Pharmacology Finals

**ANTIBIOTICS** **Penicillins** **Mechanism of Action:** - Beta-lactam antibiotics are beta-lactam antibiotics that inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins (PBPs), preventing the formation of peptidoglycan cross-links. This leads to the weaken...

**ANTIBIOTICS** **Penicillins** **Mechanism of Action:** - Beta-lactam antibiotics are beta-lactam antibiotics that inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins (PBPs), preventing the formation of peptidoglycan cross-links. This leads to the weakening of the bacterial cell wall and subsequent cell lysis. **Examples & Uses:** - **Penicillin G (IV/IM):** Treats *streptococcal infections, syphilis, meningococcal disease*. - **Penicillin V (PO):** For *strep throat, dental infections, skin infections*. - **Amoxicillin (PO):** Treats *otitis media, sinusitis, bronchitis, pneumonia*. - **Ampicillin (IV/PO):** Effective against *enterococci, Listeria*. **Cephalosporins** **Mechanism of Action:** - Cephalosporins are also ***beta-lactam antibiotics*** that ***inhibit bacterial cell wall*** synthesis by binding to PBPs. They are categorized by generations, with each having different spectrums of activity against gram-positive and gram-negative bacteria. **Examples:** **First Generation:** - **Cefazolin (IV):** Used for *surgical prophylaxis* and *skin/soft tissue infections*. - **Cephalexin (PO):** For *skin infections* and *urinary tract infections (UTIs).* **Second Generation:** - **Cefuroxime (IV/IM/PO):** Treats community-acquired pneumonia (***CAP***) and sinusitis. - **Cefoxitin (IV):** Effective for pelvic inflammatory disease (***PID***) and intra-abdominal infections. **Third Generation:** - **Ceftriaxone (IV/IM):** Commonly used for meningitis, gonorrhea, and pneumonia. - **Cefotaxime (IV):** Treats neonatal sepsis and pneumonia. **Fourth Generation:** - **Cefepime (IV):** Broad-spectrum, effective for hospital-acquired pneumonia and febrile neutropenia. **Fifth Generation:** - **Ceftaroline (IV):** Effective against MRSA and community-acquired bacterial pneumonia. **Carbapenems** **Mechanism of Action:** - Carbapenems are beta-lactam antibiotics with broad-spectrum activity. They inhibit cell wall synthesis by binding to PBPs, similar to penicillins and cephalosporins. **Examples:** - **Meropenem (IV):** For intra-abdominal infections, meningitis, and complicated skin infections. - **Imipenem/cilastatin (IV):** Used for multi-drug resistant (MDR) infections, severe hospital-acquired infections, and polymicrobial infections. - **Ertapenem (IV/IM):** For pelvic infections, community-acquired pneumonia, and complicated UTIs. **Macrolides** **Mechanism of Action:** - Macrolides inhibit bacterial protein synthesis by binding to the 50S ribosomal subunit, which blocks translocation and prevents the elongation of the protein chain. **Examples:** - **Azithromycin (PO/IV):** Commonly used for respiratory tract infections, chlamydia, and mycoplasma pneumonia. - **Clarithromycin (PO):** Treats respiratory infections, H. pylori infections, and skin infections. - **Erythromycin (PO/IV):** Effective against Legionnaire's disease, diphtheria, and pertussis. **Fluoroquinolones** **Mechanism of Action:** - Fluoroquinolones inhibit bacterial DNA gyrase (topoisomerase II) and topoisomerase IV, enzymes critical for bacterial DNA replication and repair. **Examples:** - **Ciprofloxacin (PO/IV):** Used for UTIs, bacterial gastroenteritis, and pseudomonal infections. - **Levofloxacin (PO/IV):** Treats community-acquired pneumonia, chronic bronchitis, and UTIs. - **Moxifloxacin (PO/IV):** Effective against respiratory infections, sinusitis, and skin infections. **Tetracyclines** **Mechanism of Action:** - Tetracyclines inhibit protein synthesis by binding to the 30S