4/6/2019

Financial Disclosure

• “I have had no financial relationship over the past 12 ENDOCRINE months with any commercial sponsor with a vested PRODUCTS- THYROID & interest in this presentation” DIABETES By: Avery Aldridge, Pharm.D. 4/12/19

Pharmacist Learning Technician Learning Objectives Objectives

•Identify signs and •Identify the correct symptoms of brand and generic hypothyroidism and names for thyroid THYROID DISORDERS hyperthyroidism products •Indicate the onset of •Explain appropriate Hypothyroidism/ Hyperthyroidism action for different storage requirements insulin products for insulin products

1 4/6/2019

Hypothalamic-Pituitary-Thyroid Axis Thyroid Hormones Hypothalamus - • TRH= thyrotropin- releasing hormone • Normal TSH: 0.45- 4.12 mIU/L TRH • TSH= thyroid- + • Growth & development stimulating hormone Anterior • Role in brain development - Pituitary Gland • T3=triiodothyronine • T4= thyroxine • Thermogenesis TSH + • Cardiovascular effects Thyroid T4 + T3 T4 + T3 • Hypothyroid: bradycardia Gland • Hyperthyroid: tachycardia T3 T4 • Metabolic effects Peripheral • Hypothyroid: hypercholesterolemia, decreased insulin requirements Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Tissues adapted from: Thiessen. Rosen’s Emergency Medicine. 2018. Brent GA. Goodman and Gilman’s. 2018. T4→T3

Signs/ Symptoms of Hypothyroidism Hyperthyroidism Types of Hypothyroidism •Primary: thyroid gland dysfunction (Elevated TSH, • Cold sensitivity • Heat intolerance Low free T4) • Dry skin • Increased sweating • Fatigue • Agitation, nervousness, anxiety • Hashimoto’s disease: autoimmune (most common) • Bradycardia • Tachycardia • Antithyroid peroxidase antibodies and antithyroglobulin • Constipation • Diarrhea antibodies • Goiter • Insomnia • Radiation, surgical treatment for hyperthyroidism, • Weight gain • Tremor thyroid cancer • End-stage: myxedema coma • Thyroid storm • Medications: amiodarone, lithium, sulfonylureas, (hypothermia, decreased consciousness, respiratory iodides depression)

Jonklass J. Thyroid Disorders. 2014. Garber JR. Endocr Pract. 2014.

2 4/6/2019

Levothyroxine (Levo-T®, Levothroid®, Types of Hypothyroidism Levoxyl®, Synthroid®, Unithroid®) • Mechanism of Action: Synthetic form of thyroxine (T4) which can •Secondary: hypothalamic/ pituitary be converted to the active metabolite, T3 dysfunction • Dosage Forms: •Hypothalamic disease (Low TRH) • Oral capsule: 13mcg, 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg •Pituitary disease (Low to normal TSH, Low T4) • Reconstituted intravenous solution: 100mcg, 200mcg, 500mcg • Tablets: 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg • Taken 60 minutes prior to breakfast or bedtime (3 hours or more after the evening meal)

Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Garber JR. Endocr Pract. 2014. Jonklass J. Thyroid. 2014.

Liothyronine (Cytomel®) Liotrix (Thyrolar®)

• Mechanism of Action: synthetic salt of T3 • Mechanism of action: uniform mixture of synthetic T4 and T3 in a 4:1 • Dosage Forms: ratio • Intravenous solution: 10 mcg/ml • Oral tablets: • Oral tablet: 5mcg, 25mcg, 50mcg • Levothyroxine 12.5 mcg/ liothyronine 3.1 mcg • Short term data: 3- times daily dosing may be beneficial to weight and • Levothyroxine 25 mcg/ liothyronine 6.25 mcg lipids • Levothyroxine 50 mcg/ liothyronine 12.5 mcg • Longer-term controlled trial needed with long-acting formulation • Levothyroxine 100 mcg/ liothyronine 25 mcg • Euthyroid patients with depression • Levothyroxine 150 mcg/ liothyronine 37.5 mcg • More robust trials needed • No strong evidence of superiority over levothyroxine alone • Euthyroid patients with obesity • Combination therapy showed conflicting results comparing therapy to • Lack of data showing efficacy levothyroxine alone Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Jonklass J. Thyroid. 2014. Jonklass J. Thyroid. 2014.

