‫بسم اهلل الرحمن الرحيم‬

Nahda College
Program of Pharmacy
Department of Clinical Pharmacy
2020-2021

Endocrine cases
Thyroid dysfunction cases
 CASES
• 1. Mrs MG is a 66-year-old woman. She has a history of depression over many years and has
recently been complaining of increased tiredness, lethargy and weight gain. Thyroid function
tests have shown a TSH elevated at 12 mU/L (normal range, 0.3–5 U/L), but her free T4 is
normal at 12.7 pmol/L (normal range, 10.5–25 pmol/L). Her TPO antibodies are positive at a
dilution of 1:1600.
• Questions
• 1. What is Mrs MG's thyroid state?
• Autoimmune thyroid disease and compensated hypothyroidism. The T4 is being maintained in
the normal range by virtue of increased TSH drive to the thyroid
• 2. Should T4 therapy be instituted, and if so, how should it be monitored?
• Thyroxine should be commenced at 50 μcg daily and the dose adjusted along conventional lines
by measurement of TSH at least 6 weeks after each dose change.
• 3. What warnings should she receive about treatment?
• non-specific symptoms of hypothyroidism to be mimicked by other conditions, notably
depression. Mrs MG should be counselled that thyroxine treatment, though appropriate, may
not reverse her symptoms and that if she remains symptomatic when her TSH has been
normalised
 CASES
• 2. Mr DE is a 21-year-old man who has been treated for
autoimmune hypothyroidism over 5 years. He is now prescribed
thyroxine at 350 μcg daily, but his TSH has remained elevated
varying between 24.4 and 68.2 mU/L. He also has alopecia
areata which has had a very severe effect on his self-confidence
and he has been seeing a private trichologist for advice.
• Question
• What are the possible causes of failure to satisfactorily treat
his hypothyroidism?
• patient nonadherence with treatment. malabsorption of
thyroxine
 CASES
• 3. M.W ., a 70-kg, 23-year-old voice student, thinks that her neck has
become “ fatter” over the past 3 to 4 months. She has gained 10 kg, feels
mentally sluggish, tires easily, and finds that she can no longer hit high notes.
Physical examination reveals puffy face, yellowish skin, delayed DTRs and a
firm, enlarged thyroid gland.
• Laboratory data include the following results: FT4 , 0.6 ng/dL (normal , 0.8–
1.4) TSH, 60 microunits/mL (normal , 0.45–4.1) TPOAb, 136 WHO units
(normal , <100)
• 3.1 Assess M.W.’s thyroid status based on her clinical and laboratory
findings.
These include weight gain, mental sluggishness, easy fatigability, lowering of the
voice pitch, puffy facies, yellowish tint of the skin, delayed DTRs, and enlarged
thyroid, The diagnosis of hypothyroidism is confirmed by her laboratory findings
of a low FT4, an elevated TSH value, and positive TPA antibodies.
 CASES
• 3.2 What thyroid preparation should be used to
treat M.W.’s hypothyroidism? Are differences,
advantages, or disadvantages significant
among the various generic and brand name
formulations of thyroid hormones?
 CASES
• 3.3 What would you recommend as
appropriate starting and maintenance
dosages of T4 for M.W.?
• She can be started on an estimated full replacement
dose of 125 mcg daily of l-thyroxine (70 kg × 1.7
mcg/kg/day = 120 mcg).
 CASES
• 4. A 63-year-old woman has Hashimoto’s disease. Her thyroid
laboratory values today include the following:
• TSH 10.6 mIU/L (normal 0.5–4.5 mIU/L) and a free T4
concentration of 0.5 ng/dL (normal 0.8–1.9 ng/dL). She feels
consistently run down and has dry skin that does not respond to
the use of hand creams. Which would be considered the best
drug for initial treatment of her condition?
• A. Levothyroxine.
• B. Liothyronine.
• C. Desiccated thyroid.
• D. Methimazole.
 CASES
• 5. A 69-year-old woman with hypertension and
hypothyroidism is being treated for a wound
infection. In the past, she was maintained on
125 mcg levothyroxine (Levoxyl) daily with a
normal TSH of 2.0 mIU/L. After 6 weeks of
treatment with oral ciprofloxacin (500 mg
twice a day) she complains of fatigue and
sensitivity to cold. Her serum TSH level was
14 mIU/L and FT4 was below normal.
 CASES
• What is the best management for this patient?
• (A) Increase the dose of levothyroxine
• (B) Switch the patient from Levoxyl to Synthroid
• (C) Discontinue levothyroxine until the wound is
healed
• (D) Continue therapy without any changes
• (E) Separate the administration of ciprofloxacin
and levothyroxine by at least 6 hrs
 CASES
• 6. A 33-year-old underweight woman presents to you. She is
currently taking levothyroxine 200 mcg daily. Her TSH
level is reported to be 0.15 mIU/L. What would be the most
appropriate change to make to her therapy?
• (A) Continue current therapy
• (B) Repeat TSH, continue levothyroxine 200 mcg daily
• (C) Decrease levothyroxine to 175 mcg daily and recheck TSH
in 6 weeks
• (D) Decrease levothyroxine to 150 mcg daily, recheck TSH in
6 weeks
• (E) Repeat TSH, TT4, continue levothyroxine 200 mcg daily
• 1. Which patient meets the diagnostic criteria for
diabetes, assuming tests were taken on separate visits?
– (A) An elderly female with fasting blood glucose values of 102
mg/dL and 132 mg/dL.
– (B) A teenage boy with a fasting blood glucose of 128 mg/dL
and an A1c of 6.6%.
– (C) A 10-year-old girl with a random blood glucose value of
180 mg/dL and 190 mg/dL.
