential iodination sites in TG

> inhibit coupling of monoiodotyrosine and diiodotyrosine to form T4 and T3

56
Q

PTU and Methimazole are mostly absorbed where?

A

GI tract (80-95%)

actively concentrated in the thyroid gland

57
Q

Dosing for PTU? Methimazole?

A

initial dose 300-600mg daily, divided in 3-4 doses

MMI: 30-60mg/day divided in 2-3 doses

58
Q

After starting PTU or Methimazole, when is there usually improvement in sxs?

A

within 4-8 wks

changes in dose should be made on a monthly basis

59
Q

ADEs of PTU and Methimazole?

A

agranulocytosis, rash, benign transient leukopenia, arthralgias & a lupus like syndrome, hepatoxicity

60
Q

What is agranulocytosis?

A

serious adverse effects of thiourea drug therapy and is characterized by fever, malaise, gingivitis, oropharyngeal infection, and a granulocyte count less than 250/mm3

61
Q

What drug for hyperthyroidism can be used during the first trimester of pregnancy? what about for the remainder of pregnancy?

A

PTU

MMI: risk of hepatotoxicity > risk of embryopathy

62
Q

MOA of iodides in Graves’s disease?

A

acutely blocks thyroid hormone release

inhibits thyroid hormone biosynthesis by interfering with intrathyroidal iodine utilization

decreases size/vascularity of the gland

63
Q

How long after staring Iodine therapy will pts have sxs improvement?

A

2-7 days

64
Q

Caveat to Iodide therapy?

A

Despite the reduced release of T4 and T3, thyroid hormone synthesis continues at an accelerated rate, resulting in a gland rich in stored hormones

65
Q

When used in addition to RAI, SSKI should be given…

A

3-7 days after RAI tx so that the RAI can concentrate in the thyroid

66
Q

When should Potassium iodide be given when used preoperatively?

A

7-14 days preoperatively

67
Q

ADEs of iodides?

A

Salivary gland swelling

“Iodism” > metallic taste, burning mouth/throat, sore teeth/gums, gynecomastia, GI upset

hypersensitivity rxn

68
Q

When can be used for hyperthyroid sxs relief?

A

Adrenergic blockers: Propranolol

69
Q

MOA of propranolol?

A

Blockage of beta adrenergic receptors

70
Q

Indications for propranolol for hyperthyroidism?

A

usually adjunct to antithyroid drugs

primary therapy for thyrotoxicosis

71
Q

Contraindications for propranolol?

A

decompensated HF, sinus brady, MOAI or TCA use, spontaneous hypoglycemia

72
Q

How can BB effect pregnancy?

A

prolong gestation and labor during pregnancy

73
Q

ADEs of Propranolol?

A

nausea, vomiting, anxiety, insomnia, light-headedness, bradycardia, and hematologic disturbances

74
Q

Advantages to radioactive iodine? disadvantages?

A

(+) cure of hyperthyroidism, most cost effective

(-) permanent hypothyroidism almost inevitable, pregnancy most be deferred for 6-12 mos/no breast feeding, might worsen opthalmopathy, small risk of exacerbation of hyperthyroidism

75
Q

RAI is the best treatment for…

A

toxic nodules and toxic multinodular goiter

76
Q

Advantages of surg for hyperthyroidism? disadvantages?

A

fast & effective, especially in pts with large goiters

most invasive, potential comps (recurrent laryngeal n. damage, hypoparathyroidism), most costly, permanent hypothyroid

77
Q

Potential tx for pregnant pts who are intolerant of antithyroid drugs?

A

surgery

78
Q

Which drugs can be used in the management of thyroid storm?

A 
PTU
MMI 
Sodium Iodide 
Lugol's solution
Saturated Solution of Potassium Iodide 
Propranolol 
Dexamethasone, Prednisone, Methylprednisolone, Hydrocortisone
79
Q

TSH receptor-stimulating antibody or thyroid-stimulating immunoglobulin (TSI) may be elevated in?

