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  #1  
Old 07-24-2012
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Thyroid Grave's Disease Treatment

A 33-year-old woman with history of Grave's disease arrived to the ER comprehensiveness following a bout of confusion and agitation. On the examination her temperature is 39.2 degrees C, her BP is 100/70 mm.Hg, and her pulse is 165/min. A systolic ejection murmur is heard at the apex, and the patient has 3+ pitting edema at the ankles. After stabilization this patient, which of the following constitute an appropriate pharmacotherapy for this patient's underlying condition?


A) Methimazole + Aspirin + Dobutamine
B) PTU + Aspirin+ Dobutamine
C) Methimazole + Iodine + Propranolol
D) PTU + Acetaminophen + Propranolol
E) Levothyroxine + Propranolol + Prednisone


Feel free to post your explanation
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Old 07-24-2012
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Quote:
Originally Posted by alfjof View Post
A 33-year-old woman with history of Grave's disease arrived to the ER comprehensiveness following a bout of confusion and agitation. On the examination her temperature is 39.2 degrees C, her BP is 100/70 mm.Hg, and her pulse is 165/min. A systolic ejection murmur is heard at the apex, and the patient has 3+ pitting edema at the ankles. After stabilization this patient, which of the following constitute an appropriate pharmacotherapy for this patient's underlying condition?


A) Methimazole + Aspirin + Dobutamine
B) PTU + Aspirin+ Dobutamine
C) Methimazole + Iodine + Propranolol
D) PTU + Acetaminophen + Propranolol
E) Levothyroxine + Propranolol + Prednisone


Feel free to post your explanation
aspirin---since the heart failure is due to hyperdynamic circulation and not due to coronary artery disease, i find no rationale in its use
acetaminophen--i don't think it has any use in thyroid disease or heart failure
levothyroxine--used in hypo states not hyper

so by exclusion, my answer is C
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Matched!!!
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Old 07-24-2012
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this q about side effects , clinical picture show signs of agranulosytosis which is SE of methimazol.
PTU have hepatotoxicity so probably B will be better. My guess.
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Old 07-24-2012
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Quote:
Originally Posted by eveli55 View Post
this q about side effects , clinical picture show signs of agranulosytosis which is SE of methimazol.
PTU have hepatotoxicity so probably B will be better. My guess.
all symptoms of the thyroid storm. HR is sky high, her BP was probably initially high as well but her heart started failing -> hypotension + pitting oedema at the ankles.

I would use:
- for stoping thyroid hormone production: PTU/methimazole/iodide alternatively.
- acetaminophen as an antypyretic
- propranolol
- iv steroids to consider

so I'm between C and D.

But I think D would be better because we should give some antypyretic and in C we give her 2 drugs that inhibit hormone production and no antypyretic. I know that we should remove the cause of the fever but she's above 39 degrees so she should get something

hmmm... boy oh boy you just made me realize that I have a lot to revise once I get to the endocrine part of pharmacology

Thanks for the question alfjof!
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  #5  
Old 07-24-2012
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Originally Posted by Casandra View Post
all symptoms of the thyroid storm. HR is sky high, her BP was probably initially high as well but her heart started failing -> hypotension + pitting oedema at the ankles.

I would use:
- for stoping thyroid hormone production: PTU/methimazole/iodide alternatively.
- acetaminophen as an antypyretic
- propranolol
- iv steroids to consider

so I'm between C and D.

But I think D would be better because we should give some antypyretic and in C we give her 2 drugs that inhibit hormone production and no antypyretic. I know that we should remove the cause of the fever but she's above 39 degrees so she should get something

hmmm... boy oh boy you just made me realize that I have a lot to revise once I get to the endocrine part of pharmacology

Thanks for the question alfjof!

I'm now reviewing pharm and it explain my way to solve this q))))))) Thx!!!
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Old 07-24-2012
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Since the question says " after stabilisation", I choose C. In any case, I'd choose C. Giving aspirin seemed a bit pointless to me, as the hyperthermia here isn't due to resetting of the hypothalamic thermostat, as far as I'm aware. I couldnt find any mention of the benefits of giving aspirin while I looked up the literature. On the contrary, it actually displaces thyroid from its binding protein, and precipitates thyroid storm. Aggressive hydration and cooling blankets are more important.
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Old 07-24-2012
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Answer C cause it's thyroid storm and treated with methimazole+iodine+propranolol but u can use ptu as well instead of methimazole
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Also I doubt acetaminophen has any role in thyroid storm since elevated BT may be due to thyroid excess and not pyrogens
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Old 07-25-2012
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hmmm... you are right, they are talking about 'after stabilization' so probably they managed the fever also... so C would be the answer...
I'm very curious about alfjof's answer
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Old 07-28-2012
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@alfjof - so what is the answer?
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Old 07-30-2012
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Default Explanation

Cassandra, your answer was right I don't know why you changed your mine.

D) PTU + Acetaminophen + Propranolol

This patient is presenting with a Thyroid Storm which is due to Beta-adrenergic outflow stimulated by thyroid hormones. After primary stabilization: (airway, breathing, and circulation), PTU or methimazole is the most appropiate treatment for this condition by inhibiting the endogenous synthesis of thyroxine. Aspirin cause displacement of thyroxine from TBG can worsen the symptom of thyrotoxicosis; and is contraindicated, doing Acetaminophen a better choice pharmacological for the antipyretic in those patients. Propranolol is beta-adrenergic antagonist not AGONIST would be more appropriate than Dobutamine

So, Iodine which decreases the release of thyroxine performance, can be used as an adjunct to PTU or Methimazole but should not be used until one of these agents is allowed to take effect, and thus exacerbate this condition
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I was wondering what the rationale for using an NSAID as anyipyretic is. It might not do any harm but I don't see the basis for its use other than "let's throw everything at it and hope it works". Its not like there's something wrong with the hypothalamic thermoregulation centre is it? Anyone has any publication or some sort of study to back up their use?
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Quote:
Originally Posted by alfjof View Post
Cassandra, your answer was right I don't know why you changed your mine.

D) PTU + Acetaminophen + Propranolol
hahaha I guess I should invest some time in building up my selfconfidence

Thanks for this question
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