Management of Hypothyroidism and Nursing Implications

Abstract

There is a growing concern about the increase in the number of patients suffering from hypothyroidism. The condition affects patients who experience a hormone deficiency affecting their thyroid gland. Under normal circumstances, hypothyroidism is managed in primary care settings with the use of various thyroid replacement drugs. The most common medications that are used in thyroid replacement are triiodothyronine (T3) and thyroxine (T4).

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Although many patients rely on drugs for their continued survival, there are several complications that hypothyroidism patients often experience as a result of taking drugs. Among the adverse effects associated with thyroid replacement drugs are cardiovascular problems and increased risk of coronary insufficiency with CAD. There is a need for nurses to take precautions when diagnosing thyroid replacement drugs so as to avert the occurrence of adverse effects that are associated with thyroid replacement drugs.

Keywords: hypothyroidism, drugs, patients, adverse effects, diagnosis, cardiovascular changes, hormone

Introduction

Hypothyroidism refers to a condition of hormone deficiency that occurs as a result of an abnormality in the thyroid gland (Workman & LaCharity, 2015). The complication is among the most common endocrine diseases with a prevalence ranging from 3.8 to 4.6%. According to the survey that was conducted by Whickam, the annual incidence in women is 4.1 in every 1000 women while the incidence in men is 0.6 in every 1000 men. A recent study that was conducted in the UK showed that there is a significant rise in the incidence of hypothyroidism.

The study also shows that there are geographical variations in the prevalence of the complication. For example, Denmark has nine times fewer cases of the complication in comparison with the UK based on epidemiological studies. More than 23million prescriptions were written for levothyroxine in the UK in 2010; hence making the medication the third in the list of the most frequently prescribed medications (Workman & LaCharity, 2015).

The diagnosis and treatment of hypothyroidism are regarded as a simple one and in most cases, it is conducted in a primary care setting. Although the diagnosis and treatment of the disease are regarded as simple, most studies show that several problems occur in the process of managing the condition (Lilley, Collins, & Snyder, 2016). The studies reveal that most thyroid hormone replacement patients are either under-replaced or over-replaced while a significant number of patients often report that they do not feel well even after undergoing thyroid function tests conducted within the healthy reference range. This review seeks to highlight the pharmacological effects of thyroid replacement drugs in the management of hypothyroidism and nursing implications.

Causes of Primary Hypothyroidism

The most common cause of primary hypothyroidism in Western countries is autoimmune thyroiditis. It is different from what happens in other parts of the world, where the main cause of hypothyroidism is iodine deficiency. Workman and LaCharity (2015) state that hypothyroidism is also caused by radioiodine therapy, thyroidectomy, and certain drugs including iodine, lithium, interferon, and thalidomide among others. There is a likelihood of the transient hypothyroidism occurring in sub-acute thyroiditis and in cases of postpartum thyroiditis.

In the two cases, about 75% and 85% of the affected patients regain normal thyroid function. Newborns are affected by congenital hypothyroidism as a result of thyroid gland agenesis. The complication affects one out of about 4000 newborns and it is regarded as the most common congenital endocrinopathy (Workman & LaCharity, 2015).

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Management of Hypothyroidism by Thyroid Replacement

The thyroid drug therapy is used for replacing thyroid hormone when the gland can hardly produce enough hormones on its own. A synthetic hormone that is referred to as levothyroxine is used as the treatment of choice for hypothyroidism. The drug is a synthetic derivative of T4 (thyroxine) with the capacity to normalize blood levels of TSH, T4, and T3. There are a number of levothyroxine brands with the oldest of all the brands being Synthroid. Due to the lack of restrictions in drug manufacturing in the past, there were thyroid products with varying qualities produced. However, the situation changed after the FDA had issued strong requirements of drug production that helped to correct the situation (Lilley et al., 2016).