ribosomal subunit, preventing the addition of amino acids to the growing peptide chain. **Examples:** - **Doxycycline (PO/IV):** Used for Lyme disease, acne, chlamydia, and malaria prophylaxis. - **Tetracycline (PO):** Effective for acne, cholera, and brucellosis. - **Minocycline (PO/IV):** Used for acne and skin infections. **Aminoglycosides** **Mechanism of Action:** - Aminoglycosides bind to the 30S ribosomal subunit, disrupting protein synthesis, leading to misreading of mRNA and production of nonfunctional proteins. **Examples:** - **Gentamicin (IV/IM):** Used for severe gram-negative infections, sepsis, and endocarditis. - **Amikacin (IV/IM):** Treats multi-drug resistant gram-negative bacteria. - **Tobramycin (IV/IM/Inhaled):** Used for pseudomonal infections in cystic fibrosis patients. **Sulfonamides** **Mechanism of Action:** - Sulfonamides inhibit bacterial folate synthesis by blocking the enzyme dihydropteroate synthase, which is essential for synthesizing folic acid. **Examples:** - **Sulfamethoxazole-trimethoprim (SMX-TMP) (PO/IV):** Treats UTIs, Pneumocystis jirovecii pneumonia, and MRSA skin infections. **Glycopeptides** **Mechanism of Action:** - Glycopeptides inhibit bacterial cell wall synthesis by binding to the D-alanyl-D-alanine portion of cell wall precursors, preventing cell wall formation. **Examples:** - **Vancomycin (IV/PO):** Used for MRSA, Clostridium difficile colitis (oral), and endocarditis. - **Teicoplanin (IV):** Treats gram-positive infections, including MRSA and enterococci. **Lincosamides** **Mechanism of Action:** - Lincosamides, like clindamycin, inhibit bacterial protein synthesis by binding to the 50S ribosomal subunit, preventing peptide chain elongation. **Examples:** - **Clindamycin (PO/IV/Topical):** Effective for skin infections, anaerobic infections, and acne. **Oxazolidinones** **Mechanism of Action:** - Oxazolidinones inhibit protein synthesis by binding to the 23S ribosomal RNA of the 50S subunit, preventing the formation of a functional 70S initiation complex. **Examples:** - **Linezolid (PO/IV):** Used for MRSA, VRE, and pneumonia. **Metronidazole** **Mechanism of Action:** - Metronidazole is a nitroimidazole that, when reduced in anaerobic bacteria, disrupts DNA synthesis, leading to bacterial cell death. **Examples:** - **Metronidazole (PO/IV/Topical):** Used for anaerobic bacterial infections, bacterial vaginosis, Clostridium difficile, and protozoal infection. **Nitrofurantoin** **Mechanism of Action:** - Nitrofurantoin damages bacterial DNA by producing reactive intermediates when metabolized by bacterial enzymes. **Examples:** - **Nitrofurantoin (PO):** Primarily used for uncomplicated UTIs. **Polymyxins** **Mechanism of Action:** - Polymyxins disrupt the bacterial cell membrane by interacting with the phospholipids, leading to increased permeability and cell lysis. **Examples:** - **Polymyxin B (IV/Topical):** For multi-drug resistant gram-negative infections. - **Colistin (IV/Inhaled):** Used for serious gram-negative infections, especially in cystic fibrosis. **Understanding MRSA and VRSA:** **MRSA (Methicillin-Resistant Staphylococcus aureus)** - Commonly associated with skin infections, pneumonia, and sepsis. It\'s crucial to know that MRSA is resistant to many antibiotics. - infections require specific antibiotics due to their resistance to beta-lactam antibiotics, including methicillin. Here are the **primary antibiotics** used to treat **MRSA infections**: **Vancomycin** **Class:** Glycopeptide\ **Mechanism of Action:** Inhibits cell wall synthesis.\ **Route:** IV (oral for C. difficile infections)\ **Uses:** Treatment of serious MRSA infections, including skin and soft tissue infections, pneumonia, and endocarditis. **Daptomycin** **Class:** Lipopeptide\ **Mechanism of Action:** Disrupts bacterial cell membrane potential.