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Purpose of Insulin
- Increase available insulin
- Modify carbohydrate metabolism
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Classes of Insulin
- Rapid-acting
- Short-acting
- Intermediate-acting
- Long-Acting
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Generic (Trade Name) for Rapid-acting
- Lispro insulin (Humalog)
- Insulin aspart (Novolog)
- Insulin glulisine (Aprida)
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Generic (Trade Name) for Short-acting
- Regular insulin (Humulin R)
- Regular insuline (Novolin R)
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Generic (Trade Name) for Intermediate-acting
- NPH insulin (Humulin N)
- Insulin determir (Levemir)
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Generic (Trade Name) for Long-acting
Insulin glargine (Lantus)
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What's the action of insulin?
- cellular uptake of glucose
- converts glucose into glycogen
- moves K+ into the cell
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Clients c Type 2 DM require insulin when:
- Oral hypoglycemics, diet, and exercise can't control blood glucose
- Severe renal or liver disease
- Painful neuropathy
- Undergoing surgery or DX tests
- Stress (ex. infection, trauma)
- Emergency TX of DKA or HHNS
- TX of hyperkalemia
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What med/food has additive hypoglycemic effects when use concurrently c insulin?
- Sulfonylureas
- Meglitinide
- Beta Blockers
- Alcohol
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What two meds raise blood glucose and counteract the effects of insulin?
- thiazide diuretics
- glucocorticoids
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What med masks SNS response to hypoglycemia (tachy, tremors)?
Beta blockers
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When should dosage of insulin be increased?
- increase calories
- infection
- stress
- growth spurts
- 2nd & 3rd trimester of pregnancy
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When should dosage of insulin be decreased?
- in response to level of exercise
- 1st trimester of pregnancy
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How to mix insulin?
- mix short-acting c long-acting
- drawn short-acting (clear) first then long-acting (cloudy)
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What two long-acting clear insulin should not be admin via IV and mixed with other insulin?
- glargine (Lantus)
- determir (Levemir)
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What insulin can be admin Sub Q, continuous Sub Q infusion, and IV?
- lispro (Humalog)
- aspart (Novolg)
- glulisine (Aprida)
- regular insulin (Humulin)
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How do you admin NPH (Humulin N)?
Sub Q
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Proper Insulin Storage
- unopened vials store in fridge until expiration
- premixed store for 3 mos
- mix in syringe keep 1 to 2 wks in fridge
- keep syringe vertical (needle pointing upward)
- store vial in use at room temp; discard p 1 mo
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Med Class: Oral Hypoglycemics
- Sulfonylureas
- Meglitinides
- Biguanides
- Thiazolidinaediones
- Alpha Glucosidease inhibitors
- Gliptins
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Sulfonyureas and Meglitinides
insulin release from pancreas
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Sulfonylureas
- tolbutamide (Orinase)
- glipizide (Glucotrol)
- chlorpropamide (Diabinese)
- glyburide (DiaBeta, Micronase)
- glimepiride (Amaryl)
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Meglitinides
- repaglinide (Prandin)
- nateglinide (Starlix)
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Biguanides
- reduce production of glucose w/in liver
- increase glucose uptake and use in muscles
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Biguanides
metformin HCL (Glucophage)
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Thiazolidinediones (Glitazones)
- increases cellular response to insulin by decreasing insulin resistance
- increase glucose uptake
- decrease glucose production
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Thiazolidinediones (Glitazones)
- rosiglitazone (Avandia)
- pioglitazone (Actos)
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Alpha glucosidase inhibitors
slows carb absorption and digestion
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Alpha glucosidase inhibitors
- acarbose (Precose)
- miglitol (Glyset)
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Gliptins
- promote release of insulin