3 4/6/2019

Thyroid Extract (Armour Thyroid®, Nature Throid®, NP Thyroid®) Types of Hyperthyroidism • Mechanism of Action: animal-derived T3 and T4 • Low TSH, elevated T4 and T3 • Porcine or bovine origin • Subclinical: low TSH, normal T4 • Excess thyroid hormone production and release • May contain variable amounts of T3 and T4 • Inflammation and release of hormone by the gland • Dosed in grains: • Endogenous • 1 grain=60-65 mg, ½ grain = 30-32.5 mg, ¼ grain= 15-16.25mg • Grave’s disease (most common): Thyrotropin receptor antibodies (TRAb) • Oral Tablets: • Exogenous • Armour Thyroid®: 15mg, 30mg, 60mg, 90mg 120mg, 180mg, 240mg, 300mg • Amiodarone: 3 mg iodine/ 100 mg of amiodarone • Nature Throid® : 16.25mg, 32.5mg, 48.75mg, 65mg, 81.25mg, 97.5mg, • Thyroid Storm 113.75mg, 130mg, 146.25mg, 162.5mg, 195mg, 260mg, 325mg • Untreated hyperthyroidism: exaggerated symptoms- fever, tachycardia, coma, • NP Thyroid®/ generic:15mg, 30mg, 60mg, 90mg, 120mg death Dong BJ. Basic & Clinical Pharmacology. 2018. Ross Ds. Thyroid. 2016. TM Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019 Lexi-Comp, Inc. (Lexi-Drugs ). 2019.

Iodides Thionamides Potassium iodide and iodine Saturated solution of potassium Methimazole (Tapazole®) Propylthiouracil (PTU) solution (Lugol’s Solution®) iodide (ThyroShield®, SSKI®) Mechanism of Action: Inhibits synthesis of thyroid hormones by blocking Mechanism of Action: Temporarily inhibits secretion of thyroid the oxidation of iodine in the thyroid gland; PTU also inhibits conversion of hormones; T4 and T3 levels will be reduced for several weeks but not T4 to T3 maintained 5 mg, 10 mg tablet 50 mg tablet Oral solution used in preparation for thyroidectomy for 10 days prior - Drug of choice - Used during first trimester of to surgery. Helps to decrease the vascularity, size, and fragility of - Used during 2nd and 3rd trimester pregnancy, thyroid storm, and if thyroid gland. - Hazardous drug methimazole not tolerated Dosage Forms: Oral Solution Dosage Forms: Oral Solution, - Hazardous drug Oral Tablet

Brent GA. Goodman and Gilman’s. 2018. Brent GA. Goodman and Gilman’s. 2018. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019.

4 4/6/2019

Radioactive Iodine (RAI)

• Colorless, odorless liquid • Rapidly absorbed, concentrated by the thyroid, and incorporated into storage follicles • Destruction is noted by epithelial swelling and necrosis, DIABETES MELLITUS follicular disruption, edema, and leukocyte infiltration • Easy administration, efficacious, low expense, and absence of pain Type 1 Diabetes / Type 2 Diabetes • Contraindicated in pregnancy

Brent GA. Goodman and Gilman’s. 2018

Diabetes Type 1 Type 2 Hyperglycemia Hypoglycemia

•5-10% of diabetics •90-95% of diabetics • Polyuria- excessive, • Shakiness urination •Autoimmune •Insulin resistance or • Sweating • Polydipsia- Excessive, • Hunger abnormal thirst destruction of the B-cell destruction • Nausea B-cells in the • Polyphagia- excessive, uncontrolled eating • Blurred Vision/ Headache pancreas • Weakness/ Fatigue • Confusion

Triplitt CL. Pharmacotherapy. 2017. Powers AC. Goodman and Gilman’s. 2018.

