Sandi Mellor, APRN, FNP, MSN

Objectives
1) Review pathophysiology of the thyroid
gland and the hormones it produces.
2) Identify common medications used to treat
hypothyroidism and hyperthyroidism.
3) Review a case study on hypothyroidism
and Hashimoto's thyroiditis and the
pharmacologic management.
4) Review a case study on hyperthyroidism
and Grave's Disease and the pharmacologic
management.
 The Thyroid
gland
Thyroid hormones
Iodine is absorbed from the GI tract and is transferred to the thyroid
gland where oxidization and incorporation into tyrosyl residues of
thyroglobulin occurs.

Tyrosine is further oxidized to form monoiodotyrosine (MIT) and

diiodotyrosine (DIT).

The combination of 2 molecules of DIT forms thyroxine (T4).

Triiodothyronine (T3) is made by the combination of MIT and DIT and by

the monodeiodination of T4 in the periphery.
***T3 is 4 times more active than the more abundant T4.

***The half-life of T4 is 5-7 days; the half-life of T3 is only 1 day.

Approximately 99% of the circulating thyroid hormone is bound to

plasma protein and is metabolized primarily by the liver.

Levels of thyroid hormones in the serum are tightly regulated by the

hypothalamic-pituitary-thyroid axis. Thyroid-releasing hormone (TRH)
is secreted by the hypothalamus, and stimulates the release of
thyroid-stimulating hormone (TSH) from the pituitary gland.

Mature TSH reaches the thyroid gland and stimulates thyroid hormone
production and release. The main hormone secreted from the thyroid
gland is T4, which is converted to T3 by deiodinase in the peripheral
organs.

Secreted thyroid hormone reaches the hypothalamus and the pituitary,

where it inhibits production and secretion of TRH and TSH, thereby
establishing the hypothalamic-pituitary-thyroid axis.
What do they do?
Metabolism increase basal metabolism and
produce heat, lipids- hypothyroidism = elevated
levels, carbohydrates- enhances the insulin-
dependent entry of glucose into the cell
Growth & development- hypothyroidism=
growth retardation and poor brain development
remember this with Pregnant patients
Cardiovascular- increase heart rate, cardiac
contractility and output; vasodilitation
Reproductive- fertility issues
What else do they do?
Central Nervous System- Hypothyroidism =
feels sluggish, may report memory loss or
fatigue
Hyperthyroidism- anxiety or nervousness
*** psychiatry will order a TSH for depression or
anxiety to r/o coexisting thyroid disorders***
What do you see in
hypothyroidism?
dry skin, dry brittle hair that falls out,
onychomycosis, yellowish buildup of carotene-
palms or soles of feet, peripheral edema/
myxedema, decreased sweating, cold
intolerance, constipation, muscle aches,
scalloped tongue, slowed mental responses,
depression, hoarseness, goiter, higher BP and
lower HR, wt gain, excessive sleepiness and
fatigue
Labs- elevated TSH and cholesterol panel, low
free T4, occ low T3
What do you see for
hyperthyroidism?
Fine hair, smooth velvety skin, excessive
sweating, heat intolerance, frequent BMs,
tremors, nervousness, agitation, higher HR
and lower BP, wt loss, irregular menses and
fatigue
Labs: Low TSH and elevated free T4 and total
T3
What drugs treat
Hypothyroidism?
Levothyroxine (T4) (Synthroid, Levoxyl, Levothroid,
Unithroid) - onset 48hr, peak 1-3weeks, duration 1-3weeks,
life 7days
Liothyronine (T3) (Cytomel, Triostat) - onset 48hr, peak 24-
72hr, duration 72hr, life 1-2days
Liotrix (T3, T4) (Thyrolar, Thyrolar-1, Thyrolar-1/4, Thyrolar-
2) - onset unknown, peak T3 24-72hr but T4 1-3weeks,
duration 1-3weeks, life days
*** permanent back order with no release date ***
***Armour Thyroid is not recommended by the American Association of
Clinical Endocrinologists

