• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/15

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

15 Cards in this Set

  • Front
  • Back
Refer to case (b):

Which of the following is NOT consistent with a diagnosis of hypothyroidism?
a. Dry skin and scalp.
b. Low TSH and serum free T4 level
c. Fatigue and lethargy
d. Hypercholesterolemia
b.
TSH is high, not low, in hypothyroidism. Fatigue and lethargy, changes in skin and scalp, and hypercholesterolemia, are all characteristic of hypothyroidism. (Slides 20 and 22).
Refer to case (b):

Which of the following is the best initial therapy for this patient’s hypothyroidism?
a. Institute lifestyle modification and laboratory surveillance
b. Institute levothyroxine 25 mg once daily
c. Institute levothyroxine 25 mcg once daily plus liothyronine 12.5 mcg/d
d. Institute levothyroxine 50 mcg once daily
e. Institute levothyroxine 100 mg once daily
d.
CL subclinical hypothyroidism since the TSH is elevated but the T4 and FT4 is normal. However CL has a TSH > 10 mIU/L and positive TPOAb, thus treatment is warranted. They typical dose or T4 is 1.6-1.7 μg/kg/day but since CL is >45 years of age the recommended dose (Slide 29) is 50 mcg per day. There is no advantage of adding T3 in this setting. Answer e is in milligrams which incorrect and 100 mcg might constitute and excessive starting dose in this patient over 45.
Refer to case (b) [[additional notes]]:

Which of the following interpretations is most likely to explain the findings?
a. CL’s dose of levothyroxine is too high
b. CL’s dose of levothyroxine is too low
c. CL’s dose of levothyroxine is just right
d. CL is not taking levothyroxine properly
d.
This is a common presentation in a patient who is nonadherent with thyroid replacement therapy. Patients who present this way often fail to take their levothyroxine consistently leading up to the follow-up appointment, then a few days before the appointment they consume excess T4 in order to “make-up” for missed doses. Answer A is incorrect because the TSH would be low if the dose of T4 was too high. Remember it is much more sensitive than T4 and the patient returns to clinic after 6 weeks, a period of time sufficient for the TSH to fully equilibrate. Answer B is incorrect because the T4 would not be markedly elevated if the dose were too low. Answer C is incorrect because the TSH is not WNL.
Which of the following is true regarding the management of thyroid disease?
a. Most patients started on a thionamides improve considerably or achieve normal thyroid function in 4-12 weeks
b. Once initiated, propythiouracil and methimazole should be continued indefinitely
c. Methimazole inhibits the peripheral conversion of T4 to T3 though the clinical significance of this effect is unclear
d. Radioactive iodine is the preferred agent in pregnant or breastfeeding women with hyperthyroidism
a.
Follow-up is indicated in 4-6 weeks after starting thionamide therapy and most patients have responded by week 12. (Slide 55). 12-18 months of PTU or METH achieves remission in ~60% of patients with Graves’ disease at which time treatment can be discontinued. (Slide 56). PTU inhibits peripheral conversion. (Slide 60) RAI is contraindicated in women who are pregnant or breastfeeding
RK is a 33 year old female who presents to her physician complaining of mild fatigue,
dry patchy skin, and a small weight gain over the past 3 months. She is 5’6” and 187 lbs. She is otherwise healthy with no medical history and does not take any medications
except an oral contraceptive. Her lab results include a TSH of 11.7 mIU/L (normal 0.5-
4.7 mIU/L). Her TT4 is 5.5 mg/dL (normal 5-12 mg/dL).

Which of the following strategies would be most appropriate for RK?
a. Levothyroxine 12.5 mcg/d
b. Levothyroxine 100 mcg/d
c. Propylthiouracil (PTU) 300 mg/d
d. Methimazole 15 mg/d
e. Advise the patient to keep a symptom log and recheck thyroid function tests in 6
months
f. The patient’s thyroid function is normal, recheck in 1 year
b.
The patient is hypothyroid based on an elevated TSH, the most sensitive indicator of
thyroid disease, and symptoms. Pharmacological therapy is warranted. Free T4 may also be low but only total T4 is known in this case. Oral contraceptives increase circulating TBG and could lower the free fraction of T4. Levothyroxine 12.5 mcg/d is far below the
expected maintenance dose (1.7 μg/kg/d) in this relatively young patient without heart
disease. RK should be started on the expected maintenance dose of levothyroxine, 100-
150 mcg/d. This patient is hypothyroid, not hyperthyroid- PTU and methimazole are not
correct. [objs. 1,3, and 4, various slides]
Refer to case (e):

