Week 5
• Signs and Symptoms of hypothyroidism and hyperthyroidism
• Hypothyroidism: The face is pale, puffy, and expressionless. The skin is cold
... [Show More] and dry. The hair is brittle, and hair loss occurs. Heart rate and temperature are lowered. The patient may complain of lethargy, fatigue, and intolerance to cold. T4 and T3 are lower while TSH is higher
• Hyperthyroidism: Heartbeat is rapid and strong, and dysrhythmias and angina may develop. Nervousness, insomnia, rapid thought flow, and repaid speech. Increased heat production, increased body temperature, intolerance to heat, and skin that is warm and moist. Appetite is increased. Exophthalmos. T4 and T3 are higher while TSH is lower.
• 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.
• Beta Blockers and nonradioactive iodine may be used. Beta Blockers suppress tachycardia and nonradioactive iodine inhabit synthesis and release of thyroid hormones.
• Monitoring needs and intervals for thyroid medications
• Levothyroxine: Obtain baseline TSH and free T4. Monitor TSH 6-8 weeks after initiating therapy and after any dosage change. Check yearly after stable.
• Methimazole: Obtain serum levels of TSH, free T3, and free T4. Check baseline CBC and LFTs before starting. Monitor CBC with differential if signs or symptoms of infection. Check LFTs if sings or symptoms of liver dysfunction.
• Propythiouracil (PTU) carriers a risk for liver toxicity. Although rare, the FDA recommends against using PRU as a first-line treatment due to potential for hepatic toxicity
• Effects of maternal hypothyroidism on offspring and appropriate patient teaching related to need for treatment.
• Maternal hypothyroidism can decrease IQ and other neuropsychological function, typically in the first trimester. Should be monitored and treated early. When taking thyroid supplements prior, dosage requirements usually increase.
• Patient teaching for thyroid medications
• Levothyroxine: Take in the morning at least 30-60 minutes before eating. Do not switch brands because they could have different levels.
• What drug class can interfere with the assessment and monitoring of diabetes and why?
• You will need to connect pathophysiology information of medications and diabetes together. Think about alpha and beta cells.
• Beta blockers mask the signs of hypoglycemia because the beta-blockade impairs glycogenolysis and can make insulin-induced hypoglycemia even worse.
• Thiazide diuretics, glucocorticoids, sympathomimetics can counteract the effects of insulin.
• HgbA1C goals—what are they generally? Review goal guidelines for different age groups within the ADA DM Guidelines linked in the Endocrine Case Studies.
• An A1C goal for many nonpregnant adults of ,7% (53 mmol/mol) is appropriate.
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• On the basis of provider judgment and patient preference, achievement of lower A1C levels (such as ,6.5%) may be acceptable if this can be achieved safely without significant hypoglycemia or other adverse effects of treatment.
• Less stringent A1C goals (such as ,8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite DSME, appropriate glucose
• A reasonable A1C target for most children and adolescents with type 2 diabetes treated with oral agents alone is ,7%
• Review diagnostic criteria and process for Diabetes
• Know mechanism of action and contraindications for DM drug classes
• Know examples of DM drug classes
Tablee 48.9 Drugs for Type 2 Diabetes
Class and Specific Agents Actions Major Adverse Effects Contraindications
Biguanide (Metformin) Decreases glucose production by the liver, increases tissue response to insulin GI symptoms, decreased appetite, N/ D, lactic acidosis Renal insufficiency: can cause it to accumulate rapidly
Second Gen Sulfonylureas (Glipizde) Promote insulin secretion by the pancreas; may also increase tissue response to insulin Hypoglycemia, weight gain
Meglitinides (Glinides Promote insulin section by the pancreas Hypoglycemia, weight gain
Thiazolidinediones (Glitazones) Decrease insulin resistance and thereby increase glucose uptake by muscle and adipose tissue and decrease glucose production by the liver
Hypoglycemia but only in the presence of excessive insulin, HF, bladder cancer, fractures, ovulation In Pioglitazone, Heart Failure [Show Less]