Side effects tolerated well, but reevaluate if s/s of

hyperthyroidism occur
What drugs treat
Hyperthyroidism?
Propylthiouracil (no brand name) onset 10-
21days, peak 6-10 weeks, duration weeks, half
life 1-2hr
Methimazole (Tapazole, Northyx) onset 1 week,
peak 4-10 weeks, duration weeks, life 6-13 hr
Sodium Iodine 131 (Iodotope) onset 3-6days,
peak- unknown, duration 56 days, life 8 days
Side effects rash, itching, fever, liver
inflammation and decreased WBCs
Pt to report jaundice, elevated fever or sore throat
Hypothyroidism dosing
Levothyroxine- 50mcg qam for most adults,
reevaluate in 4 weeks until euthyroid and patient
feels better
Pediatric 2-10mcg/kg/d
Dose recommended by AACE is 1.6mcg/kg/day with a
target TSH of 0.3- 3.0 mIU/L

Liothyronine -25mcg to start for adults and increase

slowly by 12.5mcg every 4 weeks
*** only used with documented T3 deficiency***
Hyperthyroidism dosing
Propylthiouracil 100mg QID initially, then
100-150mg qd maintenance, max 900mg/d

Methimazole 15-180mg qd, maintenance 5-

15mg qd depending on labs

Sodium Iodine 131 4-10 mCi x 1 dose,

repeat dose in 6-12mo depending on labs and
Cancer status
Challenges in Prescribing
Elderly and Pediatrics require lower initial doses and
maintenance doses, possibly more frequent labs
Pregnancy dosing should be supervised by a
specialist
Cardiovascular- must control HR and BP with
treatment and requires frequent monitoring and
report from pt any CP, SOB; chronic hypothyroidism
predisposes pts to CAD
Adrenal insufficiency, myxedema, diabetes mellitus
& diabetes insipidus s/s may be exaggerated or
aggravated with T4 or T3 replacement
Case Study 1
Pt presents with excessive sleepiness, rapid
weight gain, elevated BP and lowered HR.
States that he feels tired all the time, never
rested, has muscle aches, weird dry skin,
doesnt think he sweats anymore, cannot
exercise as long as he did before and feels like
he cannot remember things as well which is a
problem because he is completing his
electrical engineering degree.
Treatment course
TSH, cholesterol panel, CBC and Chem14 ordered
and a sleep study. Told to write down what he is
eating and get daily exercise. Lisinopril started for
HTN.

Return visit, 1 week later- reviewed labs BP 138/80

TSH 48.2, Tchol 201, HDL 34, LDL 118, trigs 155
AST 46, ALT 70 No other abnl labs
Started on Synthroid 25mcgx2 weeks, then 50mcg
qd
Treatment course
Returns 4 weeks after dx of hypothyroidism
and rechecked labs, US results reviewed
TSH 44, free T4 < 0.4, T3 22
Antithyroid peroxidase 56 (nl <2 IU/mL)
Antithyroglobulin autoantibodies 74 (nl <1
IU/mL)
US reviews sl. Enlg thyroid by only a few mm