Naturally, a dried powder thyroid hormone is made from animal glands. It was once a very common form of thyroid therapy but is has lost its value because of the varying potency. There are suggestions that if FDA regulations are made stricter, the natural form of thyroid hormone would be more effective and this would help in preventing exposure to autoimmunity factors. It is recommended as a natural treatment since it has a combination of T3 and T4.

Triiodothyronine (T3) is the other vital thyroid hormone. The hormone is only prescribed under special circumstances. Findings show a good response by many patients to thyroxin (T4) alone which gets converted in the body into T3 (Lilley et al., 2016). However, there are disturbances in the heart rhythm that occur as a result of using T3.

There are also combinations that contain T4 and T3 like liotrix that can also be used, but there is a lot of controversy regarding the benefits of such treatment. Although patients may like the combination products due to their ability to facilitate weight loss, it is wrong to imagine that the combination products provide any advantages in facilitating the normalization of the levels of TSH (Lilley et al., 2016).

Pharmacological Effects of Thyroid Replacement Drugs

Thyroid hormone preparations are widely used in two ways. Lilley et al. (2016) state that they are either used to correct hypothyroidism a replacement dose or to abolish secretion of thyrotropin in patients who have differentiated thyroid carcinoma after total thyroidectomy when used in suppressive doses. The later use is observed in patients with differentiated thyroid carcinoma after a complete thyroidectomy or with diffuse goiter. Despite the fact that the medication is capable of helping patients recover, there are a number of adverse effects that are associated with the therapy. One of the adverse effects is cardiovascular changes that involve a shortening of symbolic time intervals and increased frequency of atrial premature beats.

The thyroid hormone can increase the risk of coronary insufficiency with CAD. Therefore, there may be a need for the dosage to be adjusted upward for oral and insulin hypoglycemic agents. Concurrent sympathomimetics can also decrease the absorption with soybean flour, cottonseed meal, walnuts, and dietary fiber. It is also likely to increase oral anticoagulant activity besides decreasing the levels and effects of digitalis glycosides (Lilley et al., 2016).

It is unfortunate that the medications do not guarantee patients significant symptom alleviation. Lilley et al. (2016) observe that despite using the medications, some patients do not feel significantly better despite improvement in their thyroid levels that attain normalcy after going through the process of thyroid replacement. Patients who experience persistent symptoms can take advantage of triiodothyronine (T3), the other important thyroid hormone. In such a case, a natural dried thyroid hormone containing T3 or a lower-dose of thyroxin with a small amount of T3 can be helpful.

Overdosing with the medications also has adverse side effects on patients. Overdosing can result in the occurrence of the symptoms of hyperthyroidism. There is a high likelihood of abnormal heart rhythms occurring in people who have excessive thyroid hormone in their blood. In particular, excess thyroid hormone is dangerous for newborns and it is vital to ensure that their drug dosage is closely monitored so as to prevent the possibility of brain damage (Lilley et al., 2016).

There are several risks that are associated with having excessive thyroid hormone in one’s blood. Such a condition exposes a patient to unusual rhythms and makes him/her prone to heart failure. Besides, having too much thyroid hormone increases one’s heartbeat and in the case of the patients who have some heart disease, the chances of a heart attack are very high. Newborns are at a higher risk when they have too much thyroid hormone in their blood. To safeguard them from the adverse effects of such a condition, it is necessary to closely monitor their drug levels (Brenner & Stevens, 2013).

Long-term treatment with thyroid hormone also has adverse side effects. The patients with hypothyroidism usually get long-term treatment because the provision of levothyroxine therapy is a lifelong requirement for the patients (Brenner & Stevens, 2013). In fact, the study showed that there is a lot of concern about the fact that long term treatment with levothyroxine therapy leads to an increased risk of osteoporosis as in the case of suppression therapy. Another study by Kaye, Kaye, & Urman (2014) also indicated that women who have reached their postmenopausal age and are using the right dosage of long-term replacement thyroxine do not have a highly increased risk of osteoporosis.

