Endocrine Products- Thyroid & Diabetes - StarChapter · 2019-04-06 · 4/6/2019 1 ENDOCRINE PRODUCTS- THYROID & DIABETES By: Avery Aldridge, Pharm.D. 4/12/19 Financial Disclosure

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ENDOCRINE PRODUCTS- THYROID &

DIABETES By: Avery Aldridge, Pharm.D.

4/12/19

Financial Disclosure

• “I have had no financial relationship over the past 12

months with any commercial sponsor with a vested interest in this presentation”

Pharmacist Learning Objectives

• Identify signs and

symptoms of hypothyroidism and

hyperthyroidism

• Indicate the onset of action for different

insulin products

• Identify the correct

brand and generic names for thyroid

products

•Explain appropriate storage requirements

for insulin products

Technician Learning

Objectives

THYROID DISORDERS

Hypothyroidism/ Hyperthyroidism

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Hypothalamic-Pituitary-Thyroid Axis

Hypothalamus

Anterior Pituitary Gland

Thyroid Gland

PeripheralTissues

T4→T3

T4 + T3T4 + T3

-

-+

+

• TRH= thyrotropin-releasing hormone

• TSH= thyroid-stimulating hormone

• T3=triiodothyronine• T4= thyroxine

TRH

TSH

T3 T4

adapted from: Thiessen. Rosen’s Emergency Medicine. 2018.

Thyroid Hormones

• Normal TSH: 0.45- 4.12 mIU/L

• Growth & development

• Role in brain development

• Thermogenesis

• Cardiovascular effects

• Hypothyroid: bradycardia

• Hyperthyroid: tachycardia

• Metabolic effects

• Hypothyroid: hypercholesterolemia, decreased insulin requirements

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

Brent GA. Goodman and Gilman’s. 2018.

Signs/ Symptoms of Hypothyroidism Hyperthyroidism• Cold sensitivity

• Dry skin

• Fatigue

• Bradycardia

• Constipation

• Goiter

• Weight gain

• End-stage: myxedema coma (hypothermia, decreased consciousness, respiratory depression)

• Heat intolerance

• Increased sweating

• Agitation, nervousness, anxiety

• Tachycardia

• Diarrhea

• Insomnia

• Tremor

• Thyroid storm

Jonklass J. Thyroid Disorders. 2014.

Types of Hypothyroidism •Primary: thyroid gland dysfunction (Elevated TSH, Low free T4)•Hashimoto’s disease: autoimmune (most common)•Antithyroid peroxidase antibodies and antithyroglobulin antibodies

•Radiation, surgical treatment for hyperthyroidism, thyroid cancer

•Medications: amiodarone, lithium, sulfonylureas, iodides

Garber JR. Endocr Pract. 2014.

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Types of Hypothyroidism

•Secondary: hypothalamic/ pituitary

dysfunction

•Hypothalamic disease (Low TRH)

•Pituitary disease (Low to normal TSH, Low T4)

Garber JR. Endocr Pract. 2014.

Levothyroxine (Levo-T®, Levothroid®, Levoxyl®, Synthroid®, Unithroid®)• Mechanism of Action: Synthetic form of thyroxine (T4) which can

be converted to the active metabolite, T3

• Dosage Forms:

• Oral capsule: 13mcg, 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg,

125mcg, 137mcg, 150mcg

• 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)


Jonklass J. Thyroid. 2014.

