A 35-year-old woman comes to her primary care physician complaining of palpitations, weight loss, increased appetite, and diarrhea for the past 2 months. She does not use alcohol or tobacco. Her temperature is 37.1° C (98° F), blood pressure is 135/80 mm Hg, pulse is 100/min, and respirations are 14/min. Physical examination shows exophthalmos, lid lag, lid retraction, and a diffusely enlarged and nontender thyroid gland. Laboratory studies show very low serum thyroid-stimulating hormone and increased serum free T4 and T3. The patient is diagnosed with Graves' disease. Various treatment options are discussed, and she opts for long-term treatment with methimazole. Which of the following conditions is this patient at risk for developing from the medication?

Question

A 35-year-old woman comes to her primary care physician complaining of palpitations, weight loss, increased appetite, and diarrhea for the past 2 months.  She does not use alcohol or tobacco.  Her temperature is 37.1° C (98° F), blood pressure is 135/80 mm Hg, pulse is 100/min, and respirations are 14/min.  Physical examination shows exophthalmos, lid lag, lid retraction, and a diffusely enlarged and nontender thyroid gland.  Laboratory studies show very low serum thyroid-stimulating hormone and increased serum free T4 and T3.  The patient is diagnosed with Graves' disease.  Various treatment options are discussed, and she opts for long-term treatment with methimazole.  Which of the following conditions is this patient at risk for developing from the medication?

Quizplus · Accepted Answer

11ec25c8_d3b9_83d8_bc81_d5d3dc55db38_MD0003_00 The 3 major treatment options for Graves' disease are: Radioactive iodine ablation (preferred in the United States)Antithyroid drug (ATD) therapyThyroidectomy Radioactive iodine ablation (preferred in the United States) Antithyroid drug (ATD) therapy Thyroidectomy All 3 modalities are equally effective, but surgery and radioactive iodine ablation can permanently treat hyperthyroidism. However, the physician should discuss the options with the patient to make a mutual decision. The two available ATDs in the United States are propylthiouracil (PTU) and methimazole (MMI). PTU is usually not the preferred drug due to a black box warning of severe liver injury and acute liver failure. However, PTU is preferred during the first trimester of pregnancy due to fetal teratogenicity with MMI. Approximately 30%-40% of patients treated with ATDs for 1 year go into permanent remission. The most common side effect of ATDs is allergic reaction (2% of patients). The most serious side effect is agranulocytosis (0.3% of patients), and all patients must be informed about it. Those developing sore throat and fever should stop the ATD and see a physician to check their white blood cell count. However, routine monitoring of the white blood cell count is not needed due to the rarity of the condition. (Choices B and E) Hypocalcemia and recurrent laryngeal nerve damage are complications of thyroidectomy. (Choice D) Permanent hypothyroidism may result after radioiodine treatment or thyroidectomy. (Choice G) Use of ATDs is not associated with a higher risk of thyroid cancer. (Choices C and F) Pancreatitis and renal damage are not common side effects of ATD therapy or other treatments for Graves' disease. (Choice H) Radioactive iodine therapy can be associated with development or worsening of ophthalmopathy in Graves' disease patients. Educational objective: Graves' disease can be treated with anti-thyroid drugs, radioactive iodine therapy, or thyroidectomy. The most serious side effect of anti-thyroid drugs is agranulocytosis (0.3% of patients). Patients developing sore throat and fever should stop the drug and see a physician to check their white blood cell count. References: Treatment of Graves' hyperthyroidism: evidence-based and emerging modalities. (http://www.ncbi.nlm.nih.gov/pubmed/19328416) Antithyroid drug regimen for treating Graves' hyperthyroidism. (http://www.ncbi.nlm.nih.gov/pubmed/20091544)

A 35-Year-Old Woman Comes to Her Primary Care Physician Complaining