PHARMACOLOGY 3

Department of Pharmacology and Toxicology

Faculty of Pharmacy
University of Sadat City 1
Hypothyroidism

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• Definition: It is the clinical syndrome that results from inadequate secretion
of thyroid hormones from the thyroid gland.

• Signs and Symptoms of Hypothyroidism

• Hypothyroidism can affect virtually any tissue or organ in the body.
• The most common symptoms, such as:
✓ fatigue,
✓lethargy,
✓sleepiness,
✓cold intolerance,
✓and dry skin, are nonspecific and can be seen with many other disorders.
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• Causes:
1. Autoimmune disease: The most common cause
known as Hashimoto's thyroiditis.
2. Over-response to hyperthyroidism treatment:
correcting hyperthyroidism can end up lowering
thyroid hormone production too much, resulting
in permanent hypothyroidism.
3. Thyroid surgery: Removing all or a large portion
of your thyroid gland can diminish or halt
hormone production.
4. Radiation therapy: Radiation used to treat
cancers of the head and neck can affect your
thyroid gland and may lead to hypothyroidism.

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• Treatment: thyroid hormone replacement therapy.

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• PATIENT PRESENTATION
Chief Complaint
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“I’m so tired lately. I have no energy. Maybe I need some vitamins or something.”
History of Present Illness
Yi-Ling Wang is a 49-year-old woman who presents to her new physician
complaining of feeling tired, lethargic, and “not thinking straight” for the last 6
months. She has seen her previous primary care physician several times and has
been told that her symptoms are probably due to anemia from menorrhagia, stress,
depression, and/or impending menopause.

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• Despite treatment with iron (and resultant improvement of her anemia), a
hormonal contraceptive to help regulate her menstrual cycle, and an
antidepressant, her symptoms have slowly worsened. Two years ago, at a health
fair, she was told her TSH was 6.2 μU/mL (6.2 mU/L) and total cholesterol was
246 mg/dL (6.36 mmol/L).
• Her primary care physician felt the TSH value was compatible with subclinical
hypothyroidism and therefore could not explain her symptoms at that time. She
has been wondering if she really is depressed and why the depression
medication is not helping.
• Over the past few months, she has also noticed that her skin seems a little more
dry, and itchy and that she has difficulty keeping warm even in warm weather.
Finally, she asks you what is good for constipation since the Chinese herbs her
mother gave her are not helping.
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• Past Medical History
Iron-deficiency anemia diagnosed 6 months ago
• Depression × 6 months
Menorrhagia diagnosed 6 months ago
Osteopenia × 1 year

• Family History

Father had CAD and died of gastric cancer at age 74. Mother is alive at age 70
with osteoporosis and hypothyroidism. She has one brother who is healthy.

• Tobacco/Alcohol/Substance Use
Social drinker; (-) tobacco or illicit drug use
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• Allergies/Intolerances/Adverse Drug Events

Penicillin (rash as child)

• Medications (Current)

✓MOM 30 mL PO q 24 h PRN constipation

✓Chinese herb PO PRN constipation
✓Sertraline 50 mg PO q 24 h
✓Ortho Tri-Cyclen 28 PO q day
✓FeSO4 300 mg PO q 24 h
✓Calcium carbonate 1,000 mg PO q 12 h
✓Alendronate 35 mg PO weekly
✓Acetaminophen 650 mg PO PRN headache, body aches
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• Review of Systems
Occasional HA relieved with non aspirin pain reliever; (-) tinnitus, vertigo, or infections;
frequent body aches, which she attributes to lack of exercise; (-) change in urinary
frequency, but she has noticed an increase in the number of episodes of constipation
in the past year; reports cold extremities; (-) history of seizures, syncope, or loss of
consciousness; (+) dry skin.

Physical Examination
General
Well-appearing, middle-aged Asian woman in no acute distress

Vital Signs

BP 112/76 mm Hg, P 64, RR 12, T 36.2°C

Weight 127.6 lb (58 kg)
Height 62 in. (157.5 cm)

Denies pain 12
• Skin
Dry-appearing skin and scalp; (-) rashes or lesions
HEENT
PERRLA, EOMI; trace periorbital edema; (-) sinus tenderness; TMs appear
normal
Neck and Lymph Nodes
Thyroid gland smooth, slightly enlarged symmetrically; (-) thyroid nodules; (-)
lymphadenopathy; (-) carotid bruits
Chest
Clear to auscultation
Breasts
Examination deferred
Cardiovascular
RRR, normal S1, S2; (-) S3 or S4

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• Abdomen
Not tender/not distended; (-) organomegaly
• Neurology
Grossly intact; DTRs normal
• Genitourinary
Examination deferred

• Rectal
Examination deferred
Laboratory Tests
Fasting, obtained 2 days ago

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• Assessment
Forty-nine-year-old woman with signs, symptoms, and laboratory tests consistent
with hypothyroidism

• TARGETED QUESTIONS
1. What s/s of hypothyroidism does the patient have?
• Symptoms : fatigue, lethargy, sleepiness, cold intolerance, and dry skin, constipation

• Signs :

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2. Why is levothyroxine (LT4) the treatment of choice for
most patients with hypothyroidism?
1- LT4 mimics the normal physiology of the thyroid gland, which secretes
mostly T4 as a prohormone. Peripheral tissues convert T4 to T3 as needed based
on metabolic demands.

2- LT4 also has distinct pharmacokinetic advantages over T3. With a 7- to 10-day
half-life,

3- LT4 provides a very smooth dose-response curve with little peak and trough
effect

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3. What medications can cause hypothyroidism?

Several drugs can cause hypothyroidism, including

✓iodine-containing drugs such as amiodarone and iodinated radiocontrast media,
✓ lithium,
✓ interferon-α,
✓multikinase and tyrosine kinase inhibitors (imatinib, sunitinib, sorafenib),
✓p-aminosalicylic acid,
✓ethionamide,
✓sulfonylureas,
✓valproic acid and other antiepileptic drugs,
✓and aminoglutethimide
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4. What risks and adverse effects of therapy would you discuss
with the patient?

• Patients with long-term overtreatment are at higher risk for atrial fibrillation and
other cardiovascular morbidities, depression or mental status changes, and
osteoporosis.
• Elderly patients being treated with LT4 have a dose-related risk of fractures
even if the TSH is not suppressed below normal values.
• Elderly patients should receive close monitoring and dose adjustments to prevent
overtreatment.
• Patients who are undertreated are at higher risk for hypercholesterolemia and
other cardiovascular problems, depression or mental status changes, and
obstetric complications

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