Liothyronine (Cytomel®)

• Mechanism of Action: synthetic salt of T3

• Dosage Forms:• Intravenous solution: 10 mcg/ml

• Oral tablet: 5mcg, 25mcg, 50mcg

• Short term data: 3- times daily dosing may be beneficial to weight and lipids• Longer-term controlled trial needed with long-acting formulation

• Euthyroid patients with depression• More robust trials needed

• Euthyroid patients with obesity• Lack of data showing efficacy



Liotrix (Thyrolar®)

• Mechanism of action: uniform mixture of synthetic T4 and T3 in a 4:1 ratio

• Oral tablets:• Levothyroxine 12.5 mcg/ liothyronine 3.1 mcg

• Levothyroxine 25 mcg/ liothyronine 6.25 mcg


• Levothyroxine 100 mcg/ liothyronine 25 mcg


• No strong evidence of superiority over levothyroxine alone

• Combination therapy showed conflicting results comparing therapy to levothyroxine alone



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Thyroid Extract (Armour Thyroid®, Nature Throid®, NP Thyroid®)• Mechanism of Action: animal-derived T3 and T4

• Porcine or bovine origin

• May contain variable amounts of T3 and T4

• Dosed in grains:

• 1 grain=60-65 mg, ½ grain = 30-32.5 mg, ¼ grain= 15-16.25mg

• Oral Tablets:

• Armour Thyroid®: 15mg, 30mg, 60mg, 90mg 120mg, 180mg, 240mg, 300mg

• Nature Throid® : 16.25mg, 32.5mg, 48.75mg, 65mg, 81.25mg, 97.5mg,

113.75mg, 130mg, 146.25mg, 162.5mg, 195mg, 260mg, 325mg

• NP Thyroid®/ generic:15mg, 30mg, 60mg, 90mg, 120mg

Dong BJ. Basic & Clinical Pharmacology. 2018.

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

Types of Hyperthyroidism

• Low TSH, elevated T4 and T3

• Subclinical: low TSH, normal T4• Excess thyroid hormone production and release

• Inflammation and release of hormone by the gland

• Endogenous • Grave’s disease (most common): Thyrotropin receptor antibodies (TRAb)

• Exogenous• Amiodarone: 3 mg iodine/ 100 mg of amiodarone

• Thyroid Storm • Untreated hyperthyroidism: exaggerated symptoms- fever, tachycardia, coma,

death

Ross Ds. Thyroid. 2016.


Thionamides

Methimazole (Tapazole®) Propylthiouracil (PTU)

Mechanism of Action: Inhibits synthesis of thyroid hormones by blocking the oxidation of iodine in the thyroid gland; PTU also inhibits conversion of

T4 to T3

5 mg, 10 mg tablet 50 mg tablet

- Drug of choice- Used during 2nd and 3rd trimester

- Hazardous drug

- Used during first trimester of pregnancy, thyroid storm, and if

methimazole not tolerated - Hazardous drug



IodidesPotassium iodide and iodine solution (Lugol’s Solution®)

Saturated solution of potassium iodide (ThyroShield®, SSKI®)

Mechanism of Action: Temporarily inhibits secretion of thyroid hormones; T4 and T3 levels will be reduced for several weeks but not

maintained

Oral solution used in preparation for thyroidectomy for 10 days prior to surgery. Helps to decrease the vascularity, size, and fragility of

thyroid gland.

Dosage Forms: Oral Solution Dosage Forms: Oral Solution, Oral Tablet



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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, follicular disruption, edema, and leukocyte infiltration

• Easy administration, efficacious, low expense, and absence of pain

•Contraindicated in pregnancy

Brent GA. Goodman and Gilman’s. 2018

DIABETES MELLITUS

Type 1 Diabetes / Type 2 Diabetes

DiabetesType 1 Type 2

•5-10% of diabetics

•Autoimmune destruction of the B-cells in the pancreas

•90-95% of diabetics

•Insulin resistance or B-cell destruction

Triplitt CL. Pharmacotherapy. 2017.

Hyperglycemia Hypoglycemia

• Polyuria- excessive,

urination

• Polydipsia- Excessive, abnormal thirst

• Polyphagia- excessive,

uncontrolled eating

• Shakiness

• Sweating

• Hunger

• Nausea

• Blurred Vision/ Headache

• Weakness/ Fatigue

• Confusion

Powers AC. Goodman and Gilman’s. 2018.

