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MMI Scenario 3


Felicity, aged 27, attends for a clinical medication review following on from changes to her medication history. She reports feeling more tired recently and hasn’t noticed any improvement in her symptoms, despite being issued with iron tablets 3 months ago. Her current medications are as follows:
 
Levothyroxine 50mcg tablets – 1 OD
Ferrous Sulphate 200mg tablets – 1 TDS
 
What is important to explore in this case? How would you handle Felicity’s symptoms? What could be the differential diagnosis?

Example Answer


​Medicines optimisation: It is important to adopt a person centred approach and elicit Felicity’s compliance and tablet taking behaviour. In order to effectively do this, it is important to consider how and when she takes her prescription tablets.

Medicines concordance:  Is she taking levothyroxine 30 minutes before food, or caffeine containing liquids? Or at all? If not, this could impact on the absorption of levothyroxine and result in sub-optimal therapeutic effect. Importantly, is she taking her iron tablets at least 4 hours after her levothyroxine tablets, if not this could result in drug binding and more significantly causing her to absorb less thyroxine which would blunt its therapeutic effect and lead to her feeling more tired as a result to poorly managed hypothyroidism due to a drug -drug interaction.  Is Felicity taking her iron supplements with orange/apple juice? Simple advice as vitamin C aids iron absorption. Has she been taking iron with tea/coffee? Again this may inhibit absorption. 

Differential diagnosis: What else could be causing her tiredness? Has felicity changed her diet in any other ways? Is taking any over the counter/herbal medicines which, we should document? 

Nutritional input: What could be the other differentials? Is she vitamin D replete? Could we recommend an OTC vitamin D supplement or refer her for another blood test to check her thyroid stimulating hormone (TSH) level as her dose may be sub-optimal, re-check ferritin and hemoglobin (Hb) – if the level hasn’t increased sufficiently she may require change in iron/dose, vitamin D, vitamin B12?

Gynecological issues: Does she suffer from menorrhagia?  Does she lose a large amount of iron during menses, how could we support this conversation by way of family planning and contraception/sexual health advice. Does she need referral to GP to discuss options/exclude other pathology.

Social issues: Is Felicity sleeping well? Is she under stress? Other factors other then pharmacological interventions should be looked at, and it is also important to view the person behind the prescription and consider what other support we could offer her, e.g. referral to occupational health in the event of work stress.
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Other differentials: Diabetes? Check fasting glucose, recent travel? Acute illness? Night sweats? Abdominal symptoms?