NR565 Final Exam Study Guide
Week 5
Key Points
• The first-line medication for type 2 DM is metformin.
• ADA and other professional guidelines inform prescribing decisions.
• Combination injectable therapy should be considered for immediate implementation in
patients with an A1C of 10% or higher.
• TZDs, like Actos, can precipitate CHF and should be avoided in patients with heart failure.
• Older adults should be started on lower doses of levothyroxine.
• Radioactive iodine treatment results in lifelong hypothyroidism.
• When treating hypothyroidism, TSH levels should be monitored every 6-8 weeks until the
patient achieves a euthyroid state.
- Signs and symptoms of hypothyroidism and hyperthyroidism (pp. 418-419)
Hypothyroidism: The face is pale, puffy, & expressionless. The skin is cold & dry. The hair is brittle, & hair
loss occurs. Heart rate & temperature are lowered. The patient may c/o lethargy, fatigue, & cold
intolerance. Mentation may be impaired. Thyroid enlargement may occur if reduced levels of T 3 & T4
promote excessive release of TSH.
Hyperthyroidism: Heartbeat is rapid & strong, & dysrhythmias & angina may develop. The CNS is
stimulated, resulting in nervousness, insomnia, rapid thought flow, & rapid speech. Skeletal muscles may
weaken & atrophy. Metabolic rate is raised, resulting in increased heat production, increased body
temperature, intolerance to heat, & skin that is warm & moist. Increased appetite, but weight loss may
occur if caloric intake fails to match the increase in metabolic rate. (Exophthalmos w/Graves’ disease).
- What adjunctive therapy is good to prescribe to control symptoms of hyperthyroidism other
than thyroid specific medications? Know drug classes and examples of those drug classes. (pp.
419, 423)
Beta-blockers & nonradioactive iodine may be used as adjunctive therapy for hyperthyroidism.
Beta-blockers: Suppress tachycardia by blocking beta-receptors on the heart. (“-lol”)
Nonradioactive iodine: Inhibits synthesis & release of thyroid hormones. (Lugol Solution = mixture
containing 5% elemental iodine & 10% potassium iodine).
- Monitoring needs and intervals for thyroid medications. (pp. 421, 423)
Hypothyroidism: Levothyroxine (T4) (Brand-name: Levoxyl, Synthroid)
Therapeutic Goal: Resolution of signs & symptoms of hypothyroidism & restoration of normal lab values
for serum TSH & free T4.
Baseline Data: Obtain serum levels of TSH & free T4.
,Monitoring: Check TSH 6-8 weeks after initiating therapy & after any dosage change. Check TSH at least
once a year after serum TSH is stabilized.
Identifying High-Risk Patients: Use w/caution in those patients with cardiovascular disease & start w/lower
doses in older adult patients.
Evaluating Therapeutic Effects: Look for a reversal of signs of thyroid deficiency & an absence of signs of
thyroid excess. In children, normalization of intellectual function, growth, & development should occur.
Monthly measurements of height provide a good index of thyroid sufficiency. Lab tests should indicate
normal plasma levels of TSH & T4. Measure TSH levels at least 1x/year.
Minimizing Adverse Effects: Overdose may cause thyrotoxicosis. Symptoms include tachycardia, angina,
tremor, nervousness, insomnia, sweating, & heat intolerance.
Hyperthyroidism: Methimazole (a thionamide) (Brand-name: Tapazole)
Therapeutic Goal: Methimazole has 4 indications—reduction of thyroid hormone production in Graves’
disease, control of hyperthyroidism until the effects of radiation on the thyroid become manifest,
suppression of thyroid hormone production before subtotal thyroidectomy, & treatment of thyrotoxic
crisis.
Baseline Data: Obtain serum levels of TSH, T3, & T4. Check baseline CBC & LFTs prior to initiation.
Monitoring: Check CBC w/differential if signs or symptoms of infection. Check LFTs if signs or symptoms of
liver dysfunction.
Identifying High-Risk Patients: Methimazole should be avoided in the 1st trimester of pregnancy & in
women who are breastfeeding.
Evaluating Therapeutic Effects: Monitor for weight gain, decreased heart rate, & other indications that
levels of thyroid hormone have declined. Lab tests should indicate a decrease in serum free T3 & free T4.