- decrease secretion of glucagon
- lowers fasting glucose
- lowers postprandial glucose
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Gliptins
Sitagliptin (Januvia)
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Side/Adverse Effects of Glipizide and Repaglinide
hypoglycemia
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Nursing Interventions/Client Education for Glipizide and Repaglinide
- monitor for s/sx of hypoglycemia (tachy, palpitations, diaphoresis, and shakiness)
- self admin a snack of 15 g of carb (4 oz of OJ, 2 oz grape juice, 8 oz milk, glucose tab)
- notify HCP of recurrent problem
- give IV glucose for severe hypoglycemia
- wear medical alert bracelet
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Side/Adverse Effects of Metformin HCL
- GI effects (anorexia, n/v) which lead to wt loss of 6 to 8 lbs
- Vit B and folic acid deficiency
- lactic acidosis (hyperventilation, myalgia, sluggishness, somnolence)
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Nursing Intervention/Client Ed. Metformin HCL
- GI: d/c med if necessary
- Vit B & folic acid def.: supplements
- Lactic acidosis: d/c med & inform HCP
- tx severe Lactic acidosis c hemodialysis
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Side/Adverse Effects Rosiglitazone
- fluid retention
- LDL elevations
- hepatotoxicity
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Nursing Intervention/Client Ed. Rosiglitazone
- fluid retention: monitor for edema, wt. gain, and/or signs of CHF
- LDL elevation: monitor cholesterol
- hepatotoxicity: liver function test, report hepatotoxicity sxs (jaundice or dark urine)
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Side/Adverse Effects Acarbosb
- Intestinal (abd distention & cramping, hyperactive bowel sounds, diarrhea, excessive gas
- risk for anemia b/c decrease iron absorption
- hepatotoxicity
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Nursing Interventions/Client Ed. Acarbse
- Intestinal: d/c med if necessary
- anemia: monitor Hgb & Fe levels; d/c med if necessary
- hepatotoxicity: d/c med & liver funct will return to normal
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Contraindications/Precautions c Oral Hypoglycemics
- Pregnancy risk Cat. C: glipizide, repaglinide, rosiglitazone
- Preg. risk Cat. B: metformin HCL (glucophage, acarbose (Precose), sitagliptin (Januvia)
- oral usually avoided in pregnancy & lactation
- contraindicated in DKA
- Metformin HCL contraindicated for severe infection, shock, and hypoxic condition
- Acarbose contraindicated for GI disorders
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What are some things nurses should do? Nursing Administration
- encourage exercise
- follow appropriate diet
- keep log of glucose levels
- refer pt to dietician &/or diabetic nurse
- admin meds orally and at appropriate times
- some formulations may combine two meds
- monitor for signs of hypoglycemia
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Best taken 30 min prior to meal
Glipizide (Glucotrol, Glucotrol XL)
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eat w/in 30 mins of taking a dose of med 3 times/day
Repaglinide
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Take immediate release tabs 2 times/day c breakfast & dinner and take and take sustained release tabs 1 time/day c dinner
Metformin HCL (Glucophage)
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Take med once or twice a day c or s food
Rosiglitazone (Avandia)
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take c first bite of food 3 times/day
Acarbose (Precose)
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take once a day c or s food
Sitagliptin (Januvia)
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Med Class: Amyline Mimetics
primalintide (Symlin)
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Purpose of pramlintide (Symlin)
- reduce postprandial glucose levels from decreased gastric emptying
- decrease caloric intake
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Therapeutic uses of pramlintide (Symlin)
- Type 1 or 2 DM
- used in conjunction c insulin or oral hypoglycemic med (usually metformin or sulfonylurea
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Side/Adverse Effects & Nursing Interventions/Client Ed. Pramlintide (Symlin)
- Nausea: report; HCP may decrease dose
- Reaction at injection sites
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Contraindications/Precautions pramlintide (Symlin)
- Pregnancy Risk Cat. C
- contraindicated for pts c renal failure or receiving dialysis
- caution c pts c thyroid disease, osteoporosis, or alcoholism
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Med. Interaction of Pramlintide (Symlin)