There are also cases of drug interactions with levothyroxine. These cases can either enhance or negatively influence the absorption of the medication. The drugs that have been found to have the capacity of interactions with levothyroxine include:

  • amphetamines;
  • anticoagulants;
  • tricyclic antidepressants.

Interactions can also occur between levothyroxine and other drugs like anti-anxiety drugs, aspirin, insulin, some cancer drugs, and calcium carbonate and aluminum hydroxide among others (Brenner & Stevens, 2013).

The level of effectiveness of the drug is also affected by the large amounts of dietary fiber. People who include a lot of fiber in their diets may require high doses of the drug. Thyroid hormones also have the capacity to affect several other medications due to the fact that they regulate metabolism. Therefore, there is a need to adjust dosages for the patients who are undergoing treatment of other conditions. It is worth noting that even an alteration in the brand of thyroxin that one uses can have different effects on the patient’s health (Kaye et al., 2014).

Fortunately, the risks of the adverse effects of thyroid replacement drugs can be minimized. The management is done through careful monitoring of serum-free thyroxine and free liothyronine (triiodothyronine) measurements and by ensuring that the dosage is appropriately adjusted. In most cases, the adverse effects of the medications are minor and transient with the most dangerous effect being granulocytosis which is reported to be occurring in around 0.1-0.5 % of patients (Brenner & Stevens, 2013). The serious adverse effect is life-threatening but it is treatable by granulocyte colony-stimulating factor administration.

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Effects Resulting from Inappropriate Use of Thyroid Hormone

There are cases involving the inappropriate prescription of thyroid replacement hormone. The hormone should be sparingly used in the treatment of low thyroid that has been diagnosed. Cases have been reported where the thyroid hormone is wrongly used to treat complications like infertility, menstrual complications in women, and as a treatment measure for men whose sperm count is low. The treatment has at times been assigned even in situations where there are no confirmed cases of thyroid abnormalities (Brenner & Stevens, 2013).

The hormone has also been falsely used in controlling the cases of weight loss and to reduce the high levels of cholesterol. Treatment of metabolic insufficiency has also been done with the use of thyroid hormone. It is important to note that the symptoms of low metabolism should not be particularly treated with the use of thyroid hormone (Kaye et al., 2014). The only exception where thyroid therapy is beneficial for a patient is when the patient has been diagnosed with hypothyroidism. Excessive application of thyroid hormone in providing wrong treatments can have adverse effects like weakening of muscles and later even weakening of the patient’s heart. There is an exceptional case where thyroxine is used in the enhancement of drugs that are applied in treating severe depression.

For patients suffering from adrenal insufficiency, thyroid hormone replacement can lead to adrenal complications as it can enhance hepatic corticosteroid metabolism. Suspicion about the presence of adrenal insufficiency should call for a test to either rule it out or confirm it. It has been confirmed that efforts should be made to treat it first before taking measures to treat hypothyroidism.

Cardiac functioning in patients that suffer from heart disease can also be affected by thyroid hormone replacement. In such cases, it is recommended that the drug is administered in smaller starting doses of LT4 with the doses increased bit by bit (Hemmings & Egan, 2013).

The treatment involving the use of LT4 often results in a complication referred to as subclinical hyperthyroidism. Some studies have also linked osteoporosis and fracture with overtreatment but the relationship is still not very clear and it is more often observed in postmenopausal women (Hemmings & Egan, 2013).

There was a two to three-fold increase in the case of fracture in the users of LT4 who are over 70 years old based on a large population-based nested case-control study while the increase was dose-related (Hemmings & Egan, 2013). Because studies on thyroid function were not performed, the relation between subclinical hyperthyroidism and osteoporosis should be investigated further.

