Table 37.

1 Signs and Symptoms of Thyroid Dysfunction

Clinical Hypothyroidism Hyperthyroidism
Effects

CNS Depressed: Hypoactive reflexes, Stimulated: Hyperactive reflexes,

lethargy, sleepiness, slow anxiety, nervousness, insomnia,
speech, emotional dullness tremors, restlessness, increased
basal temperature

CV system Depressed: Bradycardia, Stimulated: Tachycardia,

hypotension, anemia, oliguria, palpitations, increased pulse
decreased sensitivity to pressure, systolic hypertension,
catecholamines increased sensitivity to
catecholamines

Skin, hair, Skin is pale, coarse, dry, Skin is flushed, warm, thin, moist,
and nails thickened; puffy eyes and and sweating; hair is fine and
eyelids; hair is coarse and thin; soft; nails are soft and thin
hair loss; nails are thick and
hard

Metabolic Decreased: Lower body Increased, overactive cellular

rate temperature, intolerance to metabolism: Low-grade fever,
cold, decreased appetite, intolerance to heat, increased
higher levels of fat and appetite with weight loss, muscle
cholesterol, weight gain, wasting and weakness, thyroid
hypercholesterolemia myopathy

Generalized Accumulation of Localized with accumulation of

myxedem mucopolysaccharides in the mucopolysaccharides in eyeballs,
a heart, tongue, and vocal cords; ocular muscles; periorbital
periorbital edema; edema, lid lag, exophthalmos;
cardiomyopathy; hoarseness pretibial edema
and thickened speech

Ovaries Decreased function: Menorrhagia, Altered: Tendency toward

habitual abortion, sterility, oligomenorrhea, amenorrhea
decreased sexual function

Goiter Rare; simple nontoxic type may Frequent; diffuse, highly vascular
occur

CNS, central nervous system; CV, cardiovascular.

Table 37.2 Drugs in Focus: Thyroid Agents

Drug Name Dosage/Route Usual Indications

Thyroid Hormones

levothyroxine Adult: 12.5–200 Replacement therapy in

(Synthroid, Levoxyl, Levothr mcg/d PO; 300– hypothyroidism;
Drug Name Dosage/Route Usual Indications

oid, others) 500 mcg IV suppression of TSH release;

loading dose treatment of myxedema
followed by 50– coma and thyrotoxicosis;
100 mcg/d IV synthetic hormone used in
maintenance dose patients allergic to
for myxedema desiccated thyroid
coma
Pediatric: Varies
based on age and
weight

liothyronine Adult: 25–100 mcg/d Replacement therapy in

(Cytomel, Triostat) PO; reduced hypothyroidism;
dosing for older suppression of TSH release;
adults thyroid suppression test;
Pediatric: 5–50 treatment of myxedema
mcg/d PO; 65–100 coma and thyrotoxicosis;
mcg/d IV synthetic hormone used in
patients allergic to
desiccated thyroid

thyroid desiccated (Armour Adult: 60–120 mg/d Thyroid hormone supplement

Thyroid) PO
Pediatric: 15–90
mg/d PO

Antithyroid Agents
Thioamides

methimazole (Tapazole) Adult: 15 mg/d PO Treatment of hyperthyroidism

initially, up to 30–
60 mg/d may be
needed;
maintenance, 5–15
mg/d PO
Pediatric: 0.4
mg/kg/d PO
initially;
maintenance, 15–
20 mg/m2/d PO in
three divided
doses

propylthiouracil (PTU) Adult: 300–900 mg/d Treatment of hyperthyroidism

PO initially;
maintenance, 100–
150 mg/d PO
Drug Name Dosage/Route Usual Indications

Iodine Solutions

sodium iodide I131 or Adult: Dose varies Treatment of

I123 (Hicon, generic, based on hyperthyroidism; thyroid
radioactive iodine) formulation and blocking in radiation
indication emergencies; destruction of
thyroid tissue in patients
who are not candidates for
surgical removal of the
gland

strong iodine solution, Adult and pediatric: Treatment of

potassium iodide One to two tablets, hyperthyroidism, thyroid
(Thyrosafe, Thyroshield) or 2–6 drops (gtt) blocking in radiation
PO daily to t.i.d. emergencies; presurgical
suppression of the thyroid
gland; treatment of acute
thyrotoxicosis until
thioamide levels can take
effect

TSH, thyroid-stimulating hormone.

