Jerica Mae Bautista

Samirah P. Fandino

Pharmacotherapeutics V
Case 1
Chief Complaint
“My heart feels like it is racing, and I feel jittery.”

HPI
Carrie Gibson is a 23-year-old woman who presents to her PCP with complaints of palpitations and a fine
tremor. The palpitations started a few months ago and would come and go until the past week when
they began occurring more frequently, almost daily. She denies CP. She reports that she began noticing a
fine tremor approximately 3 weeks ago. She also reports loose stools and a 5-kg weight loss over the
past 6 months, despite a good appetite and food intake. She feels hot all of the time and sweats a lot.
She further states that she has been losing her hair recently and that she is more irritable than usual.

PMH
She has been healthy up to this point with no medical conditions. She reports having had “the flu” last
November, but states that she did not seek medical attention at that time.

FH
Father has HTN; mother had a history of Graves disease and passed away 1 year ago from breast CA at
age 53. Her oldest sister is 32 years of age and has breast CA; she has two other sisters, ages 29 and 25,
and one brother, age 27, all of whom are healthy. Her aunt (mother’s sister) and grandmother both had
Graves disease.

SH
She smokes 1.5 ppd × 5 years and drinks alcohol socially on the weekends (“a few drinks on Fridays and
Saturdays”).

Meds
Drospirenone/ethinyl estradiol daily

Labs
LABORATORY RESULT NORMAL RANGE REMARKS

Na 140 mEq/L 135-145 mEq/L Normal

K 4.1 mEq/L 3.6-5.2 mEq/L Normal

Cl 98 mEq/L 96-106 mEq/L Normal

CO2 23 mEq/L 23-29 mEq/L Normal

BUN 9 mg/dL 6-24 mg/dL Normal

SCr 0.6 mg/dL 0.59-1.04 mg/dL Normal

Glu 78 mg/dL 70-100 mg/dL Normal

Hgb 12.8 g/dL 12.1-15.1 g/dL Normal

Hct 38.4% 36% to 48% Normal

RBC 3.08 x 106/mm3 4.2-5.4 x 106/mm3 Low

Plt 298 x 103/mm3 150 – 450 x 103/mm3 Normal

MCV 86.4 um3 80-100 um3 Normal

MCH 27.1 pg 27-31 pg Normal

MCHC 31.8 g/dL 32-36 g/dL Low

RDW 10.2% 12% - 15% Low

WBC 4.8 x 103/mm3 4.5-11.0 x 103/mm3 Normal

AST 14 IU/L 8-33 IU/L Normal

ALT 16 IU/L 4-36 IU/L Normal

T.Bili 0.2 mg/dL 0.1-1.2 mg/dL Normal

Amylase <30 IU/L 40-140 IU/L Low

Ca 9.5 mg/dL 8.6-10.3 mg/dL Normal

Mg 2.0 mEq/L 1.7-2.2 mEq/L Normal

 Phos 3.7 mg/dL 2.8-4.5 mg/Dl Normal

Total T4 24 mcg/dL 5.0-12.0 mcg/dL High

Free T4 4 ng/dL 0.9-2.3 ng/dL High

TSH 0.02 Miu/L 0.5-5.0 Miu/L Low

T3 Resin Uptake 35% 24% - 37% Normal

Total T3 550 ng/dL 60-180 ng/dL High

Free Thyroxine Index 28.7 4.8-12.7 mcg.dL High

Questions:

1. What would be the probable diagnosis to this case?

a) What are the signs and symptoms or laboratory values indicated that may support your
answer in number 1?
Probable diagnosis: Grave’s disease causing Hyperthyroidism
Signs and Symptoms the patient might experience:

Cardiovascular Respiratory Gastrointestinal Integumentary Musculoskeletal Other symptoms

Bounding rapid pulse Dyspnea on mild Increase appetite, Warm, smooth, Fatigue Intolerance to heat
exertion thirst moist skin
Dysrhythmias Weakness Elevated basal
Increased Weight loss Thin, brittle nails temperature
Palpitations respiratory rate detached from Proximal muscle
Increase nail bed wasting Eyelid retraction
Increased heart rate peristalsis
and force of cardiac Hair loss Osteoporosis Exophthalmos
contractions Diarrhea
Clubbing of Dependent Irritability
fingers edema
Fatigue
Fine, silky hair
Fine tremor of fingers
Diaphoresis and tongue

Vitiligo Insomnia

Restlessness
 Laboratory values:
Test Hyperthyroid Primary Secondary
(Hypothyroid (Hypothyroid)

Thyroid stimulating hormone ↓ ↑ ↓

(TSH)

T4 (Thyroxine) ↑ ↓ ↓

Total cholesterol N ↑ ↑

Low density lipoproteins (LDL) ↓ ↑ ↑

Triglycerides N ↑ ↑

Creatinine Kinase N ↑ ↑

Basal metabolic rate ↑ ↓

Thyroid peroxidase antibody N In autoimmune N

hypothyroidism (+)

➢ The Free T4 (4ng/dL) value is considered above normal since normal range is 0.9-2.3
ng/dL.
➢ Total T3 (550 ng/dL) and T4 (24 mcg/dL) values are above normal compared to the
normal T3 (60-180 mcg/dL) and T4 (5-12 mcg/dL).
➢ TSH level is too low than the normal range. The normal range is 0.5-5 mIU/L.
➢ High levels of free thyroxine index (28.7 mcg/dL) than the normal range of 4.8-12.7
mcg/dL.