Minimizing Adverse Effects:
Agranulocytosis: Inform patients about early signs of agranulocytosis, including fever or sore
throat. If follow-up blood tests reveal leukopenia, methimazole should be stopped.
Hypothyroidism: Methimazole may cause excessive reductions in thyroid hormone synthesis. If signs
of hypothyroidism develop or if plasma levels of T3 & T4 become subnormal, dosage should be
reduced.
- Propylthiouracil (PTU) carries a risk for liver toxicity. Although rare, the FDA recommends against
using PTU as a first-line treatment due to potential for hepatic toxicity. (p. 422)
Also a thionamide, PTU suppresses synthesis of thyroid hormones. Its therapeutic uses include pregnant
women in the 1st trimester, thyroid storm, & patients w/intolerance to methimazole. It has caused rare
cases of liver injury. Onset is sudden & progression is rapid.
, - Effects of maternal hypothyroidism on offspring and appropriate patient teaching related to need
for treatment. (p. 418)
Maternal hypothyroidism can result in permanent neuropsychological deficits in the child, including
decreased IQ. The effect of maternal hypothyroidism is limited largely to the 1 st trimester, a time during
which the fetus is unable to produce thyroid hormones of its own. By the 2nd trimester, the fetal thyroid
gland is fully functional, & hence the fetus can supply its own hormones from then on. To help ensure
healthy fetal development, maternal hypothyroidism must be diagnosed & treated very early. Due to the
unspecific symptoms or sometimes asymptomatic hypothyroidism, some experts recommend routine
screening for hypothyroidism as soon as pregnancy is confirmed. If diagnosed, replacement therapy
should begin immediately.
When women taking thyroid supplements become pregnant, dosage requirements usually increase—often
by as much as 50%. The need for increased dosage begins between weeks 4 to 8 of gestation, levels off at
approximately week 16, & then remains steady until giving birth. To ensure adequate hormone levels,
some providers increase T4 dosage by 30% as soon as pregnancy is confirmed. Further adjustments are
based on serum TSH levels, which should be monitored closely.
- Patient teaching for thyroid medications. (pp. 420-423)
Levothyroxine: Take the drug exactly as prescribed. Take the dose at the same time each day, preferably in
the morning at least 30-60 mins before breakfast, to maintain constant hormones levels. Taking the drug
in the morning prevents insomnia. Report signs & symptoms of thyroid hormone overdose (chest pain,
palpitations, sweating, nervousness) or aggravated cardiovascular disease (chest pain, dyspnea,
tachycardia). Advise patients to check w/their prescriber before allowing a pharmacist to switch to a
different levothyroxine product, as there are questions concerning the equivalence between them.
Patients must be made fully aware that this medication provides symptomatic relief but does not cure
hypothyroidism, therefore replacement therapy must usually continue for life.
Methimazole: Patients should be instructed to immediately report any fever, sore throat, or mouth sores
(early signs of agranulocytosis) or skin eruptions (signs of hypersensitivity). Avoid being near people who
are sick or have infections. If follow-up blood tests reveal leukopenia, this medication should be stopped.
It may cause excessive reductions in thyroid hormone synthesis. If signs of hypothyroidism develop or if
plasma levels of T3 & T4 become subnormal, dosage should be reduced.
Radioactive Iodine: Inform patients about symptoms of iodism, including brassy taste, burning sensations in
the mouth, & soreness of gums & teeth. Iodine can also cause corrosive injury to the GI tract. Instruct
patients to notify the provider if severe abdominal distress develops.
- What drug class can interfere with the assessment and monitoring of diabetes and why? (p. 406)
Beta-blockers can delay awareness of & response to hypoglycemia by masking signs that are associated
with stimulation of the sympathetic nervous system (tachycardia, palpitations) that hypoglycemia normally
causes. Furthermore, because blocking the beta cells impairs glycogenolysis & because glycogenolysis is
one means by which the body can respond to & counteract a fall in blood glucose, beta-blockers can make
insulin-induced hypoglycemia even worse by preventing the body’s natural counterregulatory response.