\ **Route:** IV\ **Uses:** Skin and soft tissue infections, bacteremia, endocarditis caused by MRSA. **Linezolid** **Class:** Oxazolidinone\ **Mechanism of Action:** Inhibits protein synthesis by binding to the 50S ribosomal subunit.\ **Route:** PO/IV\ **Uses:** MRSA pneumonia, skin infections, and VRE infections. **Clindamycin** **Class:** Lincosamide\ **Mechanism of Action:** Inhibits protein synthesis by binding to the 50S ribosomal subunit.\ **Route:** PO/IV/Topical\ **Uses:** Skin and soft tissue infections caused by MRSA, especially in penicillin-allergic patients. **Ceftaroline** **Class:** Fifth-generation cephalosporin\ **Mechanism of Action:** Inhibits cell wall synthesis.\ **Route:** IV\ **Uses:** Skin infections and community-acquired pneumonia due to MRSA. **Telavancin** **Class:** Lipoglycopeptide\ **Mechanism of Action:** Inhibits cell wall synthesis and disrupts membrane integrity.\ **Route:** IV\ **Uses:** Complicated skin and soft tissue infections, including those caused by MRSA. **Quinupristin/Dalfopristin** **Class:** Streptogramin\ **Mechanism of Action:** Inhibits protein synthesis.\ **Route:** IV\ **Uses:** Infections due to MRSA, particularly in cases of vancomycin-resistant Enterococcus (VRE). **Fosfomycin** **Class:** Phosphonic acid derivative\ **Mechanism of Action:** Inhibits bacterial cell wall synthesis.\ **Route:** PO\ **Uses:** Uncomplicated UTIs caused by MRSA. **Tigecycline** **Class:** Glycylcycline (tetracycline derivative)\ **Mechanism of Action:** Inhibits protein synthesis.\ **Route:** IV\ **Uses:** Complicated skin and soft tissue infections, and intra-abdominal infections caused by MRSA. **VRSA (Vancomycin-Resistant Staphylococcus aureus)** - Less common but poses a significant treatment challenge. It is resistant to vancomycin, which is often used as a last-resort antibiotic. - is a strain of Staphylococcus aureus that has developed resistance to vancomycin, an important antibiotic used to treat serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA). - VRSA is relatively rare but poses significant treatment challenges. Here are the **key antibiotics** used to **treat VRSA infections**: **Linezolid** **Class:** Oxazolidinone\ **Mechanism of Action:** Inhibits protein synthesis by binding to the 50S ribosomal subunit.\ **Route:** PO/IV\ **Uses:** Effective for skin and soft tissue infections caused by VRSA, pneumonia, and VRE (vancomycin-resistant enterococci) infections. **Daptomycin** **Class:** Lipopeptide\ **Mechanism of Action:** Disrupts bacterial cell membrane potential, leading to cell death.\ **Route:** IV\ **Uses:** Complicated skin and soft tissue infections, bacteremia, and endocarditis due to VRSA. **Teicoplanin** **Class:** Glycopeptide\ **Mechanism of Action:** Inhibits cell wall synthesis.\ **Route:** IV/IM\ **Uses:** Effective against VRSA and serious infections. **Ceftaroline** **Class:** Fifth-generation cephalosporin\ **Mechanism of Action:** Inhibits cell wall synthesis.\ **Route:** IV\ **Uses:** Treatment of skin infections and community-acquired pneumonia due to VRSA. **Quinupristin/Dalfopristin** **Class:** Streptogramin\ **Mechanism of Action:** Inhibits protein synthesis.\ **Route:** IV\ **Uses:** May be used in VRSA infections, particularly those resistant to other treatments. **Tigecycline** **Class:** Glycylcycline (tetracycline derivative)\ **Mechanism of Action:** Inhibits protein synthesis.\ **Route:** IV\ **Uses:** Complicated skin and soft tissue infections, intra-abdominal infections caused by VRSA. **Fosfomycin** **Class:** Phosphonic acid derivative\ **Mechanism of Action:** Inhibits bacterial cell wall synthesis.