- insulin increase risk of hypoglycemia
- use c meds that slow gastric emptying (opioids) or delay food absorption (acarbose (Precose)) may further slow gastric emptying
- oral med absorption delayed
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Nursing Intervention/Client Ed Pramlintide (Symlin)
- increase risk of hypoglycemia: decrease insulin dose (50%)
- slow gastric emptying: avoid concurrent use
- Med absorption delayed: Admin oral med 1 to 2 hr p injection of pramlintide
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Nursing Administration of Pramlintide (Symlin)
- admin sub q prior to meals
- unopened vials in fridge
- open vials discard p 28 days
- do not mix c insulin in same syringe
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Medication Class: Incretin Mimetic
Exenatide (Byetta)
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Purpose of Exenatide (Byetta)
- release insulin
- decrease secretion of glucagon
- slow gastric emptying
- fasting and postprandial glucose levels lowered
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Therapeutic uses of Exenatide (Byetta)
- supplemental glucose control for Type 2 DM
- used along c oral hypoglycemic (metformin or sulfonylurea)
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Side/Adverse Efffects of Exenatide (Byetta)
- GI effects (n/v and diarrhea)
- pancreatitis
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Nursing Intervention/Client Ed. Exenatide (Byetta)
- GI: notify HCP if sx intolerable
- Pacreatitis: stop meds and notify HCP
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Contraindications/Precaution of Exenatide (Byetta)
- Pregnancy risk Cat. C
- Contraindicated in pts c renal failure, ulcerative colitis, Crohn's diseas
- Caution in elderly & pts c renal impairment or thyroid disease
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Med Interaction Exenatide (Byetta)
- Oral med absorption delayed (oral contraceptives & antibiotics)
- use c sulfonylurea increases risk of hypoglycemia
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Nursing Intervention/Client Ed. Exenatide (Byetta)
- oral med absorp delayed: admin oral med 1 to 2 hr p
- concurrent use of sulfonylurea: lower dose of sulfonylurea
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Nursing Admin of Exenatide (Byetta)
- in prefilled injector pens
- admin sub q
- give w/in 60 mins b/f morning& evening meal
- never admin p meal
- keep injection pen in fridge
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Nursing Eval of Med Effectiveness of Exenatide (Byetta)
- Preprandial glucose levels of 90 to 130 mg/dL
- Postprandial < 180 mg/dL
- HgbA1c < 7%
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Med Clas: Hyperglycemic Agent
Glucagon
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Purpose of Glucagon
increase blood glucose
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Therapeutic uses of Glucagon
- Emergency management of hypoglycemic rxns (ex. insulin overdose)
- decrease in GI motility
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Side/Adverse Effects and Nursing Interventions of Glucagon
GI distress (N/V): turn pts on left side following admin to reduce risk of aspiration
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Contraindications/Precautions of Glucagon
- ineffective for hypoglycemia
- Pregnancy Risk Cat. B
- caution in pts c cardiovascular disease
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Nursing Administration for Glucagon
- admin SC, IM or IV immediately
- provide food as soon as pt is conscious and able to swallow
- have on hand at all times
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Nursing Eval or Med Effectiveness
elevation in blood glucose level to greater than 50 mg/dL
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Med. Class: Thyroid Hormone
- levothyroxine (Synthroid, Levothroid)
- liothyronine (Cytomel)
- liotrix (Thyrolar)
- Thyroid (Thyroid USP)
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Purpose of Thyroid Hormone (levothyroxine (Synthroid, Levothroid)
- synthetic form of T4
- increase metabolic rate, protein synthesis, CO, renal perfusion, O2 use, body temp, blood vol, and growth process
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therapuetic use of levothyroxine (Synthroid, Levothroid)
- tx hypothyroidism
- emergency tx of myxedema coma (IV route)
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Side/Adverse Effects of thyroid hormone, levothyroxine (Synthroid, Levothroid)
over-medication results in signs of hyperthyroidism
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What are the signs of hyperthyroidism?