5 4/6/2019

Complications Biguanide: Microvascular Macrovascular Metformin (Glucophage®,Riomet®) Metformin XR (Glucophage XR®, Fortamet®, Glumetza®) •Retinopathy •Coronary artery • Mechanism of Action: Decreases hepatic glucose •Neuropathy disease production, decreases intestinal absorption of glucose, and •Nephropathy •Diabetic improves insulin sensitivity cardiomyopathy • Dosage Forms: • Oral Solution (Riomet®): 500mg/ 5ml •Peripheral vascular • Oral Tablet: 500mg , 850mg, 1000mg disease • Extended Release Oral Tablet: 500mg, 750mg, 1000mg •Stroke • Adverse effects: diarrhea, nausea • Taken with food to decrease stomach upset

Powers AC. Goodman and Gilman’s. 2018. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019.

Second Generation Sulfonylureas: Glyburide, Glyburide-micronized (Micronase®, Glynase®), Glipizide Dosage Forms (Glucotrol®), Glipizide XL (Glucotrol®XL), Glimepiride (Amaryl®) • Glyburide Oral Tablets: •Mechanism of Action: Stimulates insulin • Glynase®: 1.5mg, 3mg, 6mg secretion from the pancreas by binding to • Generic: 1.25mg, 1.5mg, 2.5mg, 3mg, 5mg, 6mg the sulfonylurea receptor and inhibiting ATP • Glipizide Oral Tablets: • Glucotrol®/generic: 5mg, 10mg K+ channels of the beta cells • Glipizide Extended Release Tablets: *Only effective in those with endogenous • Glucotrol®XL/ generic: 2.5mg, 5mg, 10mg insulin production • Glimepiride Oral tablets: ® •Taken 30 minutes prior to meals • Amaryl /generic: 1mg, 2mg, 4mg

Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019.

6 4/6/2019

Meglitinides: Thiazolidinediones (TZDs): ® ® Repaglinide (Prandin ), Nateglinide (Starlix ) Pioglitazone (Actos®), Rosiglitazone (Avandia®) • Mechanism of Action: Stimulates insulin secretion from the • Mechanism of Action: Improves target cell response pancreas by binding to the sulfonylurea receptor and to insulin by activating peroxisome proliferator inhibiting ATP K+ channels of the beta cells activated receptors (PPAR), without increasing *Only effective in those with endogenous insulin production pancreatic insulin secretion • Taken 30 minutes prior to meals • May take 8-12 weeks to see full effect of the • Oral Tablets: medication • Prandin®: 1mg, 2mg • Oral Tablets: • Generic: 0.5mg, 1mg, 2mg • Actos®/generic: 15mg, 30mg, 45mg ® • Starlix®/generic: 60mg, 120mg • Avandia : 2mg, 4mg

Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019.

α-Glucosidase Inhibitors: Glucagon-like peptide-1 (GLP-1) Acarbose (Precose®), Miglitol (Glyset®) Receptor Agonists

•Mechanism of Action: Inhibits the enzyme alpha- • Mechanism of Action: Stimulates the production of insulin glucosidase in the brush border of the small in response to high blood glucose levels, inhibits the intestine, resulting in delayed carbohydrate release of glucagon after meals, slows the rate of gastric digestion and glucose absorption emptying, and increases satiety ® •Taken with the first bite of each large meal • Exenatide (Byetta ): Twice daily (short acting) ® •Oral Tablets: • Liraglutide (Victoza ): Once daily (long acting) ® ® • Precose®/generic: 25mg, 50mg, 100mg • Exenatide LAR (Bydureon ), Albiglutide (Tanzeum ), ® • Glyset®/ generic: 25mg, 50mg, 100mg Dulaglutide (Trulicity ): Once weekly (long acting)

TM Lexi-Comp, Inc. (Lexi-Drugs ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019.

