Posted: June 11th, 2024

Mary – Hypothyroidism and Iron Deficiency Anemia

Case Study Pharmacology

1. Mary – Hypothyroidism and Iron Deficiency Anemia

Mary is a 35-year-old female recently diagnosed with hypothyroidism based on an elevated TSH of 20 mIU/L. She also has microcytic anemia, evidenced by a low MCV of 78 fL, a low MCHD of 26 g/dL, a ferritin of 9 ng/mL (low iron stores), and a high TIBC of 418 mcg/dL, consistent with iron deficiency anemia of 2 months duration. Her current medications include kelp tablets daily, ibuprofen 400 mg as needed, and an oral contraceptive containing ethinyl estradiol/norgestrel.

To treat Mary’s hypothyroidism, levothyroxine should be initiated. The typical starting dose is 1.6 mcg/kg/day, which for Mary (assuming a weight of 70 kg) would be approximately 112 mcg daily (Almandoz & Gharib, 2021). The prescription would be written as follows:

Levothyroxine 112 mcg tablets
Disp: 30
Sig: Take 1 tablet by mouth daily

Monitoring of TSH should occur 6-8 weeks after initiating therapy and the dose adjusted to normalize TSH. Once stable, TSH can be checked annually. Mary should be educated that kelp tablets may contain variable amounts of iodine and interfere with thyroid function. Iron supplements should be separated from levothyroxine by at least 4 hours as iron can decrease levothyroxine absorption. Oral contraceptives may increase thyroxine-binding globulin and necessitate higher levothyroxine doses (Almandoz & Gharib, 2021).

For iron deficiency, Mary should take 60-200 mg/day of elemental iron in divided doses on an empty stomach to optimize absorption (Short & Domagalski, 2020). A sample prescription:

Ferrous sulfate 325 mg (65 mg elemental iron) tablets
Disp: 90
Sig: Take 1 tablet by mouth 3 times daily on an empty stomach

Iron studies should be rechecked after 1-2 months of treatment. Hemoglobin response may take 2-4 months. Once corrected, she can transition to a maintenance dose (Short & Domagalski, 2020). Ibuprofen may increase risk of GI bleeding and worsen anemia, so should be used sparingly.

2. Joe – Type 2 Diabetes and Chronic Kidney Disease

Joe is a 48-year-old male with type 2 diabetes diagnosed one year ago. While previously diet-controlled, his fasting glucose of 225 mg/dL and HbA1c of 7.5% indicate suboptimal control. His creatinine of 2.0 mg/dL and eGFR of 28 mL/min/1.73m2 suggest stage 4 chronic kidney disease. He takes lisinopril 20 mg daily for hypertension.

