Thyroid Disorders: Pharmacology + Therapeutics Flashcards
What are the goals of therapy when treating hypothyroidism?
1) Normalize TSH levels/ euthyroid state
- normally high in hypothyroidism patients but we want to normalize it
2) Manage symptoms
3) If pregnant, achieve optimal TSH levels
What are the 3 treatment options used to treat hypothyroidism
1) Levothyroxine/Synthetic T4
- Synthyroid: brand name; Eltroxin - generic
2) Tiriodothyronine or liothyronine/ Synthetic T3
- Brand name: Cytomel
3) Desiccated thyroid: animal based product with mix of T3 + T4
T or F: A combo of Levothyroxine and liothyronine have been used to treat patients with hypothyroidism
T - can use combo of the 2 but really no studies showing the benefit
- some people just feel better when have combo of T3 and T4
T or F: Levothyroxine has a shorter half life than liothyronine and therefore requires multiple daily doses
False
Levothyroxine: 7 day half life === able to maintain stable + predictable levels of T4 in the blood
Liothyronine: 1.5 day half life; requires multiple daily dosing == more fluctuation in T3 levels (can cause too high of levels = toxic in some cases)
What impacts/decreases the absorption of levothyroxine?
Iron + aluminum containing products
Calcium
PPIs
Cholesterol resin
Phosphate binders
Coffee
Soy + bran
Solution to this interaction: try to take on empty stomach in morning (30-60 mins before you eat) or take at night 3-4 hrs after last meal
— need to try and be consistent with timing
T or F: Desiccated thyroid has unpredictable levels of T3 + T4
true
What is the main risk of over-treatment of hypothyroidism
Hyperthyroidism symptoms
Starting dose of levothyroxine: healthy adult
1.6-1.7 mcg/kg/day
Starting dose of levothyroxine: adult >50 years
12.5 -25 mcg/day OR 1 mcg/kg/day
—- decrease in dosing compared to healthy adult
Starting dose of levothyroxine: Adult with cardiac disease or > 60 yrs
12.5-25 mcg/day
T or F: Levothyroxine dosing should be adjusted for renal and liver dysfunction
F- don’t need to change
T or F: IV dosing of levothyroxine is the same as oral dosing
F - should be 75- 80% of oral dose
For obese patients, how should levothyroxine dose be determined
using IBW
How is levothyroxine dosing changed over time
Normally start low + slow
- adjust dose by 12.5-25mcg per day every 4- 8 wks (for people with cardiac disease or elderly == change every 6-8wks)
Typically trend seen with dosing of levothyroxine with age
Infants - need a higher mcg/kg dose
- range from 8-15 mcg/kg/day
How soon after starting levothyroxine should patients experience symptom relief?
Some improvement: 2-3 wks
Max effect: 4-5 weeks
T or F: Levothyroxine can cause a transient increase in FT4
Yes - due to how it is a synthetic form of T4; blood work can show an increase in FT4 or TT4
- can be nothing to worry about especially if TSH is normal (euthyroid)
Lab test monitoring for hypothyroidism patients once start therapy
Check TSH + FT4 every 6-8 weeks to ensure we get to steady state
- TSH: most reliable measure to ensure doses of meds are good
FT4: less important, more of a diagnostic tool
What are some important clinical points about desiccated thyroid when it comes to being a treatment option for hypothyroidism?
- derived from animal thyroid glands
- unknown ratio of T4 + T3 in it that can vary based on batch
- increase allergic reaction risk to animal protein
- tabs may lose potency over time
What is the rough equivalent to use when switching a patient from desiccated thyroid to Levothyroxine?
75-100mcg of T4 per 60mg of desiccated thyroid
T or F: A patient with hypothyroidism that is pregnant with normally need an increase in their levothyroxine dose
T: normally need an increase in dose in first trimester due to how there is an increase in thyroid binding protein, volume of distribution, + T4 movement to fetus in pregnant women (need to increase dose)
- Often 30-50% dose increase —- equivalent to taking 2 extra tabs of levothyroxine spread out through the week
What is the general treatment plan for hypothyroidism in pregnancy?
1) Generally increase Levothyroxine dose by 30-50% (2 extra tabs/week)
2) Reassess TSH q4wks during first half of pregnancy
3) Assess TSH at least once in 2nd half of pregnancy