All Things Thyroid- An Advanced CE

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 3 - Approximate time required: 180 min.

Educational Goal

Provide an in-depth look at the Thyroid and the hormones it produces. 

Educational Objectives

  • Present a video about Hypothyroidism
  • Present a video about Hyperthyroidism
  • Review the anatomy, physiology, and pathophysiology of the thyroid gland
  • Cover the drugs used in thyroid therapy
  • Explain how care providers can use the materials presented to manage therapy and their resident for optimal outcomes

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

 

All things Thyroid- An Advanced CE

Being required to take Continuing Education courses is never going to be anyone’s favorite activity at work. There have been many courses I was forced to take that were a complete waste of my time. I actually fell asleep at the computer during one course. We here at AFC-CE.com have tried to make the courses interesting and fun to combat that boredom. While at the same time covering topics you wanted and containing the information you can actually use in your home. There are useful topics that I would like to cover but they can be complicated and boring for all but the most diehard nerds among us. So I am going to try something new.

 

The topic is the Thyroid, a butterfly-shaped gland located in our throats. The hormones involved in the Thyroid are among the most important and widespread chemical cascades that you will ever come across.

As a writer I am afraid of the topic though. If I start writing about the advanced chemistry and anatomy and physiology involved, those with advanced degrees will love it. But for the rest of you, it’s going to put you to sleep. If I simplify my writing, the course will lose some of its usefulness and advanced readers will be put to sleep. So here is what I am going to do to try to please everyone.

I am going to install segments of a YouTube series, produced to tutor Physician Assistance students. The presenter is kind of nerdy himself, but in a good way. He covers the topic very well and is entertaining. I then will add my thoughts in between clips that I hope will make the information useful for In-home caregivers. Just click on the start arrow to watch the video then read my comments. I recommend that you print out the exams before you watch the course. Pause the video and write down the answers as you go. The test at the end will be easier to successfully complete that way.  Fair warning.  Some of this material will be pretty advanced. Too advanced for some. If this doesn’t sound like fun to you, I have plenty of other courses that you can take. If you are brave enough to proceed, I need to help you along a bit before you start the video.

Up to speed

There are a few items to cover that will help bring everyone up to speed before watching the video.

  • There may be terms in the video that you are unfamiliar with. For the most part, it doesn’t matter if you know all the complicated terminology. You will still be able to get the gist of that matter. You can pause or repeat the video anytime and look something up if you need to.
  • The Thyroid is a butterfly-shaped gland in your neck. Its primary function is to make, store and release the Thyroid hormone. The thyroid hormone can affect virtually every cell in the body that has a nucleus and does work.
  • The element Iodide is a chemical our bodies use to make the thyroid hormone. It is stuck onto the hormone in a particular way that forms the molecular structure. If there are 3 of them in the thyroid hormone it’s nicknamed T3, if there are four of them, T4. Both molecules are considered to be the Thyroid hormone.
  • There are a lot of chemicals floating around in our bodily and intracellular fluids. They usually need help crossing layers and boundaries. Like going in and out of cells.
  • If you see -lytic or -lysis in a word, it means to break or cut up.
  • Our bodies run mostly on glucose as fuel. In our cells, glucose is converted into ATP. It is a chemical that can easily release the energy our cells need to do their work.
  • Adipose cells are your fat storage cells

Have you got the test questions printed out? (“Hint”- You should be able to answer the first four questions.) Here is another hint there will be no question about diagnosis- you could skip those parts.

Ok, let go. Click on the start arrow.

 

Caregiver Notes

Is everyone still awake? For those whose eyes are glazed over go take a break and come back. Ok now? Let’s continue. Let us now go over how you can use this information in your caregiving practice. As you know Adult Foster Care providers have a different perspective on medical issues than other care professionals. We don’t decide on therapy but we do manage the resident so they can follow it. We don’t diagnose the resident, but we do monitor the resident. As an advocate when things get out of whack, we utilize any resource to the best of our ability to make the resident feel better. From this perspective let’s evaluate the video you just watched. 

Managing Thyroid Issues

Management actions are broken into two duties. Managing the activities of the resident and managing therapy orders given by the doctor.  The video did mention that the thyroid affects every part of our body but did not mention any lifestyle choices that affected the thyroid. That’s a good thing. There are no lifestyle effects that you have to manage. One less thing for caregivers to worry about. The therapy mentioned was also very easy to manage, for most people it will be Levothyroxine. The video didn’t give any details about the drug so I will.