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Complications Microvascular Macrovascular

•Retinopathy

•Neuropathy•Nephropathy

•Coronary artery disease

•Diabetic cardiomyopathy•Peripheral vascular disease

•Stroke

Powers AC. Goodman and Gilman’s. 2018.

Biguanide: Metformin (Glucophage®,Riomet®)Metformin XR (Glucophage XR®, Fortamet®, Glumetza®)

• Mechanism of Action: Decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity

• Dosage Forms:• Oral Solution (Riomet®): 500mg/ 5ml

• Oral Tablet: 500mg , 850mg, 1000mg

• Extended Release Oral Tablet: 500mg, 750mg, 1000mg

• Adverse effects: diarrhea, nausea

• Taken with food to decrease stomach upset


Second Generation Sulfonylureas: Glyburide, Glyburide-micronized (Micronase®, Glynase®), Glipizide (Glucotrol®), Glipizide XL (Glucotrol®XL), Glimepiride (Amaryl®)

•Mechanism of Action: Stimulates insulin secretion from the pancreas by binding to the sulfonylurea receptor and inhibiting ATP K+ channels of the beta cells

*Only effective in those with endogenous insulin production

•Taken 30 minutes prior to meals Lexi-Comp, Inc. (Lexi-DrugsTM). 2019.

Dosage Forms

•Glyburide Oral Tablets:• Glynase®: 1.5mg, 3mg, 6mg • Generic: 1.25mg, 1.5mg, 2.5mg, 3mg, 5mg, 6mg

•Glipizide Oral Tablets:• Glucotrol®/generic: 5mg, 10mg

•Glipizide Extended Release Tablets:• Glucotrol®XL/ generic: 2.5mg, 5mg, 10mg

•Glimepiride Oral tablets:• Amaryl®/generic: 1mg, 2mg, 4mg


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Meglitinides: Repaglinide (Prandin®), Nateglinide (Starlix®)

•Mechanism of Action: Stimulates insulin secretion from the pancreas by binding to the sulfonylurea receptor and inhibiting ATP K+ channels of the beta cells

*Only effective in those with endogenous insulin production

• Taken 30 minutes prior to meals

•Oral Tablets: • Prandin®: 1mg, 2mg

• Generic: 0.5mg, 1mg, 2mg

• Starlix®/generic: 60mg, 120mg


Thiazolidinediones (TZDs):Pioglitazone (Actos®), Rosiglitazone (Avandia®)

•Mechanism of Action: Improves target cell response to insulin by activating peroxisome proliferator activated receptors (PPAR), without increasing pancreatic insulin secretion

•May take 8-12 weeks to see full effect of the medication

•Oral Tablets:• Actos®/generic: 15mg, 30mg, 45mg• Avandia®: 2mg, 4mg


α-Glucosidase Inhibitors: Acarbose (Precose®), Miglitol (Glyset®)

•Mechanism of Action: Inhibits the enzyme alpha-glucosidase in the brush border of the small intestine, resulting in delayed carbohydrate digestion and glucose absorption

•Taken with the first bite of each large meal

•Oral Tablets:•Precose®/generic: 25mg, 50mg, 100mg

•Glyset®/ generic: 25mg, 50mg, 100mgLexi-Comp, Inc. (Lexi-DrugsTM). 2019.

Glucagon-like peptide-1 (GLP-1) Receptor Agonists

•Mechanism of Action: Stimulates the production of insulin

in response to high blood glucose levels, inhibits the release of glucagon after meals, slows the rate of gastric

emptying, and increases satiety

• Exenatide (Byetta®): Twice daily (short acting)

• Liraglutide (Victoza®): Once daily (long acting)

• Exenatide LAR (Bydureon®), Albiglutide (Tanzeum®), Dulaglutide (Trulicity®): Once weekly (long acting)


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GLP-1 Receptor Agonists

Storage/ Stability:

