51-year-old woman • history of Graves disease • general fatigue, palpitations, and hand tremors • Dx?

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doi:doi: 10.12788/jfp.0690

Case Reports

51-year-old woman • history of Graves disease • general fatigue, palpitations, and hand tremors • Dx?

J Fam Pract. 2023 November;72(9):E8-E10 | doi: 10.12788/jfp.0690

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References

1. Tajiri J, Noguchi S. Antithyroid drug-induced agranulocytosis: special reference to normal white blood cell count agranulocytosis. Thyroid. 2004;14:459-462. doi: 10.1089/105072504323150787

2. Vicente N, Cardoso L, Barros L, et al. Antithyroid drug-induced agranulocytosis: state of the art on diagnosis and management. Drugs R D. 2017;17:91-96. doi: 10.1007/s40268-017-0172-1

3. Takata K, Kubota S, Fukata S, et al. Methimazole-induced agranulocytosis in patients with Graves’ disease is more frequent with an initial dose of 30 mg daily than with 15 mg daily. Thyroid. 2009;19:559-563. doi: 10.1089/thy.2008.0364

4. Tsuboi K, Ueshiba H, Shimojo M, et al. The relation of initial methimazole dose to the incidence of methimazole-induced agranulocytosis in patients with Graves’ disease. Endocr J. 2007;54:39-43. doi: 10.1507/endocrj.k05-068

5. Burch HB, Cooper DS. Management of Graves disease: a review. J Am Med Assoc. 2015;314:2544-2554. doi: 10.1001/jama.2015.16535

6. Robinson J, Richardson M, Hickey J, et al. Patient knowledge of antithyroid drug-induced agranulocytosis. Eur Thyroid J. 2014;3:245-251. doi: https://doi.org/10.1159/000367990

7. Kini V, Ho PM. Interventions to improve medication adherence: a review. J Am Med Assoc. 2018;320:2461-2473. doi: 10.1001/jama.2018.19271

8. Vest JR, Grannis SJ, Haut DP, et al. Using structured and unstructured data to identify patients’ need for services that address the social determinants of health. Int J Med Inform. 2017;107:101-106. doi: 10.1016/j.ijmedinf.2017.09.008

9. Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns. 2005;56:139-146. doi: 10.1016/j.pec.2004.02.011

10. The College of Family Physicians of Canada. Best advice: social determinants of health. Accessed September 15, 2023. https://patientsmedicalhome.ca/resources/best-advice-guides/best-advice-guide-social-determinants-health/

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Despite repeated explanations that it was dangerous for a patient who had developed agranulocytosis to take another antithyroid medication, the patient refused surgical treatment or radioiodine ablation because of her financial situation. (While all Japanese citizens are covered by a national health insurance program, patients ages 6 to 70 years are required to pay approximately 30% of medical and pharmaceutical costs.) On Day 21, potassium iodide was stopped, and propylthiouracil 300 mg/d was administered with careful follow-up. Agranulocytosis did not recur.

Immediate problem solved, but what about the future?

During her hospital stay, the medical team spoke with the patient many times, during which she expressed anxiety about her health conditions and the difficulties that she had experienced in her life. The clinicians acknowledged her concerns and assured the patient of their continuing commitment to her well-being even after discharge. The patient also was advised that she should take her medication as prescribed and that if she had a fever or sore throat, she should stop the medication and seek medical care as soon as possible. The patient accepted the medical team’s advice and expressed hope for the future.

Conversations about medication adherence. In 1 survey, about 60% of patients taking antithyroid drugs were unfamiliar with the symptoms of agranulocytosis.⁶ To deliver safe and effective treatment and detect conditions such as agranulocytosis at an early stage, clinicians must communicate clearly with patients who have hyperthyroidism, providing sufficient explanation and ensuring understanding on the patient’s part.

Interruption and subsequent resumption of the same antithyroid drug treatment also can be a risk factor for agranulocytosis, as in this case.

Patients may be reluctant to provide the details of medication adherence.⁷ Although it is common for patients to need services for socioeconomic issues,⁸ health care professionals sometimes fail to adequately discuss these issues with patients, especially if the patients are marginalized and/or have lower economic status.⁹ Cases such as ours underscore the importance of improving clinicians’ awareness and sensitivity to patients’ socioeconomic challenges.^10,11

Our patient received information about welfare and other government services from a medical social worker during her hospital stay. She also was informed that she could seek assistance from medical social workers in the future if needed.

Continue to: The patient was discharged...

51-year-old woman • history of Graves disease • general fatigue, palpitations, and hand tremors • Dx?

References

Immediate problem solved, but what about the future?

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