• secretes thyroxine (T4) and triiodothyronine (T3)

• severe hypothyroidism; lethargy, apathy, memory impairment, emotional changes, slow speech, deep/coarse voice, thick dry skin, cold intolerance, slow pulse, constipation, weight gain, amennhorhea

•  Is THYROID STROM – severe hyperthyroidism; high fever, extreme tachycardia, altered mental status

• decreased metabolism, heat, intolerance to cold
• weight gain even though anorexia
• bradycardia, moderate hypotension
• lethargy
• pale cool dry skin, puffy face, coarse hair, nails thick and hard
• heavy menses and may be unable to conceive (both men and women)

• increased appetite and metabolism, weight loss
• intolerance to heat
• tachycardia, moderate HTN
• nervousness, anxiety, insomnia, tremors, exopthalmos
• flushed, hot, warm skin, thinning hair
• goiter
• irregular or scant menses

1. levothyroxine (T4) Levothyroid, Synthroid
2. liothyronine (T3)
3. liotrix (T3 & T4)
4. thyroid, desiccated

1. both natural (animal) and synthetic (preferred bc potency more uniform)
2. Influences every body system by increasing metabolic rates increasing heart rate, RR, temp, CO,O2 consumption and metabolism of nutrients.  How this occurs is not well understood.

1.  
1. treat/prevent euthyroid goiter
2. t/p thyroid nodules and multinodular goiter
3. subacute or chronic thyroiditis (Hashimoto’s disease or viral thyroiditis)
4. Thyroid cancer
5. levothroxine (Synthroid) is drug of choice for hypothyroidism bc relatively cheaper, once a day dosage and more uniform potency
6. used in conjunction with antithyroid treatment for thyrotoxicosis (thyroid destroyed, and hormones replaced)
7. used as a diagnostic measure to differentiate hypothyroidism from euthyroidism
8. NURSING ALERT – variation exists bt brands.  Do nto change brands or type of hormone without approval; may need to change dose if changing brand/type

1. individualized dosing
2. most common during initial therapy is overdose and hyperthyroidism, which is corrected by titrating dose downward
3. Other adverse reactions are rare

1. uncorrected adrenal cortical insufficiency
2. thyrotoxicosis
3. Not for obesity tx
4. Not for infertility tx
5. Not used after MI (unless small dose after MI caused by hypothyroidism)

1. cardiac disease
2. lactation (fine to take during pregnancy – cat A)

1.  
1. VS and weight
2. Hx s/s
3. general physical assessment to determine outward signs of hypothyroidism
4. Signs of hypothyroidism can be confused with older age
2. Ongoing assessment
1. full effect not apparent for weeks, though early effects can start at 48 hours or so
2. Monitor VS
3. observe for signs of hyperthyroidism, signaling excess dose
4. Watch for sign of tx effect which is

                                                               i.      weight loss

                                                              ii.      mild diuresis

                                                            iii.      increased appetite

                                                            iv.      increased pulse

                                                             v.      decrased “puffiness”

                                                            vi.      increased sense of well-being and mental activity

1. once a day, preferably before breakfast
2. empty stomach enhances absorption of oral form
3. diabetics at risk for hyperglycemia (increases diabetic sxs); if hyperglycemic, notify PCP
4. Pts with CV disease – monitor for chest pain or worsening CV disease and report to PCP immediately bc may need dose reduction
5. Elderly at increased risk for adverse CV reactions, so their initial dose is smaller and increased as needed for 8 weeks or so
6. levothyroxine and liothyronine can be given IV

1. “Risk for Ineffective Therapeutic Regimen Management rt discomfort of adverse reactions during titration of individualized dosing”
1. Takes time to get dose right (for pt to become euthyroid), so pt may either see no improvement, or have adverse reactions from hyperthyroidism
2. Monitor reaction closely to help with dose adjustment
3. NURSING ALERT – signs of hyperthyroid reported before next dose bc may need reduction
2. “Anxiety rt symptoms, adverse reactions, treatment regimen, etc”
1. concerns over symptoms of disorder, and concerns about relief of sxs
2. reassure that relief not immediate, but will get better in several weeks