Much progress?
Treatment course
Synthroid increased and changed to generic
levoxyl 75mcg qam, labs repeated in 6weeks
(due to work schedule). He still reports fatigue
and inability to lose weight despite a lower
calorie diet and daily walking for 30min and
lifting weights 2-3times per week.
TSH 23, free t4 0.8 total T3 40
Medication changed to 100mcg- told to take
an extra 25mcg to his 75mcg as he had a few
weeks left of this
Treatment course
Pt complains of chest pressure, BP is 150/96 and HR is
50, feels awful and stat meds given and TSH taken
TSH 46, free T4 < 0.4
He reports compliance with medications at 75mcg
+25mcg every morning bottle checked and different
manufacturer but nothing else has changed, new
prescription issued but insurance would not pay for
the 100mcg of Synthroid that MD wrote brand name
necessary, so samples utilized and pt felt better in a
few days bottle taken in for testing and both bottles
contained 25mcg pills- pharmacist suspected
mislabeled
Treatment Wrap Up Case
Study 1
Over the course of 1 year and with 2 different
endocrinologists with varying opinions about
treating numbers vs. patients, he still has
found it difficult to lose weight especially with
increased stress and gets tested every
3months due to the varying nature of
Hashimotos thyroiditis.
Current dose of levothyroxine 225mcg per day
Current labs TSH 1. 43, free T4 0.98, total T3
90
Case Study 2
Pt presents with wt loss, anxiety, SOB, elevated HR
and severe fatigue I cant even get around the
house without getting out of breath and I have to rest
after I eat for about an hour, and I have to force
myself to eat
No other significant PMHx except lymphoma 7yr ago
Pt cannot afford insurance and cannot get on
Medicare until November and it is May
Placed on BB for tachycardia of 118 while at rest and
labs ordered- advised BP and HR monitor qd & prn
TSH <0.01, T4 total 18.4 (nl 4.5- 12.5), free T4 8.6,
T3 uptake 47, T3 total>800
Treatment course
Consulted an endocrinologist who agrees to give
some discounted care to pt with plans to delay
intervention until pt is eligible for Medicare to
save her the cost of surgery or radioactive Iodine
Put patient on methimazole 10mg BID by PCP and
seen by endocrinologist and he put her on 10mg
3 tabs TID over the course of 3 weeks
Seen in July for labs : TSH 24.67, free T4 0.3, total
T3 63 and Thyroid Stimulating Immunoglobulin
TSI ordered by endo. 174 (nl<125)
Treatment course
Seen August 7th after adjusting methimazole to
10mg BID and advised to not let more than 4
weeks pass between labs. Metoprolol increase to
100mg TID to control HTN and tachycardia
August 27th pt reports endo. Called her and told
her to increase methimazole to 20mg BID but she
is feeling awful again so he told her to stop it x 1
week and f/u
TSH 0.12, free T4 4.5, total T3 >800, T3 uptake 42
Repeat labs verify these are correct numbers as
endo. Did not believe 1st set
Treatment course
Long discussion with endocrinologist about pts
fast response to med changes and he agrees to
let PCP manage this until euthyroid
October 7th repeat labs, pt using metoprolol
300mg/d and thru teaching, is aware she can
take up to 450mg/d or 50mg extra when BP is
elevated
TSH 0.79, free T4 1.6, total T4 5.4, T3 uptake 30
first nl labs!
Pt has had consult and should get radioactive
iodine but has to be off the methimazole for
several weeks prior according to endo.
Treatment Wrap Up Case
Study 2
Speak with interventional radiologist and
discuss pts course and hyper-responsiveness
to medications, also that pt is close to max
dose of BB and previously got very
hypertensive with CP and SOB when not on
enough methimazole. He agrees to much
shorter time off methimazole and to do the
radioactive iodine on November 3 rd as she
qualifies for Medicare on November 1 st.
Pt develops SOB end of October & PCP orders
CXR, lymphoma is back with pleural effusion,
treatment delayed 1 week
Questions?
References
Gutierrez, K. (1999). Pharmacotherapeutics, Clinical Decision-Making in
Nursing. W.B. Saunders Company, USA.
McCance, K. &Huether, S. (2002). Pathophysiology, The Biologic Basis for
Disease in Adults & Children. Mosby, Inc. St. Louis, MO.
http://www.pyroenergen.com/articles08/thyroid-gland-hormones.htm
(thyroid picture)
http://emedicine.medscape.com/article/819692-overview (hormones)
http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/thyroid/physio.ht
ml (what do they do?) http://holisticprimarycare.net/topics/topics-h-
n/healthy-aging/94-the-clinical-picture-of-hypothyroidism (what do you see?
hypothyroidism) http://www.medicinenet.com/hyperthyroidism/article.htm
(what do you see? Hyperthyroidism)
http://www.endocrineweb.com/conditions/hyperthyroidism/hyperthyroidism-
overactivity-thyroid-gland (anti-thyroid drugs)
https://www.aace.com/pub/guidelines AMERICAN ASSOCIATION OF
CLINICAL ENDOCRINOLOGISTS
MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND
TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM, AACE Thyroid
Task Force, Chairman, H. Jack Baskin, MD, MACE