A 45-year-old female patient presented with facial puffiness, myalgia, increased tiredness, hoarseness of voice and headache. Lab investigations revealed hypothyroidism. She was diagnosed with hypothyroidism and prescribed levothyroxine, otilonium bromide, ranitidine, ferrous sulfate, and calcium. The pharmacist intervened to recommend changing the dosing interval between levothyroxine and calcium to 4 hours apart to maximize levothyroxine efficacy and monitoring serum TSH levels.

1. Presented by:
B.Venkata Subbareddy

2.  Number of cases collected: 150
 Number of patient counselling done: 150
 ADR’s monitored: 75
 Number of queries collected: 75
 Pharmacist interventions done: 75

3. A 45 years Female patient was admitted in female medical ward with IP
number 1394538 on 02/01/2018.
CHIEF COMPLAINTS:
C/O facial puffiness since 1 month.
PAST MEDICATION HISTORY:
No H/O any significant any medication in the past.
PERSONAL HISTORY AND HABITS:
Non-smoker, Non-alcoholic, married with not known allergies.

4. SUBJECTIVE Continued..,,
HISTORY OF PRESENT ILLNESS:
H/O swelling in front of neck for 2 months, myalgia,
increased tiredness, hoarseness of voice and headache.
H/O Orthopnoea, pain in cheek.
PAST MEDICAL HISTORY:
No H/O DM, HTN. Bike accident 7 years back.

5. VITALS D1 D2 D3 D4 D5
BP(mm of Hg) 110/60 120/80 110/80 120/70 120/80
PR (bpm) 80/min 82/min 78/min 72/min 80/min
RR (bpm) 22/min 21/min 24/min 24/min 22/min
TEMP (f) 98.6 98.5 98.4 98.2 98.6
GENERAL EXAMINATION:
Patient was conscious, Oriented.
SYSTEMIC
EXAMINATION
D1 D2 D3 D4 D5
CVS S1,S2 (+) S1,S2 (+) S1,S2 (+) S1,S2 (+) S1,S2 (+)
RS NAD NAD NAD NAD NAD
CNS NFND NFND NFND NFND NFND
GIT (P/A) Soft Soft Soft Soft Soft
SYSTEMIC EXAMINATION:

6. Parameter Observed value Normal Value
Hemoglobin 9.5 g/dl 14-17g/dl
ESR 42 mm 5-20mm
Platelets 2.82 cells/mm3
1.0-4.5 cells/mm3
FBS 87 mg/dl 60-110mg/dl
Blood Urea Nitrogen 23 mg/dl 7 - 20 mg/dl
Serum Creatinine 0.7 mg/dl 0.5 - 1.4 mg/dl
T3 0.17ng/ml 0.8-1.6ng/ml
Total T4 0.6µg/dl 4.2-12 µg/dl
TSH 134.94 µIU/mL 0.5 - 4.70 µIU/mL
LAB INVESTIGATIONS:
DIAGNOSIS: Hypothyroidism

7. DRUGS DOSE ROA FREQ NO.OF .DAYS
1 2 3 4 5
Tab. Otilonium bromide 40mg P/O BD     
Tab. Ranitidine 150mg P/O BD     
Tab. Levothyroxine 150mcg P/O OD     
Tab. Ferrous sulfate 300mg P/O OD     -
Tab. Calcium 500mg P/O OD     -
Inj. Diclofenac 2ml/75mg IM BD    - -
Tab. Norfloxacin 400mg P/O BD   - - -
MEDICATION CHART:

8. DISCHARGE ADVICE:
T. Levothyroxine -100mcg, P/O, OD
T. Otilonium bromide 40mg, BD x 1 week.

9.  L-Thyroxine to be taken as single daily dose, ideally on
awakening , at least 30min before eating
 Fibre and bran products (e.g. Ispaghula husk) may impair
absorption as also cholestryramine, colestipol, iron
sulphate , sucralfate, aluminium hydroxide.
 Do not modify dose or stop treatment without
consultation .Over treatment may leads to decreased bone
mineral density and adverse cardiac consequences.
 Increase dietary iodine intake.
 Take iron rich foods, fruits & green leafly vegetables.
 Over treatment may lead to decreased bone mineral density
and adverse cardiac consequences.

10. DRUG INTERACTIONS
Drug –food interaction: Nil
Drug--Drug interaction:
Levothyroxine + calcium carbonate
 Concurrent administration of calcium-containing products may
decrease the oral bioavailability of levothyroxine by one-third in some
patients. Pharmacologic effects of levothyroxine may be reduced.

11. MEDICATION ERRORS
 ANY ALLERGIES NOTED: NO
 DOSE ERROR: Appropriate
 ROUTE OF ADMINISTRATION: Appropriate
 DATE AND TIME OF ADMINISTRATION: Appropriate
 CONFUSION IN WRITING OF THE DRUG: NO
 PATIENT COMPLIANCE: Yes
 PATIENT OPINION REGARDING DRUGS: Satisfactory

12. Pharmacist intervention
Dosing interval of Levothyroxine and
Calcium needs to be changed to achieve maximum
efficacy of Levothyroxine. A time interval of 4
hours is recommended. Monitor serum TSH levels.