7 4/6/2019

GLP-1 Receptor Agonists GLP-1 Receptor Agonists

Exenatide (Byetta®) Storage/ Stability: albiglutide (Tanzeum®) Storage/ Stability: ® ® Exenatide LAR Byetta (5mcg, 10mcg pens) dulaglutide (Trulicity®) Tanzeum (30mg, 50mg pen- ® • Prior to initial use store injector) (Bydureon ) ◦ under refrigeration (2 C- Store unused pens under refrigeration; may be ◦ • 8 C), may store at room stored at room temperature for ≤4 weeks prior to temperature up to 30 days reconstitution. Use within 8 hours of reconstitution. Bydureon® (2mg pen) Trulicity® (0.75mg/0.5ml, • Store under refrigeration, if necessary may store at 1.5mg/0.5ml pen-injector) room temperature for up to • Store under refrigeration; if needed, each 30 days TM single-dose pen or prefilled syringe can be Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-Drugs ). 2019. Pictures available from: https://www.byettahcp.com, Pictures available from: https://d4fuqqd5l3dbz.cloudfront.net, kept at room temperature for 14 days http://www.diabetesclinic.ca http://media.renalandurologynews.com

® GLP-1 Receptor Agonists Amylin agonists: Pramlinitide(Symlin ) • Mechanism of Action: Synthetic form of human amylin; Reduction in postprandial glucose by prolongation of gastric emptying, reduction Liraglutide Storage/Stability: of postprandial glucagon secretion, and reduction of caloric intake • Prior to initial use store through appetite suppression ® (Victoza ) under refrigeration; after • Pen-injector: SymlinPen®60 (1500 mcg/1.5ml), SymlinPen®120 (2700 initial use, may be stored mcg/2.7ml) under refrigeration or • Storage/ Stability: store under refrigeration; after initial use may be room temperature. kept refrigerated or at room temperature. Discard after 30 days. Discard after 30 days Dosage Forms: • Pen-injector: 18mg/3ml

Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Picture available from: http://www.drugsdb.com Pictures available from: https://asweetlife.org

8 4/6/2019

Dipeptidyl Peptidase IV Inhibitors (DPP-4 Inhibitors): Sodium-Glucose Cotransporter 2 Inhibitors (SGLT-2 Inhibitors): Sitagliptin (Januvia®), Saxagliptan (OnglyzaTM), Dapagliflozin (Farxiga®), Canagliflozin (Invokana®), Linagliptin (TradjentaTM), Alogliptan (Nesina®) Empagliflozin (Jardiance®)

• Mechanism of Action: Inhibits dipeptidyl peptidase 4, the enzyme •Mechanism of Action: Inhibition of SGLT-2 in the responsible for degrading incretin hormones. An increase of GLP-1 proximal renal tubules, reduces glucose leads to insulin release and reduction in glucagon secretion. reabsorption and increases glucose excretion in • Oral Tablets: the urine • Januvia®: 25mg, 50mg, 100mg •Oral Tablets: TM • Onglyza : 2.5mg, 5mg • Farxiga®: 5mg, 10mg • TradjentaTM: 5mg • Invokana®: 100mg, 300mg • Nesina®/generic: 6.25mg, 12.5mg, 25mg • Jardiance®: 10mg, 25mg

Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019.

Rapid Acting Insulin Products: onset 10- 30 minutes Rapid Acting Insulin Products: onset 10- 30 minutes

Storage/ Stability: Storage/ Stability: • Unopened vials/ prefilled pens: • Unopened vials/ prefilled pens: refrigeration refrigeration (2◦C- 8◦C) until expiration (2◦C- 8◦C) until expiration date or at room Insulin glulisine date OR at room temperature for 28 Insulin lispro temperature <30◦C for 28 days ® days ® • Opened vials: refrigeration/ room temperature (Apidra ) • Opened vials: refrigeration/ room (Humalog ) for 28 days temperature for 28 days • Opened prefilled pens: room temperature for 28 • Opened prefilled pens: room days temperature and used within 28 days • CSII: changed every 7 days • Continuous subcutaneous insulin infusion (CSII): replaced every 48 hours • IV infusion: stable in NS for 48 hours refrigerated, • IV infusion: Stable in NS for 48 hours at then an additional 48 hours at room room temperature temperature while in use Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Pictures available from: http://www.medicine-online.org, Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. https://www.healthline.com Picture available from: https://cdn.diabetesdaily.com

