From the FDA Drug Label
In adult patients with primary hypothyroidism, monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dosage. The general aim of therapy is to normalize the serum TSH level Failure of the serum T4 to increase into the upper half of the normal range within 2 weeks of initiation of levothyroxine sodium therapy and/or of the serum TSH to decrease below 20 IU per litre within 4 weeks may indicate the patient is not receiving adequate therapy Assess compliance, dose of medication administered, and method of administration prior to increasing the dose of levothyroxine sodium
The patient's current TSH level is 4.210, which is higher than the previous level of 3.190. The patient has not taken any of her prescribed medications over the past three months, which is likely the reason for the worsening of her condition.
- Assess compliance: The patient has already stated that she has not taken her medications as prescribed.
- Adjust medication administration: The patient should be instructed to take her medications as prescribed, and the dosage should be adjusted as needed to normalize her TSH level.
- Monitor TSH levels: The patient's TSH levels should be monitored after an interval of 6 to 8 weeks after any change in dosage to assess the effectiveness of the treatment.
- Consider potential interactions: The potential for food or drug interactions should be considered, and the administration or dosage of levothyroxine sodium tablets should be adjusted as needed 1.
From the Research
The plan of care for this patient should focus on medication adherence and addressing her hypothyroidism, vitamin D deficiency, obesity, and skin irritation. First, restart all prescribed medications: Levothyroxine 88mcg daily to treat her hypothyroidism (TSH has increased from 3.190 to 4.210), Vitamin D 50,000 units weekly to address her severe deficiency (level at 19), Zepbound 2.5mg weekly for weight management (patient has gained 14 pounds in three months), and Lotrisone topical cream 1 gram twice daily for her skin irritation. The patient requires education about the importance of medication adherence, emphasizing that her worsening condition is directly related to not taking her prescribed medications, as highlighted in the study on medication adherence 2. Schedule a follow-up appointment in 6-8 weeks to reassess TSH and vitamin D levels, monitor weight, and evaluate treatment effectiveness. Consider increasing the levothyroxine dose if TSH remains elevated, taking into account the guidelines for treating hypothyroidism 3, 4. Implement a comprehensive approach including dietary counseling, physical activity recommendations, and possibly behavioral therapy to address her obesity (BMI approximately 37), as well as discussing potential barriers to medication adherence and developing strategies to overcome them, such as medication reminders or simplified dosing schedules, as suggested in the study on medication adherence 5. Additionally, consider the potential benefits of vitamin D supplementation on thyroid autoimmunity, as noted in the study on vitamin D and thyroid autoimmunity 6. Overall, the goal is to improve the patient's morbidity, mortality, and quality of life by addressing her multiple health issues through a comprehensive and patient-centered approach.