Aashi
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An elderly woman in a nursing home is being evaluated for her hypothyroidism. You find her thyroid-stimulating hormone (TSH) level to be elevated at 13 mU/L (normal 0.4-5 mU/L). She has been on the same dose of levothyroxine for six months since the time of diagnosis. Her past medical history is significant for anemia, peptic ulcer disease, and a stroke with right hemiparesis. She also has hypertension and chronic renal failure. The staff reports to you that she has had no change in her mental status, skin, or bowel movements. Since your last visit two months ago, an iron supplement was added to her regimen of amlodipine, famotidine, levothyroxine 75 μg, vitamin C, and aspirin. Her hematocrit is 40%, and rest of her physical examination is unremarkable. What is the next appropriate step in her management?
(A) Radioactive-iodine uptake level
(B) No change in management
(C) Titers against thyroperoxidase and thyroglobulin
(D) MRI of the brain
(E) Stop the iron and aspirin
(F) Stop the famotidine
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| mjl1717
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I semieducated guess is answer -a
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| fox
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this is a case of pernicious anemia & iron wont help.....so stop iron & aspirin....is it E??
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| vrach
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E - I think the iron supplimentation is interfering with levothyroxine absorbtion and this might be the cause of the poorly controled hypothyroidism (high TSH levels)
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| Aashi
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Answer:
(E) Stop the iron and aspirin
Explanation:
This patient most likely has poor control of her hypothyroidism due to decreased absorption of her thyroid-hormone replacement because of an interaction with iron sulfate and vitamin C. Because her hematocrit is normal she doesn't need the iron anyway, and the vitamin C is most likely just being given to increase the absorption of the iron. Calcium supplementation and Carafate can also interfere with the absorption of thyroid hormone.
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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| elitoki
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Good Ponit!,
So, iron can interfere levothyroxine absorption and it shouldn't give with it. 
but... why should we stop ASA? this pte has history of stroke..???
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| Dr.D
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elitoki, Pt has h/o of PUD. we can give her ticlopidine or clopidogrel.
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| elitoki
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 , thanks. I see it now~
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| chemamr
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E
good question
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