Homeostasis of Thyroid Hormones
Discuss about the Homeostasis of Thyroid Hormones.
The thyroid gland produces two hormones that determine the basal metabolic rate of the body. These two hormones are known as thyroxine or T4 and triiodothyronine also referred to as T3 (Warner & Mittag, 2012). The thyroid stimulating hormone that is secreted by the pituitary glands stimulates the thyroid glands to release T4 and T3 hormones. These two hormones affect almost all body cells apart from the uterus, the adult brain, the spleen, blood cells, and testes (Warner & Mittag, 2012). The hormones are transported through the plasma membrane and are attached to the receptors on the mitochondria leading to an increase in the production of adenosine triphosphate energy (López, Alvarez, Nogueiras & Diéguez, 2013). Additionally, within the nucleus, thyroxin and triiodothyronine activate the genes that are responsible for the production of energy and the oxidation of glucose. The result is that the rate of metabolism of the body increases and more heat is produced.
Once the level of the thyroid hormones in the blood has reached the ideal level, a negative signal is sent to the hypothalamus to inhibit the production of the thyrotropin-releasing hormone that further inhibits the production of thyroid stimulating hormone. As a result, the rate of metabolism is reduced and amount of heat produced by the body is also reduced (López et al., 2013). Furthermore, López et al. (2013) ascertain that after some time, the level of the thyroid hormones drop and the hypothalamus is once activated to release TRH hormone while at the same time the pituitary glands release the TSH hormone and the cycle continues.
Thyroid hormone imbalances are in most cases characterized by the overproduction or the underproduction of the T3 hormone. When the thyroid hormone is produced in excess, a condition known as hyperthyroidism is developed, conversely, when the production of the hormones is inadequate, a condition referred to as hypothyroidism is developed (Warner & Mittag, 2012). Homeostasis is therefore important in ensuring that the levels of the thyroid hormones are kept at a normal range.
Grave’s disease is a condition that may consist of goiter, hyperthyroidism, and eye disease or orbitopathy. The most common feature of Grave’s disease is hyperthyroidism and it affects almost all patients (Smith & Hegedüs, 2016). The excessive production of the thyroid hormone normally accompanies the turgid enlargement of the thyroid glands like in Ms. Kylie’s case. This enlargement of the thyroid gland and the excessive production of the thyroid hormones may lead to symptoms of hyperthyroidism (Smith & Hegedüs, 2016). Some patients may experience protrusion of the eyes, retraction of the eyelid and in some cases a double vision or occasional loss of vision.
Grave’s Disease
This condition can be described as an autoimmune disease, in that the body reacts to its own tissues as if they were foreign pathogens. Patients suffering from Grave’s disease will always release antibodies that operate on the thyroid thus increasing the size of the thyroid and the production of the thyroid hormones (Bahn, 2010). These antibodies increase the activity of the sodium iodide symporter. As a result, the uptake of iodine is increased in the absence of thyroid stimulating hormone (Bartalena & Hennemann, 2014). This disease is more common among women than men and affects middle-aged individuals in most cases. The primary cause of this disease is not clearly known but several pieces of research have revealed a genetic susceptibility to Grave’s disease (Smith & Hegedüs, 2016).
The overproduction of the thyroid hormones interferes with the physiological systems such as the nervous system, metabolism, heart function, and the temperature of the body among others. Patient with Grave’s disease-like Ms. Kylie may exhibit symptoms that include nervousness, goiter, irregular heartbeats, and heat intolerance among others (Bahn, 2010). From the presented scenario, we can notice that Ms. Kylie experiences anxiety and excessive sweating due to heat intolerance. Additionally, she has an enlarged thyroid, high blood pressure, tachycardia which causes an irregular heartbeat rate higher than 100 beats per minute and puffy eyes. All these revelations are indications of hyperthyroidism.