Based on the lab results, select the most appropriate treatment for this patient.
a. Levothyroxine (Levoxyl) 25 mcg/d
b. Levothyroxine (Levoxyl) 75 mcg/d
c. Levothyroxine (Levoxyl) 25 mcg/d plus liothyronine (Cytomel) 12.5 mcg/d
d. Liothyronine 25 mcg daily
e. Recheck TSH and FT4 in 3-6 months
a.
JB’s TSH is elevated and FT4 is low, which is consistent with hypothyroidism. TSH is the most sensitive indicator of thyroid function. TT4 is WNL but FT4, the active entity, is low. The dose of 0.25 μg/d is appropriate given the patient’s advanced age alone, though she is also at high CHD risk. B is above the suggested starting dose of 0.25 mg/d in elderly patients. There is little evidence supporting the use of combination T4/T3 therapy. In this case, the patient’s age and high CHD risk would argue against the use of T3. T3 is more active than T4 and would be of greater concern from a cardiac safety perspective. This patient displays symptoms and biochemical evidence of hypothyroidism and should be
treated immediately.
A patient enters your pharmacy with a prescription for Synthroid (levothyroxine) 100mcg/d. While waiting for the prescription to be filled he presents to the consultation
window and asks you why his doctor did not increase his dose of Synthroid following his
clinic appointment earlier today. He read on the internet that his dose of Synthroid should be increased if his TSH is high. He is concerned that his symptoms of hypothyroidism
have not resolved and his TSH is still too high. Upon reviewing his labs you discover that his TSH is above the normal range and his FT4 and T3 are slightly elevated. He reports
that he has been taking Synthroid for approximately 1 week, using samples of Synthroid his doctor gave him.

What explanation(s) would you offer the patient as to why the current dose of Synthroid might be the right dose and that an increase is not warranted at this time?
a. The TSH does not respond immediately; it may take 6 weeks before it is fully
suppressed
b. Symptoms of hypothyroidism begin to improve after 2-3 weeks with maximum improvement usually after 6 weeks
c. Explain that TSH is a poor indicator of thyroid status and shouldn’t be used to
determine the dose of Synthroid
d. All of the above
e. a and b
e.
TSH is the most sensitive indicator of thyroid status. After starting levothyroxine, the TSH
will decrease over 2-6 weeks. Symptomatic improvement occurs initially after 2-3 weeks,
with the full benefit being realized over 6 weeks
Which of the following statements regarding antithyroid medications is FALSE?
a. Methimazole (Tapazole®) differs pharmacologically from Propylthiouracil (PTU) in that methimazole inhibits the peripheral conversion of T4 to T3
b. PTU is the preferred antithyroid medication in pregnant women.
c. The duration of therapy in a patient with hyperthyroidism is typically 12-18 months for a first episode
d. Adverse events cause by PTU are often dose-dependent
e. Antithyroid medications are the preferred primary therapy in young children and
pregnant women with Grave’s disease
a.
PTU but not Methimazole inhibits peripheral T4
RK is a 33 year old female who presents to her physician complaining of mild fatigue, and a small weight gain over the past 3 months. She is 5’6” and 187#. She is otherwise healthy with no medical history and does not take any medications. Her lab
results include a TSH of 11.7 mIU/L (normal 0.5-4.7 mIU/L). Her TT4 (normal 5-12
mg/dL) and T3 (normal 80-180 ng/dL) are 7 mg/dL and 65 ng/dL, respectively.

Which of the following treatments would be most appropriate for RK?
a. Levothyroxine 75 mcg/d
b. Levothyroxine 150 mcg/d
c. Propylthiouracil (PTU) 300 mg/d
d. Methimazole 15 mg/d
e. Advise the patient to keep a symptom log and recheck thyroid function tests in 6
months
b.
This is the expected maintenance dose, which in this case represents a reasonable starting dose given the patient’s age and the absence of heart disease. In practice,
some clinicians may be reluctant to initiate this dose since as many as 1/3 of patients could be over-replaced; however, in healthy patients the dose can be lowered
without sequelae. For the purposes of the exam, this is the only correct answer
Refer to case (f):