Byetta® (5mcg, 10mcg pens)

• Prior to initial use store under refrigeration (2◦C-8◦C), may store at room temperature up to 30 days

Bydureon® (2mg pen)

• Store under refrigeration, if necessary may store at room temperature for up to 30 days

Exenatide (Byetta®)

Exenatide LAR (Bydureon®)


Pictures available from: https://www.byettahcp.com,

http://www.diabetesclinic.ca


Storage/ Stability:

Tanzeum® (30mg, 50mg pen-

injector)

• Store unused pens under refrigeration; may be

stored at room temperature for ≤4 weeks prior to

reconstitution. Use within 8 hours of reconstitution.

Trulicity® (0.75mg/0.5ml,

1.5mg/0.5ml pen-injector)

• Store under refrigeration; if needed, each

single-dose pen or prefilled syringe can be

kept at room temperature for 14 days

albiglutide (Tanzeum®)

dulaglutide (Trulicity®)


Pictures available from: https://d4fuqqd5l3dbz.cloudfront.net,

http://media.renalandurologynews.com


Liraglutide (Victoza®)

Storage/Stability:

• Prior to initial use store under refrigeration; after

initial use, may be stored under refrigeration or room temperature.

Discard after 30 daysDosage Forms:

• Pen-injector: 18mg/3ml


Picture available from: http://www.drugsdb.com

Amylin agonists: Pramlinitide(Symlin®)• Mechanism of Action: Synthetic form of human amylin; Reduction in

postprandial glucose by prolongation of gastric emptying, reduction

of postprandial glucagon secretion, and reduction of caloric intake

through appetite suppression

• Pen-injector: SymlinPen®60 (1500 mcg/1.5ml), SymlinPen®120 (2700

mcg/2.7ml)

• Storage/ Stability: store under refrigeration; after initial use may be

kept refrigerated or at room temperature. Discard after 30 days.


Pictures available from: https://asweetlife.org

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Dipeptidyl Peptidase IV Inhibitors (DPP-4 Inhibitors): Sitagliptin (Januvia®), Saxagliptan (OnglyzaTM), Linagliptin (TradjentaTM), Alogliptan (Nesina®)

• Mechanism of Action: Inhibits dipeptidyl peptidase 4, the enzyme responsible for degrading incretin hormones. An increase of GLP-1 leads to insulin release and reduction in glucagon secretion.

• Oral Tablets:

• Januvia®: 25mg, 50mg, 100mg

• OnglyzaTM: 2.5mg, 5mg

• TradjentaTM: 5mg

• Nesina®/generic: 6.25mg, 12.5mg, 25mg


Sodium-Glucose Cotransporter 2 Inhibitors (SGLT-2 Inhibitors): Dapagliflozin (Farxiga®), Canagliflozin (Invokana®), Empagliflozin (Jardiance®)

•Mechanism of Action: Inhibition of SGLT-2 in the proximal renal tubules, reduces glucose reabsorption and increases glucose excretion in the urine

•Oral Tablets:• Farxiga®: 5mg, 10mg

• Invokana®: 100mg, 300mg

• Jardiance®: 10mg, 25mg


Rapid Acting Insulin Products: onset 10- 30 minutes

Insulin glulisine (Apidra®)

Storage/ Stability:

• Unopened vials/ prefilled pens: refrigeration (2◦C- 8◦C) until expiration

date OR at room temperature for 28

days• Opened vials: refrigeration/ room

temperature for 28 days• Opened prefilled pens: room

temperature and used within 28 days

• Continuous subcutaneous insulin infusion (CSII): replaced every 48 hours

• IV infusion: Stable in NS for 48 hours at room temperature


Pictures available from: http://www.medicine-online.org,

https://www.healthline.com


Storage/ Stability:

