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M.E. is a 29-year-old woman with a 7-month history of heavy, irregular menses, a 5-lb weight gain, constipation, and decreased energy. Her past history is unremarkable. She takes no prescription medications but uses iron and calcium supplements. She has a family history of thyroid disease. On examination, her weight is 152 lbs, her heart rate is 64 bpm, and her blood pressure is 138/86. Her thyroid gland is mildly enlarged, without nodularity. She has trace edema in her lower extremities, and her reflexes are slow. Laboratory studies are as follows: TSH is 15.3 mIU/mL (elevated), free T4 is 0.3 mIU/mL, and total cholesterol is 276 mg/mL.

Diagnosis: Primary hypothyroidism

Answer the following questions. Include two references, cited in APA style.

1.List specific goals of treatment for M.E.

2.What drug therapy would you prescribe? Why?

3.What are the parameters for monitoring the success of the therapy?

4.Discuss specific patient education based on the prescribed therapy.

5.List one or two adverse reactions for the selected agent that would cause you to change therapy.

6.What would be the choice for second-line therapy?

7.What over-the-counter and/or alternative medications would be appropriate for M.E.?

8.What lifestyle changes would you recommend to M.E.?

9.Describe one or two drug–drug or drug–food interactions for the selected agent.
 

Discussion

Primary hypothyroidism is one of the most common hormonal diseases that affect United States. The treatment of hypothyroidism is considered easy by practitioners, but a large number of patients suffering from this condition are unsatisfactorily treated. Western countries suffer from Hasimoto’s thyroiditis or due to iodine deficiency (Pellegriti et al., 2013). The aim of this report is to analyze the case study provided about a female patient diagnosed with primary hypothyroidism, meaning the body failed to produce the thyroid hormone even after the gland being normally stimulated. The female patient in the case is overweight, does not undergo any medication, and faces fatigue and irregular menstruation for the past 7 months.  

Treatment Goals for the patient:

Hypothyroidism is usually treated by prescribing medication to the patient or by clinically replacing the hormone in the body, depending on the assessment of the practitioner. Treatment for hypothyroidism involves taking medication to replace the missing thyroid hormones. The patient should be tested for a thyroid peroxidase (TPO) antibody test, to ensure whether or not she has developed Hashimoto’s disease (Caturegli, De Remigis & Rose, 2014). 

Prescribed Drug Therapy:

The best choice of drug for hypothyroidism is Levothyroxine commonly known as LT4, which has to be taken daily (Okosieme et al., 2016). A healthy person without any heart condition, below fifty years of age can be administered with a complete dose of the drug respective to their body weight (1.6 µg/kg/day). Thyroid hormone is prescribed to supplement or replace hormonal production.

Importance of the said Drug:

Levythyroxine is the most common drug used to treat patients with hypothyroidism and Hashimoto’s disease. The dosage is contemplated with respect to the age, sex, body weight, cardiac output of the patient. This drugs works effectively on most people, but elderly people are not advised to take this, as the drug interferes with heart diseases. It is advised to take the medicine in an empty stomach with a glass full of water, but it can also be taken after meal in the night if complications are seen. 

Monitoring Success of the Therapy:

The success of the levothyroxine drug is dependent on the complete monitoring of the patient symptoms. Prior to administering the drug, the patient needs to be tested for TSH and T4 before 4 weeks approximately (Javed, & Sathyapalan, 2016). The patient in the case study has elevated levels of TSH (15.3 mIU/ml), but her free T4 was relatively low (0.3 mIU/ml). The possible outcome that can be deduced from this situation is that the patient is suffering from Hashimoto’s disease. The dosage should be adjusted according to the need of the patient and advised to take the medication lifelong, unless signs of side effects are seen. 

Treatment Goals for the patient

Patient Education: 

The patient should be made aware of her condition and given appropriate instruction. The patient has been taking iron and calcium supplements and these two supplements hinder the absorptive mechanism of the thyroid hormone. The patient should be advised to stop taking those supplements immediately. It is the duty of the physician to be made aware that calcium can prevent the absorption of thyroxin (Ishikawa, Hashimoto, & Kiuchi, 2013). The patient is also advised to change her lifestyle and eating habits, as she has a high level of cholesterol in her blood.