2. What are the goals of pharmacotherapy for this patient?

The overall goals are that the patient with hyperthyroidism will (1) experience relief of symptoms, (2)
have no serious complications related to the disease or treatment, (3) maintain nutritional balance, and
(4) cooperate with the therapeutic plan.

1. β-adrenergic blockers - are used for symptomatic relief of thyrotoxicosis. These drugs block the
effects of sympathetic nervous stimulation, thereby decreasing tachycardia, nervousness,
irritability and tremors. Propranolol is usually given with antithyroid agents. Atenolol is the
preferred β-adrenergic blocker for use in the hyperthyroid patient with asthma or heart disease.
Dose: A nonselective β-blocker such as propranolol is administered 20 to 40 mg four times daily.
Titrate β-blocker dose is based on signs and symptoms of the patient.
 2. Antithyroid drugs - The first line antithyroid drugs are propylthiouracil and methimazole
(Tapazole). These drugs inhibit the synthesis of thyroid hormones. Propylthiouracil is generally
used for patients who are in the first trimester of pregnancy, had an adverse reaction to
methimazole, or require a rapid reduction in symptoms. Propylthiouracil is considered the first
line of therapy in thyrotoxicosis since it also blocks the conversion of T4 to T3. Methimazole is
preferred to normalize thyroid function. The usual starting dose of MMI is 10 to 20 mg/day, and
the usual starting dose of PTU is 50 to 150 mg three times daily.

3. Iodine
- It works by blocking the synthesis of T3 and T4 and blocks these hormones from releasing into
blood circulation.
- Available as a saturated solution of potassium iodine (SSKI) and Lugol’s solution.
- Assess the patient for s/sx of iodine toxicity such as swelling of the buccal mucosa, excess
salivation, nausea and vomiting.

4. Compliance with the treatment plan is necessary. Thyroid function testing should be performed
every 4 to 6 weeks until stable. Teach the patient the signs and symptoms of thyroid failure and
to seek medical care promptly if these develop.

3. What nondrug therapies might be useful for this patient?

● Nutrition - with the increased metabolic rate, there is a high potential for the patient to have
nutritional deficit. A high calorie diet (4000 to 5000 cal/day) may be needed to satisfy hunger,
prevent tissue breakdown, and decrease weight loss.
● Diet.
- Teach the patient to avoid highly seasoned and highly-fiber foods because these foods
can further stimulate the hyperactive GI tract
- Avoid caffeine containing liquids such as coffee, tea and cola to decrease the
restlessness and sleep disturbances associated with these fluids.
- Iodine is used by the thyroid to make the hormone thyroxine, high iodine intake could
lead to increase in hormone production by the thyroid gland.
● Smoking cessation - Smoking may increase the development of the disease, reduce the
effectiveness of the treatment and may cause relapse. Quitting smoking can reduce the
symptoms of hyperthyroidism and improve treatment outcomes.
● Hyperthyroidism can make it difficult for your body to absorb calcium. This can cause brittle
bones and osteoporosis. Eating a diet high in calcium may help, although some dairy products
are fortified with iodine and may not be as beneficial for you. Food rich in calcium includes:
broccoli, almonds, kale, sardines, and okra.
● Avoiding meat and other animal products. There are studies and evidence that becoming a
vegetarian lowers the risk of hyperthyroidism.
● Exercise - Regular exercise can reduce anxiety, build bone density, increase muscle tone and
benefit the cardiovascular system.
 ● Relaxation Techniques. Reducing stress can be just as important to your health as diet and
exercise. People with Grave’s disease are at an increased risk of induced stress health
complications.

4. Are there any drug interactions or contraindications among the prescribed meds for the
patient and to the proposed pharmacotherapy?

➢ Yes there is an interaction between Drosperinone/ethinyl estradiol and the proposed

pharmacotherapy.
➢ Estrogen causes an increase in thyroxine binding globulin (TBG) levels. TBG is a type of liver
protein that is responsible for moving thyroid hormones through the circulatory system. When
you have an increase in TBG, it binds thyroid hormone and decreases the amount of thyroid
hormone available in the body.
➢ Increased estrogen also decreases the synthesis of T4 (inactive form) to T3 (active form)
resulting in a hypothyroid state. Second TBG (thyroid binding globulin) may be preoccupied with
the increased estrogen levels and there will be less free T3 circulating in the blood system and
with the addition of the proposed pharmacotherapy this may result again in a hypothyroid state
causing symptoms of fatigue, brain fog, hair loss, weight gain, low mood, constipation and
irregular menstrual cycles.

References:
https://www.everydayhealth.com/hyperthyroidism/guide/treatment/
https://doctorneville.com/blog/2022/5/5/estrogen-progestone-and-thyroid-hormones-friends-or-fo
es
https://www.thyroid.org/thyroid-function-tests/