• Unopened vials/ prefilled pens: refrigeration

(2◦C- 8◦C) until expiration date or at room

temperature <30◦C for 28 days

• Opened vials: refrigeration/ room temperature

for 28 days

• Opened prefilled pens: room temperature for 28

days

• CSII: changed every 7 days

• IV infusion: stable in NS for 48 hours refrigerated,

then an additional 48 hours at room

temperature while in use

Insulin lispro

(Humalog®)


Picture available from: https://cdn.diabetesdaily.com

4/6/2019

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Storage/ Stability:

• Unopened vials/ prefilled pens:

refrigeration (2◦C- 8◦C) until expiration

date or at room temperature <30◦C for

28 days

• Opened vials: refrigeration/ room

temperature for 28 days

• Opened prefilled pens: room


• CSII: replaced every 6 days

• IV infusion: stable in NS for 24 hours at

room temperature

Insulin aspart (Novolog®)


Picture available from: https://fightingtype1.files.wordpress.com

Inhaled Insulin (Afrezza®)

• Rapid Acting Insulin: onset ~12 minutes

• Contraindication: chronic lung disease such as asthma or COPD, due to risk of bronchospasm

• Spirometry (FEV1) test prior to initiation

• Storage/ Stability: • Prior to Use (sealed): refrigerated (2◦C- 8◦C ),

if not refrigerated must be used in 10 days

• In Use: room temperature (25◦C), open strips

must be used in 3 days Lexi-Comp, Inc. (Lexi-DrugsTM). 2019.

Picture available from: https://www.ontrackdiabetes.com

Short Acting Insulin: onset 30 minutes

Regular insulin

(Humulin R®, Novolin R®)

Storage/ Stability:

Humulin R®

• Unopened vials: refrigeration (2◦C- 8◦C) until

expiration date


<30◦C for 31 days

Novolin R®

• Unopened vials: refrigeration until expiration date

or at room temperature for up to 42 days

• Opened vials: room temperature for up to 42 days

• Unopened FlexPen: refrigeration until expiration

date or at room temperature for up to 28 days

• Opened FlexPens: room temperature for up to 28

days


Pictures available from: http://3.bp.blogspot.com, https://d3pq5rjvq8yvv1.cloudfront.net

Short Acting Insulin: onset 30 minutes

Storage/ Stability:

• Unopened/ Open Vials: refrigerator

(2◦C- 8◦C) until expiration date or may be stored at room temperature <30◦C for up to 40 days

• Unopened KwikPen: refrigerator

until expiration date or room temperature for up to 28 days

• Open KwikPen: room temperature

for up to 28 days

Insulin Regular (Humulin R U-

500® (concentrated), Humulin R U-500® KwikPen)


Picture available from: https://rx411.com

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Intermediate Acting Insulin: onset 90 minutes

Storage/ Stability:

Humulin N®

• Unopened vials: refrigeration (2◦C- 8◦C) until

expiration date


<30◦C for 31 days

• Unopened KwikPen: refrigeration until expiration

date

• Opened KwikPen: room temperature for up to

14 days

Novolin N®

• Unopened vial: refrigeration until expiration

date or room temperature for up to 42 days

• Opened vial: room temperature for up to 42

days

NPH (Humulin N®, Novolin N®)


Pictures available from: http://www.international-diabetes-

association.com, http://www.peticub.com

Long Acting Insulin: onset 3-4 hours, 6 hours

Storage/ Stability:

Lantus®

• Unopened vials/ Prefilled pens: refrigeration (2◦C- 8◦C) until expiration date or at room temperature <30◦C for 28 days

• Opened vials: refrigeration for 28 days

• Opened Prefilled pens: room temperature for 28 days

Toujeo®

• Unopened Prefilled pens: refrigeration until expiration date

• Opened Prefilled pens: room temperature for 42 days

Insulin glargine

(Lantus®or Toujeo®)