9 4/6/2019

Rapid Acting Insulin Products: onset 10- 30 minutes Inhaled Insulin (Afrezza®) Storage/ Stability: • Rapid Acting Insulin: onset ~12 • Unopened vials/ prefilled pens: refrigeration (2◦C- 8◦C) until expiration minutes Insulin aspart date or at room temperature <30◦C for • Contraindication: chronic lung 28 days disease such as asthma or COPD, (Novolog®) • Opened vials: refrigeration/ room due to risk of bronchospasm temperature for 28 days • Spirometry (FEV1) test prior to • Opened prefilled pens: room initiation temperature for 28 days • Storage/ Stability: • CSII: replaced every 6 days • Prior to Use (sealed): refrigerated (2◦C- 8◦C ), • IV infusion: stable in NS for 24 hours at if not refrigerated must be used in 10 days room temperature • In Use: room temperature (25◦C), open strips must be used in 3 days Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Picture available from: https://fightingtype1.files.wordpress.com Picture available from: https://www.ontrackdiabetes.com

Short Acting Insulin: onset 30 minutes Short Acting Insulin: onset 30 minutes

Storage/ Stability: Storage/ Stability: Regular insulin Humulin R® Insulin Regular (Humulin R U- • Unopened vials: refrigeration (2◦C- 8◦C) until • Unopened/ Open Vials: refrigerator ® ® ® (Humulin R , Novolin R ) expiration date 500 (concentrated), Humulin (2◦C- 8◦C) until expiration date or • Opened vials: refrigeration/ room temperature R U-500® KwikPen) ◦ may be stored at room <30 C for 31 days ◦ Novolin R® temperature <30 C for up to 40 days • Unopened vials: refrigeration until expiration date • Unopened KwikPen: refrigerator or at room temperature for up to 42 days until expiration date or room • Opened vials: room temperature for up to 42 days • Unopened FlexPen: refrigeration until expiration temperature for up to 28 days date or at room temperature for up to 28 days • Open KwikPen: room temperature • Opened FlexPens: room temperature for up to 28 for up to 28 days days

Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Pictures available from: http://3.bp.blogspot.com, https://d3pq5rjvq8yvv1.cloudfront.net Picture available from: https://rx411.com

10 4/6/2019

Intermediate Acting Insulin: onset 90 minutes Long Acting Insulin: onset 3-4 hours, 6 hours

® Storage/ Stability: Storage/ Stability: NPH (Humulin N , ® Humulin N ® ◦ ◦ Insulin glargine Lantus Novolin N®) • Unopened vials: refrigeration (2 C- 8 C) until expiration date ® ® • Unopened vials/ Prefilled pens: (Lantus or Toujeo ) refrigeration (2◦C- 8◦C) until expiration • Opened vials: refrigeration/ room temperature date or at room temperature <30◦C for 28 <30◦C for 31 days days • Unopened KwikPen: refrigeration until expiration • Opened vials: refrigeration for 28 days date • Opened Prefilled pens: room temperature • Opened KwikPen: room temperature for up to for 28 days 14 days Toujeo® Novolin N® • Unopened Prefilled pens: refrigeration until • Unopened vial: refrigeration until expiration expiration date date or room temperature for up to 42 days • Opened Prefilled pens: room temperature • Opened vial: room temperature for up to 42 for 42 days days Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. Pictures available from: http://www.international-diabetes- Pictures available from: https://www.lantus.com, association.com, http://www.peticub.com http://ifreebudget.com

Long Acting Insulin: onset 3-4 hours Long Acting Insulin: onset ~1 hour

Storage/ Stability: Insulin detemir Storage/ Stability: • Unopened vials/ prefilled pens: • Unopened pens: ® ◦ ◦ (Levemir ) refrigeration (2◦C- 8◦C) until Insulin degludec refrigeration (2 C- 8 C) until expiration date or at room ® expiration date or at room temperature <30◦C for 42 days (Tresiba ) temperature <30◦C for up • Opened vials: refrigeration or to 56 days room temperature for 42 days • Opened pens: • Opened prefilled pens: room refrigeration or at room temperature for 42 days temperature for up to 56 days Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019. TM Pictures available from: https://cdn.petcarerx.com, Lexi-Comp, Inc. (Lexi-Drugs ). 2019. http://5.imimg.com Picture available from: http://www.jediazucarado.com