- anxiety
- tachy
- palpitations
- altered appetite,
- abd cramping
- heat intolerance
- fever
- diaphoresis
- wt loss
- menstrual irregularities
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Contraindications/Precautions of Thyroid Hormone, Levothyroxine (Synthroid, Levothroid)
- Preg Risk A Cat
- caution in pregnancy and lactation
- contraindicated in pts c thyrotoxicosis
- contraindicated following MI
- caution in pts c cardio problems (HTN, angina pectoris, ischemic heart disease)
- do not use to tx obesity
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What med increases the anticoag effects of warfarin (Coumadin) by breaking down Vit K?
Levothyroxine
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Since levothyroxine increases the effects of warfarin, how should you educate pts?
- monitor PT and INR
- report signs of bleeding (bruising, petechia)
- decrease dose of warfarin
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How should you take Thyroid Hormone, levothyroxine?
- take daily on empty stomach
- before breakfast daily
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Should pts switch Thyroid Hormone meds whenever?
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Nursing Eval of Med Effectiveness of Thyroid Hormone, levothyroxine (Synthroid, Levothroid)
- decrease TSH levels
- Normal T4 levels
- absence of hypothyroidism sxs
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What are hypothyroidism sxs?
- depression
- wt gain
- bradycardia
- anorexia,
- cold intolerance
- dry skin
- menorrhagia
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Med Class: Antithyroid Medication
- propylthiouracil (PTU)
- methimazole (Tapazole)
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What's the purpose of antithyroid meds, propylthiouracil (PTU)?
- blocks synthesis of thyroid hormones
- prevents oxidation of iodine
- blocks conversion of T4 into T3
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How are antithyroid hormones, propylthiouracil (PTU) used?
- tx Graves disease
- make euthryoid prior too thyroid removal surgery
- use c irradiation of thyroid gland
- emergency tx of thyrotoxicosis
- admin oral
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What happens if pt over-medicates on antithyroid med, propylthiouracil (PTU?
hypothyroidism
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What are the s/sx of hypothyroidism?
- drowsiness
- depression
- wt gain
- edema
- brady
- anorexia
- cold intolerance
- dry skin
- menorrhagia
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What should the pt do if hypothyroidism effects occur in a pt using antithyroid meds, propylthiouracil (PTU)?
- report signs of over-medication
- reduce dose
- may temporarily admin thyroid supplements
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Agranulocytosis
Side Effect of antithyroid hormone
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Signs of agranulocytosis
sore throat fever
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Nursing intervention/client education for agranulocytosis side effect of antithyroid hormone, propylthiouracil, (PTU)
- monitor for early signs
- monitor blood count
- stop tx and monitor reversal
- give neupogen to tx
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Contraindication/Precaution of antithyroid med, propylthiouracil (PTU)
use cautiously in bone marrow depression and/or immunosupression
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What happens if you use antithyroid med, propylthiouracil (PTU) c anticoag?
increase anticoagulation
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use antithyroid med, propylthiouracil (PTU) and digoxin (Lanoxin0 together
increase glycoside
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if antithyroid med propylthiouracil (PTU) and anticoags are used together
- monitor PT, INR, aPTT
- adjust dosages of anticoag
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if antithyroid med, propylthiouracil (PTU) and dig are used together
- monitor dig level
- reduce dig dose as need
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how should pt take antithyroid hormone med, propylthiouracil (PTU)
- take same time each day
- take c meals (maintain consistent therapeutic level and decrease gastric distress)
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should pts d/c antithryroid med, propylthiouracil (PTU) abruptly?
No
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What labs should be monitored for antithyroid med, propylthiouracil (PTU)
- CBC for leukopenia
- thrombocytopenia
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What's the purpose of antithyroid med, radioactive iodine?
- absorbed by thyroid
- destroys thyroid producing cells
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What are some therapeutic uses for high dose thyroid-radioactive iodine?
- hyperthyroidism
- thyroid cancer
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What are some therapeutic uses for low dose thyroid-radioactive iodine?
diagnosis of thyroid disorders
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Side/Adverse Effects of radioactive iodine
- radiation sickness
- bone marrow suppression
- hypothyroidism
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which antithyroid med use should you monitor pts for anemia, leukopenia, and thrombocytopenia?
radioactive iodine
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