Pictures available from: https://www.lantus.com,

http://ifreebudget.com

Long Acting Insulin: onset 3-4 hours

Storage/ Stability: • Unopened vials/ prefilled pens:

refrigeration (2◦C- 8◦C) until

expiration date or at room temperature <30◦C for 42 days

• Opened vials: refrigeration or room temperature for 42 days

• Opened prefilled pens: room


Insulin detemir (Levemir®)


Pictures available from: https://cdn.petcarerx.com,

http://5.imimg.com

Long Acting Insulin: onset ~1 hour

Storage/ Stability:

•Unopened pens: refrigeration (2◦C- 8◦C) until expiration date or at room temperature <30◦C for up to 56 days

•Opened pens: refrigeration or at room temperature for up to 56 days

Insulin degludec (Tresiba®)


Picture available from: http://www.jediazucarado.com

https://cdn.petcarerx.com/LPPE/images/articlethumbs/Levemir_Large.jpg

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Mixtures

• Insulin NPH and Regular Insulin 70/30 (Humulin 70/30®, Humulin 70/30® KwikPen, Novolin 70/30®)

• Insulin aspart protamine/ insulin aspart 70/30 (Novolog Mix 70/30®, Novolog Mix 70/30® FlexPen)

• Insulin lispro protamine/ insulin lispro (Humalog Mix 50/50®, Humalog Mix 50/50® KwikPen, Humalog Mix 75/25®, Humalog Mix 75/25® KwikPen)


Pharmacist Post-test Question

Which of the following is not a symptom of

hypothyroidism?

a. Constipation

b. Insomnia

c. Dry Skin

d. Cold Sensitivity


Which of the following is not a symptom of

hypothyroidism?

a. Constipation

b. Insomnia

c. Dry Skin

d. Cold Sensitivity


What is the onset of action of NPH (Humulin N®,

Novolin N®)?

a. 10- 30 minutes

b. 3-4 hours

c. 6 hours

d. 90 minutes

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What is the onset of action of NPH (Humulin N®,

Novolin N®)?

a. 10- 30 minutes

b. 3-4 hours

c. 6 hours

d. 90 minutes

Technician Post-test Question

Which of the following thyroid products is correctly

matched with its Brand name?

a. Methimazole (ThyroShield®)

b. Liothyronine (Tirosint®)

c. Liotrix (Thyrolar®)

d. Thyroid Extract (Cytomel®)


Which of the following thyroid products is correctly

matched with its Brand name?

a. Methimazole (ThyroShield®)

b. Liothyronine (Tirosint®)

c. Liotrix (Thyrolar®)

d. Thyroid Extract (Cytomel®)


How long can unopened insulin detemir (Levemir®)

prefilled pens be stored at room temperature?

a. 28 days

b. 42 days

c. 56 days

d. 14 days

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How long can unopened insulin detemir (Levemir®)

prefilled pens be stored at room temperature?

a. 28 days

b. 42 days

c. 56 days

d. 14 days

Questions?

References

• Brent GA, Koenig RJ. Thyroid and antithyroid drugs. In: Brunton LL, Hilal-Dandan R, Knollmann BC, editors. Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 13e New York, NY: McGraw-Hill; 2018 [cited 2019 Feb 24]. Available from:. Accessed February 24, 2019. http://accesspharmacy.mhmedical.com/content.aspx?bookid=2189&sectionid=172481901

• Dong BJ. Thyroid & antithyroid drugs. In: Katzung BG,eds. Basic & Clinical Pharmacology [Internet]. 14ed. New York, NY: McGraw-Hill;2018[cited 2019 March 5].Available from: http://accesspharmacy.mhmedical.com/content.aspx?bookid=2249&sectionid=17522169

• Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, et al. CLINICAL PRACTICE GUIDELINES FOR HYPOTHYROIDISM IN ADULTS: COSPONSORED BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND THE AMERICAN THYROID ASSOCIATION. Endocr Pract. 2012 Dec 4; 18 (6): e1-e45. Available from: https://www.aace.com/files/hypothyroidism_guidelines.pdf

• Jonklass J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, etal. Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid, a Mary Ann Liebert, Inc. publication. 2014 Dec 14; 24(12):1670-1751.Available from: https://www.liebertpub.com/doi/pdf/10.1089/thy.2014.0028

• Jonklass J, Talbert RL. Thyroid Disorders. In: DiPiro JT, et al (eds): Pharmacotherapy: A Pathophysiologic Approach. 9th ed. New York: McGraw-Hill; 2014. pp.1191-1216.