A

Graves’s disease

hyperthyroidism

80
Q

Presentation of hypoparathyroidism?

A

usually asxs

Acute: mild-severe tetany

Chronic: lethargy, anxiety/depression, urolithiasis, renal impairment, dementia, blurry vision from cataracts of keratoconjuctivitis

81
Q

What systems are effected by hypoparathyroidism?

A

endocrine/metabolic

musculoskeletal

nervous

opthomalogic

renal

82
Q

What is PTH involved in?

A

the control of serum ionized calcium levels

83
Q

What happens where there is loss of PTH action?

A

hypocalcemia

hyperphosphatemia

hypercalciuria

84
Q

What is crucial for PTH secretion and activation of the PTH receptor?

A

Mg

85
Q

Tx of hypoparathyroidism?

A
  • Maintain serum calcium in low-norm range 8-8.5
  • oral calcium carbonate
  • Calcitrol
  • Maintain serum Mg in range
  • Phosphate binders if high calcium phosphate product
  • Thiazide diuretics + low salt diet
86
Q

What alternative to calcium carbonate can be used in geriatric pts, those on PPI or those with constipation?

A

calcium citrate

87
Q

Why are Thiazides and low salt diet recommended for pts with hypoparathyroidism?

A

to prevent hypercalciuria, nephrocalcinosis and nephrolithiasis

88
Q

In pt with hypoparathyroidism, what should be monitored wkly during initial management?

A

Ca
Phosphate
Mg
Cr

89
Q

Describe primary hyperparathyroidism

A

intrinsic parathyroid gland dysfunction resulting in excessive secretions of PTH with a lack of response to feedback inhibition by elevated calcium

90
Q

Describe secondary hyperparathyroidism. Tertiary?

A

excessive secretion of PTH in response to hypocalcemia, which can be caused by vitamin D deficiency or renal failure

autonomous hyperfunction of the parathyroid gland in the setting of long-standing secondary HPT

91
Q

High PTH (>3) suggests…

Low PTH (<3) suggests…

A

primary HPT

non-PTH mediated hypercalcemia

92
Q

What is curative for primary HPT?

A

operative management

for those awaiting/unable to have surg:
-Bisphosphonates (Alendronate)

  • Calcimimetics
  • Selective estrogen receptor modulator therapy
  • Hormone replacement (postmenopausal women who refuse surg)
93
Q

Tx for secondary HPT?

A

Calcium replacement

Vitamin D analogues (paricalcitol and calcitriol)

Phosphorus-binding agents (sevelamer)

Calcimimetic (cinacalcet): activates calcium-sensing receptor in parathyroid gland thereby inhibiting PTH secretion

94
Q

tx for tertiary HPT?

A

Medical treatment is not curative and generally not indicated

95
Q

Minimum dietary requirement for iodine?

A

75-150mg/day

96
Q

Thyroglobulin (Tg) levels are used primarily in____, can also be elevated in_____

A

Thyroid CA

Acute thyroiditis, Graves’s disease

97
Q

You would most likely see elevated Antithyroid Microsomal ABs (Antithyroid peroxidase Abs) in?

A

Hashimoto’s disease

less common: graves

98
Q

You would most likely see elevated Tg abs in?

A

Hashimoto’s disease

less common: graves (Helpful to predict if patient with Graves’ will eventually become hypothyroid without iatrogenic destruction of the gland)

99
Q

TSH receptor abs (TrAB) can be?

A

stimulating, blocking or neutral

ex. TSI, TBII

100
Q

Thyroid stimulating immoglobulins (TSI) are commonly seen in?

A

Graves

less common: Hashimoto’s

101
Q

What test is used as the newborn screening for hypothyroidism?

A

total T4

102
Q

What type of nodule is more likely to be CA?

A

cold (hypofunctioning)

Pharm II- Exam 1 (6 decks)

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