Table 37.4 Drugs in Focus: Parathyroid Agents

Drug Name Usual Dosage Usual Indications

Antihypocalcemic Agents

abaloparatide 80 mcg/d subcutaneously in Treatment of postmenopausal

(Tymlos) periumbilical region of patients with osteoporosis at
abdomen high risk for fracture

calcitriol 0.5–2 mcg/d PO in the Management of hypocalcemia

(Rocaltrol) morning and reduction of
parathormone levels;
management of hypocalcemia
and metabolic bone disease
in patients with renal
impairment

parathyroid 50 mcg/d subcutaneously, Maintenance of serum calcium

hormone adjust dose to maintain levels in adults with
(Natpara) serum calcium levels in the hypoparathyroidism
lower range of normal

teriparatide 20 mg subcutaneously daily Management of osteoporosis in

(Bonsity, Forteo) postmenopausal females and
males with primary
hypogonadal osteoporosis
Drug Name Usual Dosage Usual Indications

who do not respond to

standard therapy; treatment
of patients on sustained
systemic glucocorticoid
therapy at high risk for
fractures

Antihypercalcemic Agents
Bisphosphonates

alendronate Dosing varies based on Treatment of Paget’s disease;

(Bonosto, Fosam indication and formulation postmenopausal osteoporosis
ax) treatment and prevention;
treatment of glucocorticoid-
induced osteoporosis;
osteoporosis in males

ibandronate 2.5 mg/d PO or 150 mg PO Treatment and prevention of

(Boniva) once per month on the osteoporosis in
same day each month; 3 postmenopausal patients
mg IV given over 15–30 s
once every 3 mo

pamidronate 30–90 mg IV as an infusion Treatment of Paget’s disease,

(Aredia) postmenopausal osteoporosis,
hypercalcemia of malignancy,
osteolytic bone lesions in
cancer patients

risedronate 30 mg/d PO for 2 mo; reduce Treatment of symptomatic

(Actonel, Atelvia dose in renal dysfunction; 5 Paget’s disease in patients
) mg/d PO for who are at risk for
osteoporosis or 35 mg PO complications; treatment and
once per week or 150 mg prevention of osteoporosis
PO once per month; 35 mg (postmenopausal,
PO once per week for males glucocorticoid related and in
to increase bone mass; 35 males); treatment of
mg PO once a week postmenopausal osteoporosis
(Atelvia) (Atelvia)

zoledronic acid IV infusions; dosing and Treatment of Paget’s disease,

(Zometa, Reclas frequency varies based on postmenopausal osteoporosis,
t) indication and formulation hypercalcemia of malignancy,
osteolytic bone lesions in
certain cancer patients;
prevention of new fractures in
patients with low-trauma hip
fractures
Drug Name Usual Dosage Usual Indications

Calcitonins

calcitonin salmon Paget’s disease: 50–100 IU/d Treatment of Paget’s disease,

(Miacalcin) subcutaneous or IM postmenopausal osteoporosis
Postmenopausal osteoporosis: in conjunction with vitamin D
100 IU/d subcutaneous or and calcium supplements;
IM with calcium and vitamin emergency treatment of
D hypercalcemia
Hypercalcemia: 4–8 IU/kg
subcutaneous or IM q12h

calcitonin salmon 200 IU/d intranasally; Treatment of postmenopausal

(generic) alternate nostrils daily osteoporosis in conjunction
with calcium supplements
and vitamin D

able 51.1 Drugs in Focus: Diuretics

Drug Name Usual Dosage Usual Indications

Thiazide Diuretics and Thiazide-Like Diuretics

Thiazide Diuretics

chlorothiazide Adult: 0.5–2 g PO or IV, Treatment of edema caused by HF,

(Diuril) daily to b.i.d. for edema; liver disease, or renal disease;
0.5–2 g/d PO for monotherapy or as adjunctive
hypertension treatment of hypertension
Pediatric (<6 mo): up to 33
mg/kg/d PO in two doses
Pediatric (>6 mo to 2
y): 125–325 mg PO in
two divided doses
Drug Name Usual Dosage Usual Indications