1. Is a life-time regimen except for those who have a transient hypothyroidism
2. Take in morning preferably before breakfast
3. Notify PCP if headache, nercousness, palpitations, diarrhea, excess sweating, heat intolerance, chest pain, incrased pulse rate, or anmy unusual change
4. Dosages are usually changed until correct dose reached
5. Therapy is evaluated at intervals; about 2 weeks initially, then q 6-12 months
6. weigh self weekly and report significant changes
7. do not change brands without approval

·         methimazole (Tapazole)

·         propylthiouracil (PTU)

·         sodium iodine (¹³¹I) (Iodotope)

1. For hyperthyroidism
2. Inhibit manufacture of thyroid hormone
3. does not affect existing hormone already made, either circulating or stored at thyroid.  
4. This is why it takes weeks for therapeutic effect (takes a while to use up stores)
5. Radioactive iodine used bc the thyroid has affinity for iodine; the radioactive accumulates at thyroid and destroys thyroid tissue without damaging other body tissues
6. Not all pts respond adequately to anti-thyroid drugs and may need surgical removal

1. methimazole and propylthiouracil used for hyperthyroidism
2. potassium iodide given orally with above to prepare for surgical thyroidectomy (to decrease bleeding or highly vascular area)
3. Radioactive iodine (¹³¹I) used for hyperthyroidism and some thyroid cancers

1. Hay fever, sore throat, skin rash, fever, headache
2. N/V
3. paresthesias
4. Severe reactions – agranulocytosis (decreased WBC), exfoliative dermatitis, granulocytopenia and hypoprothrombinemia

1.  
1. hypersensitivity to components of drug
2. methimazole or propylthiouracil – do not breastfeed
3. radioactive iodine is preg cat X and contraindicated during lactation

1. oral anticoagulants à increased risk for bleeding

1. Hx s/s
2. VS, weight
3. note outward sxs and physical assessment
4. careful allergy hx for those prescribed iodine procedure – esp. re: iodine or seafood (contains iodine)
1. Ongoing assessment
1. adverse reactions, therapeutic reaction
2. watch for thyroid storm incase dose too low

1. Goiter may cause difficulty swallowing
2. radioactive iodine usually given 1 time and effects show up in 24 hours with max effects at 10-15 days
3. When hospitalized, must follow radiation safety precautions
4. Once euthyroid obtained, may then take thyroid hormone to tx consequent hypothyroidism
5. Pt with hyperthyroidism likely to have CV sxs like elevated pulse or palpitations; may then get some beta blacker as adjunct for several weeks until euthyroid obtained

1. “Risk for Ineffective Therepeutic Regimen Management rt consistent dosing routine requirements”
1. Concerns over taking q 8 hours (can’t sleep long then)
2. May forget to take
3. May interfere with sleep, talk to PCP
2. “Risk for Infection rt adverse reactions”
1. from agranulocytosis, most severe reaction
2. notify if signs of infection
3. protect from infection, esp. URI
4. monitor for signs of infection
3. “Risk for Impaired Skin Integrity rt adverse reactions”
1. may get rash, so assess and report
2. may require tx (lotions, no soap)

1. Methimazole and propylthiouracil

                                                               i.      take around the clock usually q 8 hours

                                                              ii.      notify if signs of infection

                                                            iii.      record weight 2 x week and notify if sudden change

                                                            iv.      May need to self-monitor pulse, so direct on correct technique and to bring record to PCP

                                                             v.      avoid nonprescription drugs unless approved

2. Radioactive Iodine

                                                               i.      follow precautions

                                                              ii.      tenderness and swelling of neck, sore throat, and cough may occur 2-3 days after procedure

                                                            iii.      may consequently need thyroid hormone to compensate for thyroid destruction

It takes a while to get it right.  

Adjustments are made about q 2 weeks at first, and then q 6-12 months are reevaluated.

Blood cell changes

Agranulocytosis (decreased WBC) and therefore decreased immunity

Granulocytopenis

hypothrombinemia

Pregnancy category X

Contraindicated during lactation

methimazole & propylthiouracil 

and

pregnancy & lactation

precautionary use during pregnancy

contraindicated during breastfeeding

A

Fine to take druing pregnancy

These drugs can cause agranulocytosis which is reduction in WBCs and protection from infection

Therefore, the pt taking antithyroid drugs should watch for and avoid infection

The patient should also notify PCP if signs of infection

methimazole and propylthiouracil - do not breastfeed; cautious use in pregnancy

radioactive iodine do not use in either pregnancy or lactation

CV stimulation and problems

Hyperglycemia