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CASES STUDY IN CLINICAL PHARMACY 2

CASE- 1

Mrs SM is a 49 year-old patient with known Graves' disease.

She was initially treated with carbimazole but developed a
severe urticaria rash, which necessitated withdrawal of the drug.
A similar rash occurred within 2 weeks of starting PTU. She is
overtly thyrotoxic with a blood pressure of 160/60 mmHg, a
pulse of 110 bpm and a very large thyroid gland with a vascular
bruit. Laboratory results show an elevated FT4 and an
undetectable TSH.

QUESTIONS:

1. What are the options for treatment and what factors would
you discuss with her that could influence her choice of
treatment modality?
2. Mrs SM elects to have an ablative dose of radioactive
iodine. What adjunctive therapy would you now consider?
3. What are the indications for surgery in patients with
thyrotoxicosis?
4. What preoperative thyroid preparation is needed for Mrs
SM prior surgery?
5. What postoperative complications are associated with
thyroidectomy?

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 CASE- 2.

Mrs Smith, who is 35-year –old comes into your pharmacy with
her 1-year –old daughter and gives you a prescription for
levothyroxine 50 μg tablets take on daily. This the first time she
Has taken the drug. She has gained a lot of weight since the
birth of her daughter and has not been able to shift it even by
sticking to a calorie –controlled diet. She feels cold all the time ,
even on a hot day, and her hair is thinning. She has no energy at
all, whereas before the birth of her daughter she used to go to
aerobics at least three times a week.

Questions:

1. What do the patient's signs and symptoms indicate?

2. What are the possible causes of the disease?
3. What blood tests would she have for this condition?
4. What monitoring is required for this condition?
5. Does she have to pay for her prescription?

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 CASE -3

Mr JJ is 55 years old. Six years previously, he had a myocardial

infarct complicated by ventricular tachycardia. He had an
implantable defibrillator placed and has been taking amiodarone
200 mg daily. He is complaining of increasing exertional
dyspnea and weight loss. His FT4 is returned at 99.1 pmol/L
(normal range, 10.5–25 pmol/L) with a fully suppressed TSH
confirming thyrotoxicosis.
Questions
1. How does amiodarone cause thyrotoxicosis?
2. What investigations should be considered?
3. How should he be managed?

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 CASE-4

Mrs EA a 66- year-old women. She has recently been

complaining of tiredness, lethargy and weight gain. Her
primary care doctor performed routine TFTs and found she has
primary hypothyroidism. She has had CHF for 5 years. Her
doctor now wishes to commence her on T4 replacement therapy.
Her current drug therapy includes: Ramipril 5 mg daily ,
Furosemide 80 mg in the morning.

Questions:

1. What are the therapeutic objectives in this patient?

2. How should T4 therapy be instituted?
3. How should the replacement therapy be monitored?

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 CASE – 5

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. TFTs have
shown a TSH elevated at 12 mU/L (normal range, 0.3–5 U/L),
but her FT4 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?

2. Should T4 therapy be instituted, and if so, how should it be
monitored?
3. What warnings should she receive about treatment?

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 CASE -6

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

1. What are the possible causes of failure to satisfactorily

treat his hypothyroidism?

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 CASE – 7
Mrs EH, aged 55 years ,has been attending the anticoagulant
clinic for several years. She is on long –term anticoagulant
therapy following a prosthetic heart valve replacement 3 years
ago. Recently , her anticoagulant control has been difficult and
she has required decreasing doses of warfarin to maintain a
therapeutic international normalized level(INR). Other recent
symptoms include diarrhea and weight loss, which have been
investigated by her primary care doctor, as a result of which she
has been found to have thyrotoxicosis. Her current drug
therapy is warfarin 2 mg daily.
Questions:
1. How may thyroid disease influence warfarin dosage?
2. What will happen to Mrs EH's warfarin requirements when
her thyrotoxicosis is treated?