What is the plan of care for a 56-year-old female patient with a history of breast cancer (in remission since 2008), hypertension with Chronic Kidney Disease (CKD) stage 1, and hypothyroidism, presenting with elevated Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT), hyperlipidemia, and borderline Thyroid-Stimulating Hormone (TSH) levels, who is non-adherent to Levothyroxine (thyroid hormone replacement therapy)?

From the Guidelines

The plan of care for this 56-year-old female patient should focus on addressing her medication non-adherence, elevated liver enzymes, high cholesterol, and thyroid management. First, the patient should immediately restart her levothyroxine 88mcg daily as prescribed, with emphasis on the importance of consistent use for thyroid function, as treatment of hypothyroidism with levothyroxine generally lasts for many years 1. A medication reminder system should be implemented, such as a pill organizer, smartphone alerts, or automatic refill services to prevent future lapses. The elevated liver enzymes (AST 47, ALT 86) require further investigation through additional liver function tests and possibly an ultrasound to rule out fatty liver disease or other hepatic conditions, and the patient's alcohol consumption should be assessed, and she should be advised to avoid hepatotoxic medications and supplements. For her elevated LDL of 115, lifestyle modifications including a heart-healthy diet low in saturated fats, regular exercise (at least 150 minutes of moderate activity weekly), and weight management should be recommended, as the 2016 ESC/EAS guidelines for the management of dyslipidaemias suggest that lifestyle modifications are the first line of treatment for elevated LDL 1. A follow-up TSH test should be scheduled in 6-8 weeks after restarting levothyroxine to ensure proper thyroid function. Given her history of breast cancer and current hypertension with CKD stage 1, comprehensive monitoring should continue with regular cancer screenings and kidney function tests. The patient should maintain her current metoprolol 50mg daily for hypertension management, but her vitamin D3 dosage (50,000 units four times weekly) appears unusually high and should be reassessed with vitamin D level testing. Some key points to consider in the plan of care include:

• Medication adherence: implementing a reminder system to ensure the patient takes her medications as prescribed
• Liver enzyme elevation: further investigation and possible ultrasound to rule out underlying conditions
• High cholesterol: lifestyle modifications and possible initiation of lipid-lowering therapy
• Thyroid management: restarting levothyroxine and scheduling a follow-up TSH test
• Hypertension management: continuing metoprolol and monitoring blood pressure
• Vitamin D level testing: reassessing the patient's vitamin D dosage and levels to ensure they are within normal range. A follow-up appointment in 2-3 months would be appropriate to reassess all conditions and medication effectiveness.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Assessment and Lab Results

The patient presents with a past medical history of breast cancer, hypertension with CKD stage 1, and hypothyroidism. Recent labs show elevated AST and ALT, elevated LDL, and borderline TSH.

Potential Causes of Elevated Liver Enzymes

• The patient's elevated liver enzymes (AST and ALT) could be related to her hypothyroidism, as studies have shown that thyroid diseases can be associated with liver injuries or biochemical test abnormalities 2, 3, 4.
• The patient's non-adherence to her Levothyroxine medication for the past three months may have contributed to her elevated liver enzymes, as Levothyroxine has been reported to cause liver dysfunction in some cases 5, 6.

Plan of Care

• The patient should be advised to resume taking her Levothyroxine medication as prescribed, and her liver enzymes should be monitored closely to assess for any changes 5, 6.
• The patient's LDL level is elevated, and her cardiovascular risk factors should be addressed, including her hypertension and CKD stage 1.
• The patient's borderline TSH level should be monitored, and her Levothyroxine dose may need to be adjusted to achieve a normal TSH level.
• The patient's liver function tests should be interpreted with caution, considering her thyroid dysfunction, and any abnormalities should be investigated further 4.

Medication Management

• The patient's medication regimen should be reviewed, and any potential interactions or side effects should be considered, particularly with regards to her Levothyroxine medication and its potential impact on her liver enzymes 5, 6.
• The patient should be educated on the importance of adhering to her medication regimen and the potential consequences of non-adherence.

Further Evaluation and Monitoring

• The patient's liver enzymes should be monitored regularly to assess for any changes or improvements.
• The patient's thyroid function should be monitored regularly, and her Levothyroxine dose may need to be adjusted to achieve a normal TSH level.
• The patient's cardiovascular risk factors should be addressed, and her hypertension and CKD stage 1 should be managed accordingly.