• Lexi-Comp, Inc. (Lexi-DrugsTM). Lexi-Comp, Inc.; 1 March 2019.

References

• Powers AC, D’Alessio. Endocrine pancreas and pharmacotherapy of diabetes mellitus and hypoglycemia. In: Brunton LL, Hilal-Dandan R, Knollmann BC, eds. Goodman & Gilman's: The Pharmacological Basis of Therapeutics [Internet]. 13ed. New York, NY: McGraw-Hill; 2018 [cited 2019 March 7]. Available from: http://accesspharmacy.mhmedical.com/content.aspx?bookid=2189&sectionid=172482821.

• Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid.2016 Oct;26(10):1343-1421.

• 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: Concepts and Clinical Practice [Internet].9th ed. Philadelphia: Elsevier, Inc.; 2018 [cited 2019 Feb 24]. Available from: https://www.clinicalkey.com/service/content/pdf/watermarked/3-s2.0-B9780323354790001203.pdf?locale=en_US

• Triplitt CL, Repas T, Alvarez C .Diabetes mellitus. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L Eds. Pharmacotherapy: A Pathophysiologic Approach [Internet]. 10ed. New York, NY: McGraw-Hill; 2017[cited 2019 March 7]. Available from: http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146065891.

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Pictures

• https://cdn.diabetesdaily.com/wp-content/blogs.dir/21/files/2017/06/humalog-lispro-injection.png

• https://fightingtype1.files.wordpress.com/2015/05/novolog.gif

• http://www.medicine-online.org/img/cms/apidra.jpg

• https://www.healthline.com/hlcmsresource/images/diabetesmine/wp-content/uploads/2013/02/Aprida.jpg

• https://www.ontrackdiabetes.com/sites/default/files/imagecache/gallery-large/wysiwyg_imageupload/4174/2017/03/09/Afrezza%20Inhaler%20%28closed%29%20with%204-unit%2C%208-unit%20and%2012-unit%20cartrigdes%20%28REVISED%29.jpg

• https://rx411.com/wp-content/uploads/2016/07/humulin-r-500.jpg

• http://3.bp.blogspot.com/_na2-dwMBheA/SeELjRymVsI/AAAAAAAAABM/4zEruOu_2gU/s320/20070723153123.jpg

Pictures

• https://d3pq5rjvq8yvv1.cloudfront.net/catalog/product/cache/1/image/9df78eab33525d08d6e5fb8d27136e95/n/o/novo2.jpg

• http://www.international-diabetes-association.com/wp-content/uploads/2015/11/8473-1-humulin-n.jpg

• http://www.peticub.com/wp-content/uploads/2017/03/Novolin-N.jpg

• https://www.lantus.com/-/media/EMS/Conditions/Diabetes/Brands/Lantus/Microsite/VIAL-PEN_2.png?la=en&hash=72BD375B011050D4579D38F9FB316362B6655842

• http://ifreebudget.com/images/toujeo.png

• https://cdn.petcarerx.com/LPPE/images/articlethumbs/Levemir_Large.jpg

• http://5.imimg.com/data5/MW/XP/MY-3686936/levemir-flexpen-500x500.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

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Endocrine Products- Thyroid & Diabetes - StarChapter · 2019-04-06 · 4/6/2019 1 ENDOCRINE PRODUCTS- THYROID & DIABETES By: Avery Aldridge, Pharm.D. 4/12/19 Financial Disclosure

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