– (D) A morbidly obese male with a random blood glucose value
of 102 mg/dL and an oral glucose tolerance test result of 160
mg/dL.
• The answer is B
• Regardless of age or gender, diagnostic criteria
for diabetes in the non pregnant individual is a
positive of at least two of the following values:
random blood glucose ˃ 200 mg/dL; fasting
blood glucose ≥ 126 mg/ dL; OGTT ≥ 200;
A1c ≥ 6.5%.
• 2. An individual with T2DM currently takes metformin XR 500 mg 2
b.i.d., pioglitazone 45 mg, and glimepiride 4 mg b.i.d. He takes his
morning medications at 8 a.m. with breakfast and his evening
medications at 6 p.m. with supper. He does not eat lunch. He brings
in his log book and meter today, which reveal multiple hypoglycemic
events (45 to 62 mg/dL) around 1 p.m. to 2 p.m. His A1c today is
6.0%. Which would be the most appropriate recommendation for
glycemic control at this time?
– (A) Discontinue morning dose of metformin
– (B) Discontinue evening dose of metformin
– (C) Discontinue daily dose of pioglitazone
– (D) Discontinue morning dose of glimepiride
– (E) Discontinue evening dose of glimepiride
• The answer is D.
• The pharmacologic agent most responsible for
causing hypoglycemia is the sulfonylurea
(glimepiride), which is compounded by the fact
that the patient does not eat lunch. The morning
dose of glimepiride would peak around lunch
time when food intake should be occurring. In
the absence of lunch, hypoglycemia results.
• 3. A 64-year-old female is taking metformin,
pioglitazone, and sitagliptin for T2DM. Her liver
function tests were elevated (AST 132 u/L and ALT
140 u/L) and she tested positive for Hepatitis C.
Which is the best recommendation at this time?
– (A) Discontinue metformin only
– (B) Discontinue pioglitazone only
– (C) Discontinue sitagliptin only
– (D) Discontinue metformin and pioglitazone
– (E) Discontinue all agents for glycemic control
• The answer is D
• Metformin and pioglitazone should not be
used in a patient with liver disease and
elevated LFTs. Sitagliptin may be used in
hepatic impairment. When the LFTs go back to
a normal range, it can be considered to
reinitiate metformin and pioglitazone.
• 4. Which best describes the mechanism of
action of repaglinide?
– (A) Insulin secretagogue
– (B) Insulin sensitizer
– (C) DPP-IV inhibitor
– (D) GLP-1 agonist
– (E) alfa-glucosidase inhibitor
• The answer is A
• Repaglinide is a meglitinide, which works to
produce a rapid burst of insulin secretion from
the pancreas.
• 5. A patient has been hospitalized for the past 3 days following a
severe asthma exacerbation, but is being discharged today. He
weighs 228 lb, but he has no previous history of diabetes. Blood
work today shows a random blood glucose of 320 mg/dL and an
A1c of 5.2%. His current medication list includes albuterol nebules,
prednisone, pulmicort, and oxygen. Which statement is most
appropriate?
– (A) The patient has diabetes and should be discharged on an
insulin regimen.
– (B) The patient has hyperglycemia induced by his inhaled
corticosteroid.
– (C) The patient has hyperglycemia induced by his beta agonist.
– (D) The patient has hyperglycemia induced by his oral
glucocorticoid
• The answer is D
• Inhaled corticosteroids have no effect on the
blood glucose of an individual without
diabetes and beta Agonists have no effect.
• However, oral steroids, such as prednisone can
induce significant hyperglycemia, particularly
in the midafternoon when dosed in the
morning.
• 6. A patient currently takes Glimepride,
Pioglitazone , Sitaglibtin, and Insulin glargine. He
presents to the clinic today concerned about the
swelling in his lower extremities, significant weight
gain, and shortness of breath. Which is the most
likely cause of presenting symptoms?
– (A) Glimepride
– (B) Pioglitazone
– (C) Sitaglibtin
– (D) Insulin glargine
• The answer is B
• Patients taking a TZD should be monitored for
peripheral edema, weight gain, and shortness
of breath due to its propensity to cause or
worsen heart failure.
• 7. A patient presents for treatment of his type 2
diabetes mellitus (T2DM). His A1C is 7.2% and he
has hepatitis C (AST " 150 units/L; ALT " 132
units/L), hypertension, dyslipidemia, rheumatoid
arthritis, and mild renal impairment (SCr " 1.6).
Which would be the best initial agent at this time?
– (A) saxagliptin
– (B) metformin
– (C) pioglitazone
– (D) glulisine
• The answer is A
• Metformin and pioglitazone should not be used
in liver impairment and metformin must be
used cautiously in renal impairment. Rapid
acting insulin would help with postprandial
blood glucose values, but is not considered a
standard recommendation for initial insulin
therapy in T2DM. Saxagliptin may be used in
patients with hepatic and renal impairment.
• 8. An obese woman (350 lb) has used metformin
1000 mg bid to control her T2DM for the past 2
years. Her A1C today is 8%. Which would be the
most appropriate recommendation to improve
glycemic control without providing further weight
gain?
– (A) sulfonylurea
– (B) thiazolidinedione
– (C) GLP-1 agonist
– (D) amylin agonist
• The answer is C.
• Both sulfonylureas and TZDs have the
potential to increase weight, whereas GLP-1
agonists and amylin agonists can provide
weight loss. Amylin agonist is not appropriate
because it should only be
• 9. All of the following are correct statements
about metformin except
– (A) metformin may cause renal impairment.
– (B) metformin should not be used in patients who
are alcoholic.
– (C) metformin should be discontinued in women
with a SCr % 1.4.
– (D) metformin may cause vitamin B12 depletion
• The answer is A
• Metformin should not be used in patients with
renal disease, but the metformin itself does not
cause renal impairment.