Levothyroxine prescriptions are a synthetic version of T4. Brand names are Levothroid, Levoxyl, Synthroid, Tirosint, and Unithroid. Most prescriptions will be written for a generic version of the first three. 

Foods can affect the absorption of levothyroxine so give the doses 30 minutes before a meal. Usually, it is given in the morning. But it doesn’t have to be as long as you are consistent with the time of administration. If dispensing the drug before meals is problematic, ask the doctor about giving it at bedtime. You can crush the medication and hide it in food, but you will have to be consistent with the amount and kind of food it is mixed in. If you have to hide it in food the doctor will have to approve it beforehand. The prescriber might order additional blood tests to see if he has to alter the dose.

Medications can also affect the absorption of levothyroxine and must be taken four hours apart. The occasional PRN dose of the drugs will probably not have any therapeutic effect. So their infrequent use is not a big issue. The drugs to watch for are:

  • calcium carbonate (Oyster Shell Calcium, Rolaids, Tums,)
  • cholestyramine, colesevelam, colestipol
  • ferrous sulfate iron supplement
  • sucralfate
  • sodium polystyrene sulfonate (Kalexate, Kayexalate, Kionex)
  • stomach acid reducers - Nexium, Prilosec, Prevacid, Protonix, Zegerid,
  • antacids that contain aluminum or magnesium - Gaviscon, Maalox, Milk of Magnesia, Mintox, Mylanta, Pepcid Complete, and others.

If you regularly dispense any of the above you will have to consult with the doctor or pharmacist about administration times.

 

Levothyroxine is well tolerated. Any side effects are usually related to how normal T4 acts in the body and are dose-related. Common side effects may include:

  • chest pain, irregular heartbeats
  • shortness of breath
  • headache, leg cramps, muscle pain, or weakness
  • tremors, feeling nervous or irritable, trouble sleeping
  • increased appetite
  • feeling hot
  • weight loss
  • changes in your menstrual periods
  • diarrhea
  • skin rash, partial hair loss

Other thyroid prescriptions are Armour Thyroid (thyroid harvested from animals, usually from pigs) and Cytomel (a synthetic version of T3). Manage them just like you would levothyroxine except Cytomel does not need to be taken 30 minutes before a meal. 

Monitoring-

Monitoring is broken into two activities. Monitoring for change in the resident and Monitoring for the effect of therapy. Since we just talked about the drugs let's start there.

The goal of drug therapy is to return the patient to normal functioning. Though the thyroid affects everything in the body. The video did mention certain items of physiology. When monitoring for drug effect, I recommend not getting caught up in the details but keep track of those mentioned effects as overall trends. Also, life is variable. Small changes happen every day so keep your mind on long-term monitoring, not normal short-term fluctuations.

Consistency is a key aspect of therapy. If things get out of whack, look for what has changed. Switching brands may produce lesser or greater therapeutic effects so monitor the patient more closely for a while after a change of brand.  Get to know what is normal for that resident. Now that you know what to look for if you see multiple symptoms starting to occur, it’s time to contact the doctor and start asking questions.

Advocating-

Advocating for the resident is working the medical system to get what the residents need. Sometimes it feels like you’re the only one looking out for the patient. The most powerful advocating method that I know is recording measurable observations and showing the data to the doctor. Following up by asking the “Why is this happening?” questions. Better still, if you know your stuff, the “Is out of whack thyroid levels causing the issue” type of question. In a nutshell, watch for changes and ask why, if you see signs and symptoms patterns. Keep asking until you get the response you and the resident can live with. Don’t be afraid to go back to the doctor and report that his or her therapy choices don’t seem to be working as expected.

Well, that’s enough of that. Let's get on with the next video. Don’t mind that it starts out with the same info. It’s good to review the basics.

 

 

 

Caregiver Notes

Hyperthyroid issues-

You will have noticed that there are a lot of things that can cause too much thyroid hormone to be produced. The one that is man-made is the drugs Amiodarone and Lithium. Amiodarone is taken for cardiac and B/P issues and Lithium is for mental health issues. Both of these conditions have similar signs and symptoms to Hyperthyroidism. Someone will have to be asking the question “are these heart problems and acting abnormal behaviors issues being aggravated by Hyperthyroid conditions? It might be time for a blood test for High T4. 

I would also like to point out that if there is ongoing thyroid tissue damage, there is the possibility of flipping from Hyper to Hypothyroidism. Someone will have to watch for hypothyroidism symptoms. Caregivers will see them before the doctor does so I guess that would be you.