With an eGFR <30 mL/min/1.73m2, metformin is contraindicated due to risk of lactic acidosis. A reasonable first line option would be a dipeptidyl peptidase-4 (DPP-4) inhibitor like linagliptin, which requires no dose adjustment for renal impairment (Cehic et al., 2018). A sample prescription: Linagliptin 5 mg tablets Disp: 30 Sig: Take 1 tablet by mouth once daily If not at goal in 3 months, consider adding a GLP-1 receptor agonist or basal insulin, with dose adjustments for renal function. A1C and kidney function should be monitored every 3-6 months. Lisinopril does not require adjustment at this level of kidney function but should be discontinued if hyperkalemia develops (Cehic et al., 2018). Joe should be educated on the signs of hypoglycemia and how to treat it. A low sodium, low potassium diet is advised for blood pressure and kidney health. Annual eye exams, foot exams, and urine albumin screening are important for detecting diabetes complications. Smoking cessation and statin therapy provide cardiovascular benefit. 3. Jose - Uncontrolled Type 2 Diabetes Mellitus Jose is a 55-year-old truck driver with type 2 diabetes on metformin 1000 mg twice daily and glipizide 20 mg daily. His fasting glucose of 325 mg/dL and HbA1c of 10.6% indicate poor control, likely related to his occupation. He also takes diltiazem for hypertension and is allergic to sulfa. Given the high HbA1c, combination injectable therapy is warranted. Adding basal insulin is preferred over prandial insulin for patients with inconsistent meal patterns. Insulin glargine is a long-acting insulin indicated for this scenario (Buse et al., 2020). A sample prescription, assuming a weight of 100 kg: Insulin glargine 100 units/mL vial Disp: 10 mL vial Sig: Inject 20 units subcutaneously once daily The starting dose of 0.2 units/kg/day can be titrated by 2-4 units weekly to achieve a fasting glucose of 70-130 mg/dL. When the glucose <180 mg/dL, glipizide should be discontinued to reduce hypoglycemia risk. Metformin can be continued (Buse et al., 2020). Jose must be educated on proper insulin administration, storage, and disposal. Self-monitoring of blood glucose is critical for insulin titration and safety - aim for 4-7 readings daily including a fasting, pre-meal, and bedtime reading. Hypoglycemia symptoms and treatment with 15 g of carbohydrates should be reviewed. He will need to coordinate insulin dosing with meals and inform his employer and coworkers about his diabetes. Commercial driver medical certification requires an HbA1c <10% and no recent severe hypoglycemia (Buse et al., 2020). 4. Jenny - Gastroesophageal Reflux Disease Jenny is a 63-year-old woman with symptoms consistent with gastroesophageal reflux disease (GERD). She has heartburn 4-5 times weekly worsened by recumbency, and a nighttime cough suggesting possible aspiration. OTC omeprazole provided only partial relief. Her medications include Diltiazem, hydrochlorothiazide, metformin, aspirin, and fluticasone/salmeterol inhaler. First-line therapy for GERD is an 8-week course of a proton pump inhibitor (PPI). Since omeprazole failed, a different PPI like esomeprazole can be tried (Mermelstein et al., 2020). A sample prescription: Esomeprazole 40 mg capsules Disp: 60 Sig: Take 1 capsule by mouth 30 minutes before breakfast daily If a twice daily PPI is required, the 2nd dose should be given 30 minutes before dinner. After 8 weeks, the PPI can be tapered to the lowest effective dose needed to control symptoms. H2-receptor antagonists like famotidine are an alternative for maintenance therapy (Mermelstein et al., 2020). Jenny should take the PPI on an empty stomach as food decreases absorption. Diltiazem may delay gastric emptying and worsen reflux. If her blood pressure allows, a change to a non-dihydropyridine calcium channel blocker could be considered. Elevating the head of the bed, avoiding meals within 2-3 hours of bedtime, losing weight, and avoiding dietary triggers can help reduce symptoms. If cough and aspiration are ongoing concerns, further evaluation may be indicated (Mermelstein et al., 2020). References: Almandoz, J. P., & Gharib, H. (2021). Hypothyroidism: Etiology, diagnosis, and management. Medical Clinics of North America, 105(2), 219-230. https://doi.org/10.1016/j.mcna.2020.10.003 Buse, J. B., Wexler, D. J., Tsapas, A., Rossing, P., Mingrone, G., Mathieu, C., D'Alessio, D. A., & Davies, M. J. (2020). 2020 update to: Management of hyperglycemia in type 2 diabetes, 2019: A consensus report by the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care, 43(2), 487-492. https://doi.org/10.2337/dci18-0033 Cehic, M. G., Muir, C. A., Greenfield, J. R., & Hay, S. J. (2018). Medications used for the management of diabetes in patients with chronic kidney disease. The Medical Journal of Australia, 209(6), 267-270. https://doi.org/10.5694/mja17.01145 Mermelstein, J., Reisinger, S. N., & Gonzalez, A. (2020). Management of gastroesophageal reflux disease. JAMA, 324(10), 1017-1018. https://doi.org/10.1001/jama.2020.10912 Short, M. W., & Domagalski, J. E. (2020). Iron deficiency anemia: Evaluation and management. American Family Physician, 201(4), 219-227. https://pubmed.ncbi.nlm.nih.gov/32043336/ ______________________________________ Case Study Pharmacology. Cases studies pharm Directions: For each of the scenarios below, answer the questions below using clinical practice guideline where applicable. Explain the problem and explain how you would address the problem. If prescribing a new drug, write out a complete medication order just as you would if you were completing a prescription. Use at least 3 sources for each scenario and cite sources using APA format. For a pharmacist to dispense, the prescription must include specific information to be considered valid: · Date of issue. · Patient's name and address. · Patient's date of birth. · Clinician name, address, DEA number. · Drug name. · Drug strength. · Dosage form. · Quantity prescribed. 1. Mary is a 35-year-old woman that has been diagnosed with hypothyroidism. Her labs today show a TSH of 20, MCV 78, MCHD 26, Ferritin 9, TIBC 418. She has a history of iron deficiency anemia for 2 months. Current medications include Kelp tablets daily, ibuprofen 400 mg daily as needed, and ethinyl estradiol/norgestrel one tablet daily.What medication would you start this patient on for her hypothyroidism? How would you monitor this patient’s response to the medication? What education would you provide regarding her medications and their interactions? 2. Joe is a 48-year-old male diagnosed with Type II Diabetes Mellitus for a year ago. He has controlled his blood glucose through dietary changes. He has hypertension and is currently on Lisinopril 20 mg po daily. He has no known allergies. His lab work includes these results: fasting BG is 225 mg/dL; HgA1C = 7.5%. Basic Metabolic Profile (BMP) is normal except for a Cr of 2.0 and eGRF of 28. What treatment plan would you implement for Joe? What medications would you prescribe and how would you monitor them? What education would you provide regarding his treatment plan? 3. Jose is a 55-year-old truck driver being evaluated for his commercial driver’s license. He has a known history of diabetes mellitus type II. Current medications include Metformin 1000 mg Bid, Glipizide 20 mg po daily. Diltiazem 120 mg po BID. He is allergic to sulfa. Lab results show a fasting blood glucose of 325 mg/dL, HgA1C = 10.6%. Basic metabolic Profile is normal. What treatment plan would you implement for Jose? What medications would you prescribe and how would you monitor them? What education would you provide regarding his treatment plan? 4. Jenny is a 63-year-old woman with complaints of heartburn 4 to 5 times a week over the past 3 months. Her symptoms are worse at night after going to bed. Her heartburn is worse, and she coughs a lot at night. She has tried OTC Prevacid 24 hour once daily for the past 2 weeks. This has helped the symptoms some, but she is still bothered by them. Current medications include Diltiazem CD 120 mg PO once daily, Hydrochlorothiazide 25 mg PO once daily, Metformin 500 mg PO twice daily, Aspirin 81 mg PO daily, Fluticasone/salmeterol DPI 100 mcg/50 mcg one inhalation twice daily. Your working diagnosis for this patient is GERD. What treatment plan would you implement for Jenny? What medications would you prescribe and how would you monitor them? What education would you provide regarding her treatment plan?

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