Adverse Reaction of the Therapy:

Levothyroxine has some common side effects the first few months of administration. The possible symptoms include hair loss and uneasiness until the patient’s body gets accustomed to the drug. The patient in the case study also showed mild symptoms and delayed response to the drug until the effects of her iron and calcium supplements wore out. There are other possible adverse effects are irregular menstrual cycle, insomnia, heat flashes and loss of appetite (Burman, 2015). If these symptoms persist, alternative second line medication should be administered.

Choice of Second Line Therapy:

Levothyroxine is suited to 85% of the affected patient. Sometimes, administration of these drugs may have adverse effects. Some patients have been reported to have side effects while ingesting the drug in an empty stomach. Those people are recommended to take the medicine after meal, which does not alter its effect on TSH (Geer, Potter, & Ulrich, 2015). Sometimes a combination of levothyroxine and Triiodothyronine can also be advised. Changing diet or lifestyle may also help the practitioner to treat the patient. 

Over the counter or Alternative Medication:

Armour Thyroid, Cytomel and Synthoid are also some alternative choices, if the patient’s metabolism does not accept Levothyroxine.

Drug Interaction:

A number of medications, dietary supplements, and food habits can interfere with the absorption and action of levothyroxine (Irving, Vadiveloo & Leese, 2015). Iron supplements, calcium supplements can affect levothyroxine absorption. Cholestyramine, a cholesterol lowering drug is not advised to the patient even if her levels seem high. Aluminum hydroxide, present in certain antacids should be avoided.

The patient is advised to continue her medication throughout her life and replace with other alternatives if any side effects are observed. Since the patient is presumably suffering from Hashimoto’s disease, an autoimmune disorder, her thyroid levels will continuously need to be checked. The patient is recommended to change her lifestyle, get more exercise to control her cholesterol level, as Cholestyramine will interfere with her thyroid medication. The patient is advised to immediately stop taking her iron and calcium supplements in order to avoid drug interaction. The patient should regularly check her thyroid activity in order control TSH-T4 absorption. The patient should try to exercise, and avoid any further weight gain, as that might lead to cardiac diseases. The patient is advised to monitor her menstrual cycle after initial adjustment period is over. If adverse symptoms persist, she should inform the doctor to change her medication. Over expression of Iodine, could be the reason for the thyroid gland swelling.

Conclusion: 

Primary hypothyroidism is a very treatable disease and could be kept in check easily. Most affected people do not realize the root of the problem, as seen in the situation of the provided case study. She developed Hashimoto’s disease and kept on taking iron and calcium supplements, which worsened her health. The patient is advised to continue her medication throughout her life. The United States population should be made of the clinical symptoms, as more and more people are being affected by it. 

References:

A Irving, S., Vadiveloo, T., & Leese, G. P. (2015). Drugs that interact with levothyroxine: an observational study from the Thyroid Epidemiology, Audit and Research Study (TEARS). Clinical endocrinology, 82(1), 136-141.

Burman, K. D. (2015). Introduction. In A Case-Based Guide to Clinical Endocrinology (pp. 121-125). Springer, New York, NY.

Caturegli, P., De Remigis, A., & Rose, N. R. (2014). Hashimoto thyroiditis: clinical and diagnostic criteria. Autoimmunity reviews, 13(4-5), 391-397.

Geer, M., Potter, D. M., & Ulrich, H. (2015). Alternative schedules of levothyroxine administration. American Journal of Health-System Pharmacy, 72(5), 373-377.

Ishikawa, H., Hashimoto, H., & Kiuchi, T. (2013). The evolving concept of “patient-centeredness” in patient–physician communication research. Social Science & Medicine, 96, 147-153.

Javed, Z., & Sathyapalan, T. (2016). Levothyroxine treatment of mild subclinical hypothyroidism: a review of potential risks and benefits. Therapeutic advances in endocrinology and metabolism, 7(1), 12-23.

Okosieme, O., Gilbert, J., Abraham, P., Boelaert, K., Dayan, C., Gurnell, M., ... & Williams, G. (2016). Management of primary hypothyroidism: statement by the British Thyroid Association Executive Committee. Clinical endocrinology, 84(6), 799-808.

Pellegriti, G., Frasca, F., Regalbuto, C., Squatrito, S., & Vigneri, R. (2013). Worldwide increasing incidence of thyroid cancer: update on epidemiology and risk factors. Journal of cancer epidemiology, 2013

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