11 4/6/2019

Mixtures Pharmacist Post-test Question

• Insulin NPH and Regular Insulin 70/30 (Humulin Which of the following is not a symptom of 70/30®, Humulin 70/30® KwikPen, Novolin 70/30®) hypothyroidism? • Insulin aspart protamine/ insulin aspart 70/30 a. Constipation (Novolog Mix 70/30®, Novolog Mix 70/30® FlexPen) b. Insomnia • Insulin lispro protamine/ insulin lispro (Humalog Mix c. Dry Skin 50/50®, Humalog Mix 50/50® KwikPen, Humalog Mix d. Cold Sensitivity 75/25®, Humalog Mix 75/25® KwikPen)

Lexi-Comp, Inc. (Lexi-DrugsTM ). 2019.

Pharmacist Post-test Question Pharmacist Post-test Question

Which of the following is not a symptom of What is the onset of action of NPH (Humulin N®, hypothyroidism? Novolin N®)? a. Constipation a. 10- 30 minutes b. Insomnia b. 3-4 hours c. Dry Skin c. 6 hours d. Cold Sensitivity d. 90 minutes

12 4/6/2019

Pharmacist Post-test Question Technician Post-test Question

What is the onset of action of NPH (Humulin N®, Which of the following thyroid products is correctly Novolin N®)? matched with its Brand name? ® a. 10- 30 minutes a. Methimazole (ThyroShield ) ® b. 3-4 hours b. Liothyronine (Tirosint ) ® c. 6 hours c. Liotrix (Thyrolar ) ® d. 90 minutes d. Thyroid Extract (Cytomel )

Technician Post-test Question Technician Post-test Question

Which of the following thyroid products is correctly How long can unopened insulin detemir (Levemir®) matched with its Brand name? prefilled pens be stored at room temperature? a. Methimazole (ThyroShield®) a. 28 days b. Liothyronine (Tirosint®) b. 42 days c. Liotrix (Thyrolar®) c. 56 days d. Thyroid Extract (Cytomel®) d. 14 days

13 4/6/2019

Technician Post-test Question

How long can unopened insulin detemir (Levemir®) prefilled pens be stored at room temperature? a. 28 days b. 42 days Questions? c. 56 days d. 14 days

References References

• Brent GA, Koenig RJ. Thyroid and antithyroid drugs. In: Brunton LL, Hilal-Dandan R, Knollmann BC, editors. • Powers AC, D’Alessio. Endocrine pancreas and pharmacotherapy of diabetes mellitus and Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 13e New York, NY: McGraw-Hill; 2018 [cited hypoglycemia. In: Brunton LL, Hilal-Dandan R, Knollmann BC, eds. Goodman & Gilman's: The 2019 Feb 24]. Available from:. Accessed February 24, 2019. http://accesspharmacy.mhmedical.com/content.aspx?bookid=2189§ionid=172481901 Pharmacological Basis of Therapeutics [Internet]. 13ed. New York, NY: McGraw-Hill; 2018 [cited 2019 March 7]. Available from: • Dong BJ. Thyroid & antithyroid drugs. In: Katzung BG,eds. Basic & Clinical Pharmacology [Internet]. 14ed. New http://accesspharmacy.mhmedical.com/content.aspx?bookid=2189§ionid=172482821. York, NY: McGraw-Hill;2018[cited 2019 March 5].Available from: http://accesspharmacy.mhmedical.com/content.aspx?bookid=2249§ionid=17522169 • Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid • Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, et al. CLINICAL PRACTICE GUIDELINES FOR Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of HYPOTHYROIDISM IN ADULTS: COSPONSORED BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS Thyrotoxicosis. Thyroid.2016 Oct;26(10):1343-1421. AND THE AMERICAN THYROID ASSOCIATION. Endocr Pract. 2012 Dec 4; 18 (6): e1-e45. Available from: https://www.aace.com/files/hypothyroidism_guidelines.pdf • Thiessen MEW. Thyroid and adrenal disorders. In: Walls RN, Hockberger RS, Gausche-Hill M, Bakes K, Baren JM, Erickson TB, Jagoda AS, Kaji AH, VanRooyen M, Zane RD, editors. Rosen’s Emergency Medicine: • Jonklass J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, etal. Guidelines for the Treatment of th Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Concepts and Clinical Practice [Internet].9 ed. Philadelphia: Elsevier, Inc.; 2018 [cited 2019 Feb 24]. Thyroid, a Mary Ann Liebert, Inc. publication. 2014 Dec 14; 24(12):1670-1751.Available from: Available from: https://www.clinicalkey.com/service/content/pdf/watermarked/3-s2.0- https://www.liebertpub.com/doi/pdf/10.1089/thy.2014.0028 B9780323354790001203.pdf?locale=en_US • Jonklass J, Talbert RL. Thyroid Disorders. In: DiPiro JT, et al (eds): Pharmacotherapy: A Pathophysiologic • Triplitt CL, Repas T, Alvarez C .Diabetes mellitus. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Approach. 9th ed. New York: McGraw-Hill; 2014. pp.1191-1216. Posey L Eds. Pharmacotherapy: A Pathophysiologic Approach [Internet]. 10ed. New York, NY: McGraw- • Lexi-Comp, Inc. (Lexi-DrugsTM). Lexi-Comp, Inc.; 1 March 2019. Hill; 2017[cited 2019 March 7]. Available from: http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861§ionid=146065891.

