1. Clinical Case # 9 By CHEN, I – CHUN (Afra)

2. Case study C.D. a 33 year old from the Mt. Province came in with a complaint of cold intolerance, forgetfulness, puffiness & periorbital swelling noted for several months, associated with a bulging anterior neck mass. PE showed a cardiac rate of 55 beats/min. She has coarse and dry hair. Her skin is dry, thick, and scaly. Her neck mass is about 10x15 cm and moves with deglutition.

3. Diagnosis: Hypothyroidism Hypothyroidism is the most common pathologic hormone deficiency. It is usually a primary process resulting from failure of the gland to produce adequate amounts of hormone. It may also be caused by a lack of thyroid hormone secretion secondary to the failure of adequate thyrotropin secretion from the pituitary gland or thyrotropin- releasing hormone (TRH) from the hypothalamus (secondary or tertiary hypothyroidism). Patients may be largely asymptomatic or may rarely present with coma and multisystem organ failure (myxedema coma).

4. Clinical Feature Somnolence, poor memory; sluggish speech/movement Bradycardia Constipation Cold intolerance; ↓ sweating Cold dry skin; dry hair Myxedema Primary/secondary amenorrhea

5. Plan of management (× 2) 1. Synthetic thyroid hormone (× 3) 2. Natural thyroid hormone (× 2)

6. 1. Synthetic thyroid hormone (×3) Levothyroxine (Synthroid, Levoxyl, Levothroid, Unithroid) Liothyronine (Cytomel, Triostat) Liotrix

7. Levothyroxine Description: In active form, influences growth and maturation of tissues. Involved in normal growth, metabolism, and development. Produces stable levels of T3 and T4. Administered as a single dose in the morning on an empty stomach. May be administered PO/IV/IM. Has long half-life (7-10 d), and parenteral dosing is rarely needed. Initial subtherapeutic doses are recommended to avoid the stress of rapid metabolic change in elderly patients and in those with coronary artery disease or severe COPD.

8. Liothyronine Description: Synthetic form of the natural thyroid hormone T3 converted from T4. Used when a rapid effect is desired perioperatively or for nuclear medicine studies. Not intended as sole maintenance therapy. Can be used in combination with levothyroxine in small doses (5-15 mcg/d). Duration of activity is short (half-life is 12-24 h) and allows for quick dosage adjustments in event of overdosage. May be preferred when GI absorption is impaired (95% absorbed compared to 50-80% of T4) or if peripheral conversion is impaired.Dosage recommendations are for short- term use in special circumstances with the guidance of an endocrinologist.

9. Levothyroxine & Liothyronine Side effect: Weight loss Chest pain Rapid heartbeat Racing heart Shortness of breath headache vomiting excessive sweating fever hair loss tremors

10. Liotrix Description: A mixture of levothyroixine and liothyronine in a ratio of 4:1

11. 2. Natural thyroid hormone (×2) Thyroid Fine powder from desiccated pig thyroid Preparation: Armour of thyroid= 16-325 mg/tab Thyroglobulin Purified pig extrace Preparation: Proloid= 32.5 and 65 mg/tab Dose= 60-300 mg/day

12. Thank You!!