Pediatric (2–12 y): 375 mg

to 1 g PO in two divided
doses

hydrochlorothiazi Adult: 25–100 mg/d PO or Treatment of edema caused by HF,

de (generic) intermittently, up to 200 liver disease, or renal disease;
mg/d maximum for monotherapy or as adjunctive
edema; 25–100 mg/d PO treatment of hypertension
for hypertension
Pediatric (<6 mo): up to 3
mg/kg/d PO in two
divided doses
Pediatric (6 mo to 2
y): 12.5–37.5 mg/d PO in
two divided doses
Pediatric (2–12 y): 37.6–
100 mg/d PO in two
divided doses

Thiazide-Like Diuretics

chlorthalidone 50–100 mg/d PO for Treatment of edema caused by HF

(generic) edema; 25–100 mg/d PO or by liver or renal disease;
for hypertension adjunctive treatment of
hypertension

indapamide 1.25–5 mg/d PO for edema Treatment of edema caused by HF

(generic) or hypertension, based or by liver or renal disease;
on patient response adjunctive treatment of
hypertension

metolazone 2.5–5 mg/d PO for Treatment of edema caused by HF

(Zaroxolyn) hypertension; 5–20 mg/d or by liver or renal disease;
PO for edema, based on adjunctive treatment of
patient response hypertension

Loop Diuretics

bumetanide 0.5–2 mg/d PO as a single Treatment of acute HF, acute

(Bumex) dose repeated to a pulmonary edema, hypertension,
maximum of 10 mg; 0.5– and edema of HF, renal disease,
1 mg IM or IV given over or liver disease
1–2 min, may be
repeated in 2–3 h, not to
exceed 10 mg/d
Older or renal-impaired
patient: 12 mg by
continuous IV infusion
over 12 h may be most
Drug Name Usual Dosage Usual Indications

effective and least toxic

ethacrynic Adult: 50–200 mg/d PO Treatment of acute HF, acute

acid/sodium based on patient pulmonary edema, hypertension,
(Edecrin) response; 0.5–1 mg/kg IV and edema of HF, renal disease,
slowly ascites due to malignancy,
Pediatric: 25 mg PO with lymphedema, or liver disease;
slow titration up as indicated for treatment of edema
needed when an agent with greater
diuretic potential than those
commonly employed is required
Special consideration: not for use in
infants

furosemide Adult: 20–80 mg/d PO, up Treatment of acute HF, acute

(Lasix) to 600 mg/d may be pulmonary edema, hypertension,
given; 20–40 mg IM or IV and edema of HF, renal disease,
given slowly; 40 mg IV or liver disease
over 1–2 min for acute
pulmonary edema,
increase to 80 mg after 1
h if response is not
adequate; 40 mg PO
b.i.d. for hypertension
Older or renal-impaired
patient: 2–2.5 g/d PO
Pediatric: 2 mg/kg/d PO for
hypertension, not to
exceed 6 mg/kg/d; 1
mg/kg IV or IM for
edema, increased by
1 mg/kg as needed; not
to exceed 6 mg/kg

torsemide 5–20 mg/d PO initially Treatment of acute HF, acute

(Soaanz) based on indication; pulmonary edema, hypertension,
titration to max of 200 and edema of HF, renal disease,
mg/d PO based on or liver disease
individual response

Carbonic Anhydrase Inhibitors

acetazolamide PO or IV dosing; dosages Treatment of edema, chronic

(generic) vary per indication and simple (open-angle) and
acuity of the situation secondary glaucoma; adjunctive
treatment of edema due to heart
failure, centrencephalic epilepsy,
altitude sickness, preoperative
Drug Name Usual Dosage Usual Indications

acute angle-closure glaucoma to

lower intraocular pressure if need
to delay surgery

dichlorphenamide 50 mg once or twice daily; Treatment of primary hyperkalemic

(Keveyis) titrate based on paralysis
individual response, max
dose of 200 mg/d

methazolamide 50–100 mg PO b.i.d. to t.i.d. Treatment of glaucoma

(generic)