- Hgb A1C goals- what are they generally? (p. 400) Review goal guidelines for different age
Week 5
Key Points
• The first-line medication for type 2 DM is metformin.
• ADA and other professional guidelines inform prescribing decisions.
• Combination injectable therapy should be considered for immediate implementation in
patients with an A1C of 10% or higher.
• TZDs, like Actos, can precipitate CHF and should be avoided in patients with heart failure.
• Older adults should be started on lower doses of levothyroxine.
• Radioactive iodine treatment results in lifelong hypothyroidism.
• When treating hypothyroidism, TSH levels should be monitored every 6-8 weeks until the
patient achieves a euthyroid state.
- Signs and symptoms of hypothyroidism and hyperthyroidism (pp. 418-419)
Hypothyroidism: The face is pale, puffy, & expressionless. The skin is cold & dry. The hair is brittle, & hair
loss occurs. Heart rate & temperature are lowered. The patient may c/o lethargy, fatigue, & cold
intolerance. Mentation may be impaired. Thyroid enlargement may occur if reduced levels of T 3 & T4
promote excessive release of TSH.
Hyperthyroidism: Heartbeat is rapid & strong, & dysrhythmias & angina may develop. The CNS is
stimulated, resulting in nervousness, insomnia, rapid thought flow, & rapid speech. Skeletal muscles may
weaken & atrophy. Metabolic rate is raised, resulting in increased heat production, increased body
temperature, intolerance to heat, & skin that is warm & moist. Increased appetite, but weight loss may
occur if caloric intake fails to match the increase in metabolic rate. (Exophthalmos w/Graves’ disease).
- What adjunctive therapy is good to prescribe to control symptoms of hyperthyroidism other
than thyroid specific medications? Know drug classes and examples of those drug classes. (pp.
419, 423)
Beta-blockers & nonradioactive iodine may be used as adjunctive therapy for hyperthyroidism.
Beta-blockers: Suppress tachycardia by blocking beta-receptors on the heart. (“-lol”)
Nonradioactive iodine: Inhibits synthesis & release of thyroid hormones. (Lugol Solution = mixture
containing 5% elemental iodine & 10% potassium iodine).
- Monitoring needs and intervals for thyroid medications. (pp. 421, 423)
Hypothyroidism: Levothyroxine (T4) (Brand-name: Levoxyl, Synthroid)
Therapeutic Goal: Resolution of signs & symptoms of hypothyroidism & restoration of normal lab values
for serum TSH & free T4.
Baseline Data: Obtain serum levels of TSH & free T4.
,Monitoring: Check TSH 6-8 weeks after initiating therapy & after any dosage change. Check TSH at least
once a year after serum TSH is stabilized.
Identifying High-Risk Patients: Use w/caution in those patients with cardiovascular disease & start w/lower
doses in older adult patients.
Evaluating Therapeutic Effects: Look for a reversal of signs of thyroid deficiency & an absence of signs of
thyroid excess. In children, normalization of intellectual function, growth, & development should occur.
Monthly measurements of height provide a good index of thyroid sufficiency. Lab tests should indicate
normal plasma levels of TSH & T4. Measure TSH levels at least 1x/year.
Minimizing Adverse Effects: Overdose may cause thyrotoxicosis. Symptoms include tachycardia, angina,
tremor, nervousness, insomnia, sweating, & heat intolerance.
Hyperthyroidism: Methimazole (a thionamide) (Brand-name: Tapazole)
Therapeutic Goal: Methimazole has 4 indications—reduction of thyroid hormone production in Graves’
disease, control of hyperthyroidism until the effects of radiation on the thyroid become manifest,
suppression of thyroid hormone production before subtotal thyroidectomy, & treatment of thyrotoxic
crisis.
Baseline Data: Obtain serum levels of TSH, T3, & T4. Check baseline CBC & LFTs prior to initiation.
Monitoring: Check CBC w/differential if signs or symptoms of infection. Check LFTs if signs or symptoms of
liver dysfunction.
Identifying High-Risk Patients: Methimazole should be avoided in the 1st trimester of pregnancy & in
women who are breastfeeding.
Evaluating Therapeutic Effects: Monitor for weight gain, decreased heart rate, & other indications that
levels of thyroid hormone have declined. Lab tests should indicate a decrease in serum free T3 & free T4.