Close monitoring of osteoporosis patients and patients who are subjected to long term use of LT4 as a supportive dose need close monitoring. Normally, thyroid cancer patients are put on a higher dose of LT4. The requirement for the level of TSH is largely dependent on the stage that a cancer patient has reached and on whether or not there is evidence of an actively progressing disease. In the case of stage IV thyroid cancer patients, it is desirable to keep the TSH below 0.1 mIU/L in the long term (Hemmings & Egan, 2013).

Patients should be aware that in rare cases, vision may be temporarily impaired when hormone therapy is initiated. Pseudotumorcerebri may occur more often (Bryant & Knights, 2010).

Nursing Implications

Based on the adverse effects of thyroid replacement drugs, nurses need to take into account various considerations when giving prescriptions. As earlier discussed, the treatment measures that are taken for treating the disease are aimed at preventing the complication from clinically progressing (Bryant & Knights, 2010). The administering of thyroid hormone is done with the aim of supplementing or replacing endogenous production. As such, hypothyroidism is generally treatable through constantly taking levothyroxine (LT4) in the right dosage. It is acceptable to start the use of the thyroid hormone by taking full doses in the case of young patients and patients who do not have other health complications. It is a different case when patients have confirmed ischemic heart complications where it is recommended that the treatment starts from a small dosage (Bryant & Knights, 2010).

After determining the dosage, it is important to have the dosage adjusted by making small increments within a minimum of four to six weeks. Patients suffering from hypothyroidism are likely to start noticing the clinical benefits of medication after three to five days and the condition is likely to alleviate within the duration of about four to six weeks. T4 levels are used instead of TSH in managing hypothyroidism in patients who have central hypothyroidism. It is vital to have patients closely monitored after adjusting the dosage (Bryant & Knights, 2010).

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Lilley et al. (2016) emphasized the need for close monitoring of hypothyroidism patients after adjusting the dosage due to the possibility of unfriendly symptoms occurrence. The treatment measures that are used for hypothyroidism patients can have unfriendly complications whose manifestation is observed by looking at the number of symptoms. The observation should be based on observing the symptoms like tachycardia, palpitations, atrial fibrillation, and nervousness. Patients can also show other symptoms like increased excitability, tremor, sleeplessness, possible angina, and tiredness. Close monitoring of patients for the symptoms is vital as a means of ensuring that the adverse effects are checked before they cause much harm to the patients. It is necessary to ensure that the right medication is given so as to limit the possibility of symptoms occurrence (Lilley et al., 2016).

There is no significant difference in terms of the level of the efficiency of T4 and T3 immunotherapy in treating hypothyroidism. It is because the study showed that two treatment options had similar side effects (Lilley et al., 2016). Another study showed that the patients of hypothyroidism are highly heterogeneous in regard to the production of T3 when their treatment involves the use of levothyroxine (Braverman & Cooper, 2013)

Those who continue experiencing symptoms like fatigue and weight gain despite having a normalized level of TSH are advised to consider other causes different from hypothyroidism. It is not advisable to address the symptoms through the mere addition of the thyroid hormone dose due to the observed symptoms (Brophy, 2011).

Conclusion

This discussion shows that hypothyroidism is a common health complication that is rated among the most common endocrine diseases. The complication is often cared for in primary care settings based on the perception that it is a simple complication that can be easily dealt with. There are a number of drugs that are used to control hypothyroidism. Among the commonly used drugs in the treatment of hypothyroidism are triiodothyronine (T3) and thyroxine (T4). Although the drugs are recommended for the treatment of hypothyroidism, a number of complications are associated with their long-term use. Besides, patients experience some complications resulting from over and underdosing of the drugs.

Among the adverse effects associated with the use of thyroid replacement drugs are cardiovascular changes and increased risk of coronary insufficiency with CAD. The adverse effects have an influence on nursing while thee way hypothyroidism patients should be cared for. It is vital to closely monitor the patients who are on the thyroid replacement drugs to identify dangerous symptoms and to appropriately adjust the dosages. It can be carried out by closely monitoring the patient’s response to the drugs and checking their condition.

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