Potassium-Sparing Diuretics

amiloride 5–20 mg/d PO with Adjunctive treatment of edema

(Midamor) monitoring of electrolytes caused by HF, liver disease, or
renal disease; hypertension;
hypokalemia; and
hyperaldosteronism
Special consideration: not for use in
children

eplerenone 25–50 mg PO daily for HF Improve survival for patients with

(Inspra) patients; 50 mg PO daily HF with reduced ejection fraction
or 50 mg twice a day for after acute MI; treatment for
HTN hypertension

spironolactone PO dosing will vary per Adjunctive treatment of edema

(Aldactone, indication and caused by HF, liver disease, or
CaroSpir) medication formulation renal disease; hypertension;
hypokalemia; and
hyperaldosteronism; increases
survival, and decreases need of
hospitalization for patients with
HF with reduced ejection fraction

triamterene 100 mg/d PO b.i.d., max of Adjunctive treatment of edema

(Dyrenium) 300 mg/d for edema; 25– caused by HF, liver disease, or
100 mg/d PO for renal disease; hypertension;
hypertension hyperkalemia; and
hyperaldosteronism
Special consideration: not for use in
children

Osmotic Diuretics

mannitol 50–100 g IV for oliguria; Treatment of elevated intracranial

(Osmitrol) 1.5–2 g/kg IV to reduce pressure, acute renal failure,
intracranial pressure; acute glaucoma; also used to
Drug Name Usual Dosage Usual Indications

dose not established for decrease intracranial pressure, to

children <12 y prevent oliguric phase of renal
failure, and to promote
movement of toxic substances
through the kidneys
HF, heart failure.

Therapeutic Actions and Indications

Thiazide and thiazide-like diuretics act to block the chloride pump. Chloride is actively
pumped out of the tubule by cells lining the ascending limb of the loop of Henle and
the distal tubule. Sodium passively moves with the chloride to maintain electrical
neutrality. (Chloride is a negative ion, and sodium is a positive ion.) Blocking of the
chloride pump keeps the chloride and the sodium in the tubule to be excreted in the
urine, thus preventing the reabsorption of both chloride and sodium in the vascular
system (Fig. 51.1). Because these segments of the tubule are impermeable to water,
there is little increase in the volume of urine produced, but it will be sodium-rich, a
natriuretic effect. It is common for there to be some loss of potassium and bicarbonate
as well. Thiazides are considered to be mild diuretics compared with the more potent
loop diuretics. These drugs are the first-line drugs used to manage essential
hypertension when drug therapy is needed. See Table 51.2 for usual indications for
these agents.
p. 913

p. 914

Table 51.2 Comparison of Diuretics

Diuretic Major Site Usual Indications Major Adverse Effects
Class of Action

Thiazide, Distal Edema of HF, renal, and GI upset, CNS

thiazide- convoluted liver disease complications,
like tubule hypovolemia,
electrolyte alterations,
hyperglycemia,
hyperuricemia

Loop Loop of Acute HF; acute pulmonary Hypokalemia and other

Henle edema; hypertension; electrolyte alterations,
edema of HF, liver, and volume depletion,
renal disease hypotension, CNS
effects, GI upset,
hyperglycemia,
ototoxicity,
hyperuricemia
Diuretic Major Site Usual Indications Major Adverse Effects
Class of Action

Carbonic Proximal Glaucoma, diuresis in HF, GI upset, urinary

anhydras tubule mountain sickness, frequency
e epilepsy
inhibitors

Potassium- Distal tubule Adjunct for edema of HF, Hyperkalemia, CNS

sparing and liver, and renal disease; effects, diarrhea
collecting treatment of hypokalemia;
duct adjunct for hypertension;
hyperaldosteronism

Osmotic Glomerulus, Reduction of intracranial Hypotension, GI upset,

tubule pressure, prevention of fluid and electrolyte
oliguric phase of renal imbalances
failure, reduction of IOP,
renal clearance of toxic
substances
GI, gastrointestinal; CNS, central nervous system; HF, heart failure; IOP, intraocular pressure.

BOX 51.4

Potassium-Rich Foods
Avocados Dried fruits Navy beans Prunes Sunflower seeds

Bananas Grape -fruit Oranges Rhubarb Tomatoes

Broccoli Lima beans Peaches Decaffeinated Coffee Watermelon

Cantaloupe Nuts Potatoes Spinach