Minimizing Adverse Effects:
Agranulocytosis: Inform patients about early signs of agranulocytosis, including fever or sore
throat. If follow-up blood tests reveal leukopenia, methimazole should be stopped.
Hypothyroidism: Methimazole may cause excessive reductions in thyroid hormone synthesis. If signs
of hypothyroidism develop or if plasma levels of T3 & T4 become subnormal, dosage should be
reduced.
- Propylthiouracil (PTU) carries a risk for liver toxicity. Although rare, the FDA recommends against
using PTU as a first-line treatment due to potential for hepatic toxicity. (p. 422)
Also a thionamide, PTU suppresses synthesis of thyroid hormones. Its therapeutic uses include pregnant
women in the 1st trimester, thyroid storm, & patients w/intolerance to methimazole. It has caused rare
cases of liver injury. Onset is sudden & progression is rapid.
, - Effects of maternal hypothyroidism on offspring and appropriate patient teaching related to need
for treatment. (p. 418)
Maternal hypothyroidism can result in permanent neuropsychological deficits in the child, including
decreased IQ. The effect of maternal hypothyroidism is limited largely to the 1 st trimester, a time during
which the fetus is unable to produce thyroid hormones of its own. By the 2nd trimester, the fetal thyroid
gland is fully functional, & hence the fetus can supply its own hormones from then on. To help ensure
healthy fetal development, maternal hypothyroidism must be diagnosed & treated very early. Due to the
unspecific symptoms or sometimes asymptomatic hypothyroidism, some experts recommend routine
screening for hypothyroidism as soon as pregnancy is confirmed. If diagnosed, replacement therapy
should begin immediately.
When women taking thyroid supplements become pregnant, dosage requirements usually increase—often
by as much as 50%. The need for increased dosage begins between weeks 4 to 8 of gestation, levels off at
approximately week 16, & then remains steady until giving birth. To ensure adequate hormone levels,
some providers increase T4 dosage by 30% as soon as pregnancy is confirmed. Further adjustments are
based on serum TSH levels, which should be monitored closely.
- Patient teaching for thyroid medications. (pp. 420-423)
Levothyroxine: Take the drug exactly as prescribed. Take the dose at the same time each day, preferably in
the morning at least 30-60 mins before breakfast, to maintain constant hormones levels. Taking the drug
in the morning prevents insomnia. Report signs & symptoms of thyroid hormone overdose (chest pain,
palpitations, sweating, nervousness) or aggravated cardiovascular disease (chest pain, dyspnea,
tachycardia). Advise patients to check w/their prescriber before allowing a pharmacist to switch to a
different levothyroxine product, as there are questions concerning the equivalence between them.
Patients must be made fully aware that this medication provides symptomatic relief but does not cure
hypothyroidism, therefore replacement therapy must usually continue for life.
Methimazole: Patients should be instructed to immediately report any fever, sore throat, or mouth sores
(early signs of agranulocytosis) or skin eruptions (signs of hypersensitivity). Avoid being near people who
are sick or have infections. If follow-up blood tests reveal leukopenia, this medication should be stopped.
It may cause excessive reductions in thyroid hormone synthesis. If signs of hypothyroidism develop or if
plasma levels of T3 & T4 become subnormal, dosage should be reduced.
Radioactive Iodine: Inform patients about symptoms of iodism, including brassy taste, burning sensations in
the mouth, & soreness of gums & teeth. Iodine can also cause corrosive injury to the GI tract. Instruct
patients to notify the provider if severe abdominal distress develops.
- What drug class can interfere with the assessment and monitoring of diabetes and why? (p. 406)
Beta-blockers can delay awareness of & response to hypoglycemia by masking signs that are associated
with stimulation of the sympathetic nervous system (tachycardia, palpitations) that hypoglycemia normally
causes. Furthermore, because blocking the beta cells impairs glycogenolysis & because glycogenolysis is
one means by which the body can respond to & counteract a fall in blood glucose, beta-blockers can make
insulin-induced hypoglycemia even worse by preventing the body’s natural counterregulatory response.
- Hgb A1C goals- what are they generally? (p. 400) Review goal guidelines for different age