Based on the labs results, select the most appropriate treatment for this patient.
a. Levothyroxine (Levoxyl) 0.25 mg/d
b. Levothyroxine (Levoxyl) 0.75 mg/d
c. Levothyroxine (Levoxyl) 0.25 μg/d plus liothyroxine (Cytomel) 0.00125 mg/d
d. Liothyronine 25 μg daily to avoid the cardiotoxic effects of T4
e. Recheck TSH and TT4 in 3-6 months
a.
JB’s TSH is elevated and FT4 is low, which is consistent with hypothyroidism. TSH
is the most sensitive indicator of thyroid function. TT4 is WNL but FT4, the active
entity, is low. The dose of 0.25 μg/d is appropriate given the patient’s advanced age
alone, though she is also at extremely high CHD risk
A patient waiting for a refill on his Synthroid (levothyroxine), asks for you to explain why his doctor did not increase his dose today following his clinic
appointment. Upon reviewing his labs you discover that his TSH is elevated and his
FT4 and T3 are slightly elevated. He has a history of diabetes, hyperlipidemia, PUD,
hypertension, and hypothyrodism. His current medications include glyburide
(Diabeta), HCTZ, omeprazole (Prilosec), rosuvastatin (Crestor), and aspirin. Your pharmacy records indicate that one week ago sucralfate was discontinued and he was started on omeprazole. How would you respond?
a. Explain that HCTZ displaces TSH from its transport proteins, thus the TSH levels are falsely elevated and the dose is correct
b. Explain that the addition of omeprazole will lower TSH once steady state is
reached by interfering with thyroid hormone absorption so no change in dose is
necessary
c. Explain that the patient’s is being too conservative and the dose of levothyroxine
should be increased immediately to prevent further cardiovascular damage
d. Explain that TSH is a poor indicator of thyroid status, and that the dose of levothyroxine is correct
e. Explain that when sucralfate was discontinued, the patient’s FT4 and T3
probably increased because of improved absorption and the TSH is expected to decrease over the next several weeks so this dose may be adequate
e.
Sucralfate decreases thyroid hormone absorption, thus the discontinuation of sucralfate is reflected in the increased thyroid hormone levels. However, the ensuing decrease in TSH is delayed and should be appreciated over the next few weeks. In
the meantime, a dosage change is unnecessary until the effects of the interaction is
fully realized
Which of the following statements regarding antithyroid medications is FALSE?
a. Propylthiouracil (PTU) differs pharmacologically from methimazole (Tapazole®)
in that PTU inhibits the peripheral conversion of T4 to T3
b. PTU is the preferred antithyroid medication in pregnant women.
c. The duration of therapy in a patient with hyperthyroidism is typically12-18 months for a first episode
d. Agranulocytosis is a serious adverse effect that occurs only with propylthiouracil
e. Antithyroid medications are preferred primary therapy in young children and pregnant women with Grave’s disease
d.
Agranulocytosis, the hallmark of which is fever and sore throat, occurs at a similar
frequency with both antithyroid medications
JP is a 45 year old male who was diagnosed today with hypothyroidism by his family
physician. He is 5’11” and weighs 200 lbs. He presents to your pharmacy with a new
prescription for Synthroid® 150 mcg daily. He is in good health otherwise and visits his
physician regularly. He does not take any other medications and just recently began having symptoms of hypothyroidism.

Which of the following is TRUE regarding JP’s prescription?
a. This dose is much too low. Newly diagnosed hypothyroid males should be started on at least 175mcg/day.
b. This dose is much too high. Newly diagnosed hypothyroid patients should be started at 25-50mcg/day and titrated up weekly to avoid cardiac
toxicity.
c. This dose is an appropriate starting dose.
d. JP does not need Synthroid® therapy at this time. He has not been
symptomatic for greater than two years, and therefore no therapy is warranted
c.

Average starting dose of levothyroxine is 1.6-1.7mcg/kg/day in most patients (slide lists exceptions). This patient’s weight is ~91kg, so dose range would be 145-155 mcg daily.
RK is a 33 year old female who presents to her physician complaining of mild fatigue, and a small weight gain over the past 3 months. Other than these recent
complaints, she is otherwise healthy and does not currently take any medications. Her lab results include a TSH of 10.2 mIU/L (normal – 0.5-4.7
mIU/L), and low T4 and T3 levels. The patient’s clinical presentation and
laboratory values are consistent with which of the following conditions?
a. Subclinical hypothyroidism
b. Hypothyroidism
c. Subclinical hyperthyroidism
d. Hyperthyroidism
b.
This patient has High TSH and Low T4 and T3.
TL is a 34 year old male who presents to your community pharmacy with a prescription for methimazole (Tapazole®). You notice that he also filled a new prescription for metoprolol (Toprol XL®) 2 months ago. When he comes into the
pharmacy to pick up the prescription, he seems frustrated and asks why he has to take two medications now. Being the incredibly good Gator pharmacist that
you are, you accurately and empathetically explain to him:
a. These medications are often used together in the initial treatment of
hyperthyroidism.
b. Metoprolol, or other beta-blockers, can help with symptomatic improvement while methimazole is working to help normalize thyroid
hormone levels.
c. Beta-blockers can also be used alone in many patients to permanently reverse hyperthyroidism.
d. You tell him A and B, but wisely leave out C.
d.

C is an untrue statement – beta blockers are used for initial symptomatic relief only.