Posters
Iatrogenic Thyrotoxicosis due to Compounding Error of Liothyronine
Presentation Type
Poster
Discipline Track
Patient Care
Abstract Type
Case Report
Abstract
Background: This case is one of four recorded reports of thyrotoxicosis due to compounding error of liothyronine. The presentation of this differs from classic thyrotoxicosis caused by endogenous hormones. Compounding pharmacy regulation has been a source of regulatory conflict for decades.
Case Presentation: A 70-year-old woman was brought to the emergency department by her daughter for concerns of a 2 days of altered mental status. She had a past medical history of Hashimoto’s thyroiditis and hypertension. Physical exam was notable for elevated blood pressure, which was around the patients’ baseline. Sinus tachycardia was also noted. The patient had recently had a change to her thyroid medication, though could not provide more information regarding this. Workup in the emergency department revealed Free T3 levels elevated out of range at >22.80 pg/mL. Upon further investigation, the patient was found to be taking liothyronine from a compounding pharmacy. An independent analysis of the medication concluded that the patient was administered a dose of liothyronine that was 1000-times greater than prescribed by her endocrinologist.
Conclusions: This case presentation highlights an unusual presentation of thyrotoxicosis, particularly as associated with liothyronine overdose. In this report we will outline the previously recorded reports of iatrogenic thyrotoxicosis due to compounding pharmacy error. We will discuss the inherent risk associated with use of compound pharmacies and detail other instances of adverse events traced to compound pharmacy error.
Recommended Citation
Onyechi, Stephanie and Falkoff, Maxwell, "Iatrogenic Thyrotoxicosis due to Compounding Error of Liothyronine" (2023). Research Symposium. 53.
https://scholarworks.utrgv.edu/somrs/theme1/posters/53
Iatrogenic Thyrotoxicosis due to Compounding Error of Liothyronine
Background: This case is one of four recorded reports of thyrotoxicosis due to compounding error of liothyronine. The presentation of this differs from classic thyrotoxicosis caused by endogenous hormones. Compounding pharmacy regulation has been a source of regulatory conflict for decades.
Case Presentation: A 70-year-old woman was brought to the emergency department by her daughter for concerns of a 2 days of altered mental status. She had a past medical history of Hashimoto’s thyroiditis and hypertension. Physical exam was notable for elevated blood pressure, which was around the patients’ baseline. Sinus tachycardia was also noted. The patient had recently had a change to her thyroid medication, though could not provide more information regarding this. Workup in the emergency department revealed Free T3 levels elevated out of range at >22.80 pg/mL. Upon further investigation, the patient was found to be taking liothyronine from a compounding pharmacy. An independent analysis of the medication concluded that the patient was administered a dose of liothyronine that was 1000-times greater than prescribed by her endocrinologist.
Conclusions: This case presentation highlights an unusual presentation of thyrotoxicosis, particularly as associated with liothyronine overdose. In this report we will outline the previously recorded reports of iatrogenic thyrotoxicosis due to compounding pharmacy error. We will discuss the inherent risk associated with use of compound pharmacies and detail other instances of adverse events traced to compound pharmacy error.