Carbimazole is used to treat overactive thyroid gland or hyperthyroidism. As a result, it helps in treating Ms. Kylie’s enlarged thyroid. It also blocks the organic binding of iodine by inhibiting the tyrosine iodination (Manna, Roy & Mugesh, 2013). It further acts on peroxidase that is used by the thyroid glands to synthesize thyroxine.
Levothyroxine is a medication used to treat hypothyroidism. It acts in the same way as thyroxine to bring the levels of the thyroid hormones T3 and T4 back to normal. It acts to replace the low levels of thyroxine hormone and return the metabolism of the body to the required level (Bartalena, 2013).
Propranolol (Deralin) is used to treat hypertension and irregular heartbeats characterized by tachycardia in Kylie’s case. This drug acts by affecting the response of the body to nerve impulses (Marcocci & Marinò, 2012). It thus reduces the heart’s need for oxygen and blood thus reducing the amount of the work done by the heart.
Cimetidine (Magicul 400mg) is used to treat stomach and intestinal ulcers and prevent their reoccurrence. As a result, it could be fundamental in treating Ms. Kylie’s gastro-esophageal reflux. This drug works by reducing the stomach acidity thus helping to treat ulcers and relieve heartburn.
Mode of Action of the Drugs
One of the pharmacological problems that Ms. Kylie would experience is gastrointestinal upset. The consumption of Carbimazole (Neo-Mercazole) could have possible side effects like gastrointestinal upset that causes diarrhea in the patient. This medication could also interact with theophylline which is a medication used to treat asthma (Schmidinger et al., 2011). The assessment reveals that she is asthmatic which means she could be using theophylline.
Reports also indicate that Levothyroxine (Eltroxin) hastens the metabolism for propranolol. Propranolol is a beta blocker and it interacts with Levothyroxine (Eltroxin) to reduce thyroid functions by reducing the peripheral conversion of Levothyroxine to triiodothyronine (Bartalena & Hennemann, 2014). It is also important to note that the absorption of this medication may be affected by cimetidine and therefore, the administration of the two should be separated by approximately 5 hours. Levothyroxine also has possible side effects of diarrhea. Propranolol may also interact with cimetidine thus increasing the levels of propranolol in blood. Drugs used to treat asthma also interact with propranolol causing additional side effects.
The right medication; this implies that the type of medication administered is the appropriate medication. Errors may arise when the pharmacy dispenses a similar medication to the ordered one but not actually the right medication. Additionally, errors arise when a registered nurse administers a medication with an almost similar name or when they administer a medication that had been prepared by someone else (Elliott & Liu, 2010). From the assessment in the provided scenario, the pharmacist dispenses Carbimazole (Neo-Mercazole) 5 mg as had been directed by the general practitioner.
The right patient; this implies that the medication is given to the patient it was intended for. The avoidance of errors is done by using two identifiers and requesting the patients to state their names (Elliott & Liu, 2010). The names are documented in the medication administration records for reference. There was an error in this case as the medication is dispensed to Mr. Kyle as opposed to Ms. Kylie who was supposed to get the medication.
The right dosage; this ensures that the patient gets the most appropriate dosage for their condition. It is important that the patient receives the dosage that had been ordered (Elliott & Liu, 2010). An error arises when the pharmacist dispenses Carbimazole (Neo-Mercazole) 5 mg and instructs the patient to take one tablet by mouth thrice per day as opposed to two times a day as had been directed by the general practitioner.
Pharmacological Problems
The right route; this requires that the medication is administered in the ordered route that is appropriate and safe for the patient (Elliott & Liu, 2010). It is clear from the assessment that the right route was followed.
The right time; this demands that the medication is given at an appropriate time in accordance with the policies of an agency (Elliott & Liu, 2010). It is important that the nurse identifies the drugs that are not supposed to be taken with food and those that are taken with food.
