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Let’s start our USMLE Review with Hypothyroidism and Hyperthyroidism from the Gold Standard USMLE Foundations of Medicine Audio Review program.
Play USMLE Audio MP3 11 04 Myxedema Coma in Elderly or Heart Disease 1 Below
Begin 11 04 Myxedema Coma in Elderly or Heart Disease 1 Transcription
As noted earlier, if Levothyroxine is given IV in large doses there is inherit risk of precipitating angina, heart failure or arrhythmias in older patients with underlying coronary artery disease. It is imperative to treat older myxedema patients with lower Levothyroxine doses, building up gradually, especially for those with long standing hypothyroidism or known cardiovascular disease.
What is the recommended dose regimen for this patient population? Pause the tape please.
- For myxedema patients with long standing hypothyroidism or advanced age, especially those with known cardiovascular disease, Levothyroxine is given at a dosage of 0.025mg per day for 2 weeks then increasing by 0.025mg every 2 weeks until a daily dose of 0.1-0.125mg is reached.
And on this regimen about how long does it usually take for an older or a heart disease myxedema patient to come into Thyroxine equilibrium?
- About 2 months. These patients are highly sensitive to the level of circulating Thyroxine and if angina pectoris or cardiac arrhythmia should develop it’s essential to reduce the Levothyroxine dose at once.
Student doctor please pause the tape and summarize a treatment of elderly myxedema patients or those with known heart disease, remembering that large IV doses of Levothyroxine can precipitate angina, heart failure or arrhythmias in older myxedema patients with heart disease.
- It’s imperative to start Levothyroxine treatments slowly. A recommended dose regimen is Levothyroxine 0.025mg per day for 2 weeks then increasing by 0.025mg every 2 weeks until a daily dose of 0.1-0.125mg is reached. It will likely take about 2 months on this regimen to achieve Thyroxine equilibrium.
We’ll conclude our discussion of hypothyroidism with a few points on the course and prognosis for myxedema. Untreated myxedema has a course of slow deterioration, eventually leading to myxedema coma and death. With appropriate treatment though long term prognosis is excellent. Due to the 7 day half-life of Thyroxine, it takes some time to get to equilibrium on a fixed dose.
How often should free Thyroxine or free Thyroxine index be monitored while equilibrium is being reached? And how often thereafter?
- FT4 or FT4i should be monitored in a myxedema patient every 4-6 weeks until Thyroxine equilibrium is reached and once a year thereafter.
Should the Thyroxine dose be increased during pregnancy and lactation period?
- Yes, T4 dose should be increased about 25% during pregnancy and lactation.
The mortality rate of myxedema coma once stood at about 80%. The prognosis has vastly improved with the advent of which 2 treatment measures? Just list them please.
- The use of mechanically assisted respiration and intravenous Levothyroxine has greatly reduced the mortality rate for myxedema coma. Currently, treatment outcome probably depends more on the effect of management of underlying diseases than it does on the myxedema coma itself.
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