14 4/6/2019

Pictures Pictures

• https://cdn.diabetesdaily.com/wp-content/blogs.dir/21/files/2017/06/humalog- • https://d3pq5rjvq8yvv1.cloudfront.net/catalog/product/cache/1/image/9df78eab335 lispro-injection.png 25d08d6e5fb8d27136e95/n/o/novo2.jpg • https://fightingtype1.files.wordpress.com/2015/05/novolog.gif • http://www.international-diabetes-association.com/wp- • http://www.medicine-online.org/img/cms/apidra.jpg content/uploads/2015/11/8473-1-humulin-n.jpg • https://www.healthline.com/hlcmsresource/images/diabetesmine/wp- • http://www.peticub.com/wp-content/uploads/2017/03/Novolin-N.jpg content/uploads/2013/02/Aprida.jpg • https://www.lantus.com/- • https://www.ontrackdiabetes.com/sites/default/files/imagecache/gallery- /media/EMS/Conditions/Diabetes/Brands/Lantus/Microsite/VIAL- large/wysiwyg_imageupload/4174/2017/03/09/Afrezza%20Inhaler%20%28closed%2 PEN_2.png?la=en&hash=72BD375B011050D4579D38F9FB316362B6655842 9%20with%204-unit%2C%208-unit%20and%2012- unit%20cartrigdes%20%28REVISED%29.jpg • http://ifreebudget.com/images/toujeo.png • https://rx411.com/wp-content/uploads/2016/07/humulin-r-500.jpg • https://cdn.petcarerx.com/LPPE/images/articlethumbs/Levemir_Large.jpg • http://3.bp.blogspot.com/_na2- • http://5.imimg.com/data5/MW/XP/MY-3686936/levemir-flexpen-500x500.jpg dwMBheA/SeELjRymVsI/AAAAAAAAABM/4zEruOu_2gU/s320/20070723153123.jpg • http://www.jediazucarado.com/wp-content/uploads/2015/11/tresiba.jpg

Pictures

• https://www.byettahcp.com/content/PhysicianServices/US/160-hcp-byetta- com/en/us/home/_jcr_content/container/textimage_0/image.img.png/1430128496674 .png • http://www.diabetesclinic.ca/en/prof/5treat/oral_med/bydureon.jpg • https://d4fuqqd5l3dbz.cloudfront.net/products/tms/Package_21930.JPG • http://media.renalandurologynews.com/images/2014/09/23/trulicitydiabetespendrugs h_659976.jpg?format=jpg&zoom=1&quality=70&anchor=middlecenter&width=320&mo de=pad • http://www.drugsdb.com/images/2012/03/Victoza-Side-Effects.jpg • https://asweetlife.org/wp-content/uploads/2013/02/SymlinPen.jpg

15