Hyperthyroid Drugs

  • Propylthiouracil

Propylthiouracil can cause liver damage, especially in the first 6 months of therapy. Call the doctor right away if you notice in your resident upper stomach pain, nausea, vomiting, loss of appetite, fever, itching, tiredness, dark urine, clay-colored stools, or yellowing of your skin or eyes.  Other serious side effects that must be called into the doctor are fever, chills, sore throat, mouth sores, feeling light-headed, unusual bleeding, purple or red discoloration of your skin, skin rash, skin pain or swelling, pink or dark urine, foamy urine, little or no urination, shortness of breath, or coughing up blood.

  • Methimazole

“Methimazole is presently the preferred one due to less severe side effects. These drugs work well to control the overactive thyroid, and do not cause permanent damage to the thyroid gland. In about 20% to 30% of patients with Graves’ disease, treatment with antithyroid drugs for a period of 12 to 18 months will result in prolonged remission of the disease.” American Thyroid Association

According to Drug.com Methimazole has many of the same side effects as propylthiouracil but has no listed liver failure warning.

  • Beta-blockers are a class of high-blood-pressure meds. They usually make the patient feel better within hours to days, but they do not change the high levels of thyroid hormone in the blood. These drugs may be helpful in slowing down the heart rate and reducing the symptoms of palpitations, shakes, and nervousness. If these symptoms are an issue, they are an add-on therapy you could ask the Doctor about.

For a full list of possible side effects and possible drug interaction of any drug mentioned in my CE courses, see the drug insert that comes with the prescription.

Thyroid function Tests were mentioned in both videos. Caregivers should know that estrogens and Biotin can interfere with these test results.

 

 

Conclusion

Being such a relatively small organ the Thyroid has a big impact. I hope you enjoyed the way I covered some of the basic concepts. There was a lot more I could have covered but I have to cut it off at 3 hours’ worth of materials. I hope you can use the information to better manage, monitor, and advocate for those in your care.

As always Good Luck with your Caregiving

Mark Parkinson BsPharm

 

References:

  1. Zach Murphy PA-C. Endocrinology | Thyroid Overview. Ninja Nerd, Apr 30, 2017. https://www.youtube.com/watch?v=5aq_rxTbtws&list=PLTF9h-T1TcJjOIhflPV32PZxgcN8wLlvj&index=10
  2. Zach Murphy PA-C. Endocrinology | Target Organs of the Thyroid. Ninja Nerd, June 19, 2017. https://www.youtube.com/watch?v=PdBGkp0UaG0&list=PLTF9h-T1TcJjOIhflPV32PZxgcN8wLlvj&index=9
  3. Zach Murphy PA-C. Endocrinology | Synthesis of Thyroid Hormone. Ninja Nerd, May 11, 2017. https://www.youtube.com/watch?v=BeI0-xw_cSQ&list=PLTF9h-T1TcJjOIhflPV32PZxgcN8wLlvj&index=8
  4. Zach Murphy PA-C. Hypothyroidism | Physiology, Pathophysiology, Diagnosis, Treatment, Myxedema Coma. Ninja Nerd, Mar 15, 2021. https://www.youtube.com/watch?v=4WigUZMM-yA
  5. Zach Murphy PA-C. Hyperthyroidism | Physiology, Pathophysiology, Diagnosis, Treatment, Thyroid Storm. Ninja Nerd, Mar 8, 2021. https://www.youtube.com/watch?v=lwPR5m7VZlw&t=3662s
  6. Thyroid Disease (Hyperthyroidism vs. Hypothyroidism). Dirty Medicine. Aug 20, 2021. https://www.youtube.com/watch?v=3yfdXzZ6Uu0
  7. Hank Green. Endocrine System, Part 2 - Hormone Cascades: Crash Course Anatomy & Physiology #24. CrashCourse, Jun 29, 2015. https://www.youtube.com/watch?v=SCV_m91mN-Q
  8. Cytomel (liothyronine). GoodRX.com, July 31, 2020. https://www.goodrx.com/liothyronine/what-is
  9. Synthroid - Uses, Side Effects, and More. WebMD, 9/22. https://www.webmd.com/drugs/2/drug-7033/synthroid-oral/details
  10. Synthroid. Drug.com. May 3, 2022. https://www.drugs.com/synthroid.html
  11. Thyroid Function Tests. American Thyroid Association, 9/22 https://www.thyroid.org/thyroid-function-tests/
  12. Hyperthyroidism. American Thyroid Association, 8/22. https://www.thyroid.org/hyperthyroidism/

 

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