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A 33-year-old woman with a history of Graves’ disease is brought to the emergency department unresponsive following a bout of confusion and agitation. On physical examination her temperature is 39.2° C (102.5° F), her blood pressure is 100/70 mm Hg, and her pulse is 165/min. A systolic ejection murmur is heard at the apex, and the patient has 3+ pitting edema at the ankles. Following primary stabilization, which of the following would constitute appropriate pharmacotherapy for this patient’s underlying condition?

(A) Aspirin
(B) Dobutamine
(C) Iodine
(D) Levothyroxine
(E) Propylthiouracil
in Pharmacology by

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(E) Propylthiouracil
This patient is presenting with a medical emergency: an extreme form of thyrotoxicosis known as “thyroid storm.” The symptoms of this syndrome are due primarily to increased β-adrenergic out- flow stimulated by thyroid hormones. After primary stabilization (airway, breathing, and circulation), propylthiouracil or methimazole is the most appropriate pharmacologic treatment for this condition. These agents inhibit the endogenous synthesis of thyroxine, which can cause or worsen this condition.

Answer A is incorrect. Aspirin displaces thyroxine from thyroid-binding globulin and can thus worsen the symptoms of thyrotoxicosis. In contrast, acetaminophen is useful as an antipyretic in the treatment of thyrotoxicosis and thyroid storm.

Answer B is incorrect. Dobutamine is a β- adrenergic agonist that is useful in the treatment of acute congestive heart failure but would exacerbate the adrenergic effects of high-output congestive heart failure secondary to thyrotoxicosis. A β-adrenergic antagonist such as propranolol would be more appropriate in the treatment of thyrotoxicosis.

Answer C is incorrect. Iodine, which decreases the release of preformed thyroxine, can be used as an adjunct to propylthiouracil or methimazole but should not be used until one of these agents is allowed to take effect. Iodine can stimulate the endogenous synthesis of thyroxine and thus exacerbate this condition.

Answer D is incorrect. Levothyroxine, a synthetic form of thyroid hormone, is contraindicated in the treatment of thyrotoxicosis. The addition of more thyroid hormone to a patient with a condition of symptomatic hyperthyroid- ism would only worsen the condition.