The right reason; this ensures that the right medication was requested for the right purpose. From the assessment, it is clear that the ordered drugs were meant for hyperthyroidism. Therefore, the pharmacist dispensed Carbimazole (Neo-Mercazole) 5 mg for the right reasons.
The right documentation; the nurse must document any medication delivery immediately after they have been given to avoid re-administration of the medications (Elliott & Liu, 2010). Documentation should be done in accordance with the agency policy. If the documentation had been done appropriately, then the pharmacist could have known that the medication was meant for Ms. Kylie and not Mr. Kyle.
The main pharmacological goal for the patient should be aimed at stopping the overproduction of thyroid hormones. This will help in controlling the symptoms of Grave’s disease and ensuring quality care. The best antithyroid drug that should be administered to Ms. Kylie is Carbimazole (Manna, Roy & Mugesh, 2013). This drug inhibits the thyroid hormone synthesis. The dosage form of the medication is in terms of tablets that are normally swallowed whole with a glass of water. Ms. Kylie, therefore, needs to swallow the tablets without chewing or crushing. It is important to add levothyroxine during a low dose therapy of antithyroid drug (Manna, Roy & Mugesh, 2013). The optimal therapy duration should be between 12 -18 months with an assessment twice every week to track her recovery.
If the patient develops significant side effects due to the antithyroid drugs administered, then I would recommend total thyroidectomy. It is an effective and safe option for treating patients with symptoms of Grave’s disease (Bartalena, 2013). Additional adjustments could be made to incorporate propranolol which is a beta blocker to help address the issue of tachycardia and anxiety. Radiation therapy is also an important adjustment to treating this condition (Matthiesen et al., 2012). Some non-pharmacological therapies that could be used to treat Ms. Kylie include good eating habits, routine exercises, and stress avoidance (Passani & Blandina, 2011).
References
Bahn, R. S. (2010). Graves’ ophthalmopathy. New England Journal of Medicine, 362(8), 726-738.
Bartalena, L. (2013). Diagnosis and management of Graves disease: a global overview. Nature Reviews Endocrinology, 9(12), 724-734.
Bartalena, L., & Hennemann, G. (2014). Graves’ Disease: Complications.
Elliott, M., & Liu, Y. (2010). The nine rights of medication administration: an overview. British Journal of Nursing, 19(5), 300-305.
López, M., Alvarez, C. V., Nogueiras, R., & Diéguez, C. (2013). Energy balance regulation by thyroid hormones at central level. Trends in molecular medicine, 19(7), 418-427.
Manna, D., Roy, G., & Mugesh, G. (2013). Antithyroid drugs and their analogues: synthesis, structure, and mechanism of action. Accounts of chemical research, 46(11), 2706-2715.
Marcocci, C., & Marinò, M. (2012). Treatment of mild, moderate-to-severe and very severe Graves’ orbitopathy. Best Practice & Research Clinical Endocrinology & Metabolism, 26(3), 325-337.
Matthiesen, C., Thompson, J. S., Thompson, D., Farris, B., Wilkes, B., Ahmad, S., … & Bogardus, C. (2012). The efficacy of radiation therapy in the treatment of Graves’ orbitopathy. International Journal of Radiation Oncology• Biology• Physics, 82(1), 117-123.
Passani, M. B., & Blandina, P. (2011). Histamine receptors in the CNS as targets for therapeutic intervention. Trends in pharmacological sciences, 32(4), 242-249.
Schmidinger, M., Vogl, U. M., Bojic, M., Lamm, W., Heinzl, H., Haitel, A., … & Zielinski, C. C. (2011). Hypothyroidism in patients with renal cell carcinoma. Cancer, 117(3), 534-544.
Smith, T. J., & Hegedüs, L. (2016). Graves’ disease. New England Journal of Medicine, 375(16), 1552-1565.
Warner, A., & Mittag, J. (2012). Thyroid hormone and the central control of homeostasis. Journal of molecular endocrinology, 49(1), R29-R35.
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