\ **Route:** PO\ **Uses:** May be effective for certain urinary tract infections caused by VRSA. PPT \#2 **ANTICANCER AGENTS** +-----------------------------------+-----------------------------------+ | **ANTICANCER AGENTS** | | +===================================+===================================+ | **Alkylating Agents** | **Mechanism of Action**: | | | Alkylating agents bind to DNA, | | | causing cross-linking between DNA | | | strands, which prevents proper | | | DNA replication and | | | transcription, leading to | | | apoptosis (cell death). | +-----------------------------------+-----------------------------------+ | **Cyclophosphamide** | **Specific Use:** Breast cancer, | | | lymphomas, ovarian cancer, | | | multiple myeloma\ | | | **Route:** Intravenous (IV), | | | Oral\ | | | **Nursing Care:** | | | | | | - Monitor for ***hemorrhagic | | | cystitis***; encourage | | | increased fluid intake. | | | | | | - Monitor ***CBC*** for bone | | | marrow suppression (anemia, | | | neutropenia, | | | thrombocytopenia). | | | | | | - Administer ***antiemetics*** | | | for nausea and vomiting. | | | | | | - Ensure ***hand hygiene*** and | | | protective gloves during | | | handling, as it is cytotoxic. | +-----------------------------------+-----------------------------------+ | **Ifosfamide** | **Specific Use:** Testicular | | | cancer, sarcomas, lymphomas.\ | | | **Route:** Intravenous (IV)\ | | | **Nursing Care:** | | | | | | - Hydrate the patient well and | | | administer ***mesna*** to | | | prevent hemorrhagic cystitis. | | | | | | - Monitor ***renal function*** | | | and for signs of bleeding or | | | infection. | | | | | | - Ensure frequent assessments | | | of ***neurological | | | function*** as it can cause | | | neurotoxicity. | +-----------------------------------+-----------------------------------+ | **Antimetabolites** | **Mechanism of Action**: | | | Antimetabolites interfere with | | | DNA and RNA synthesis by | | | mimicking natural substances | | | required for nucleic acid | | | production, halting cell | | | division. | +-----------------------------------+-----------------------------------+ | **Methotrexate** | **Specific Use:** Leukemias, | | | breast cancer, osteosarcoma, | | | non-Hodgkin's lymphoma, | | | autoimmune diseases.\ | | | **Route:** Intravenous (IV), | | | Intramuscular (IM), Oral, | | | Intrathecal (spinal canal)\ | | | **Nursing Care:** | | | | | | - Monitor for ***mucositis*** | | | (mouth sores) and provide | | | oral care. | | | | | | - Administer ***leucovorin*** | | | (folinic acid) as a rescue | | | drug to reduce toxicity. | | | | | | - Assess for ***renal and liver | | | function***; avoid NSAIDs as | | | they increase toxicity. | | | | | | - Educate patients on | | | ***avoiding alcohol*** and | | | maintaining good hydration. | +-----------------------------------+-----------------------------------+ | **5-Fluorouracil (5-FU)** | **Specific Use:** Colorectal | | | cancer, breast cancer, gastric | | | cancer, pancreatic cancer.\ | | | **Route:** Intravenous (IV), | | | Topical\ | | | **Nursing Care:** | | | | | | - Monitor for ***hand-foot | | | syndrome*** (skin peeling, | | | pain in palms and soles). | | | | | | - Provide frequent oral care to | | | prevent ***mucositis***. | | | | | | - Monitor ***CBC*** for bone | | | marrow suppression and signs | | | of infection. | | | | | | - Administer antiemetics for | | | nausea and monitor for | | | ***diarrhea***. | +-----------------------------------+-----------------------------------+ | **Cytarabine** | **Specific Use:** Acute myeloid | | | leukemia (AML), acute lymphocytic | | | leukemia (ALL).\ | | | **Route:** Intravenous (IV), | | | Subcutaneous (SubQ), Intrathecal | | | (spinal canal)\ | | | **Nursing Care:** | | | | | | - Monitor for ***cerebellar | | | toxicity*** (balance, | | | coordination issues). | | | | | | - Check ***eyes*** for | | | ***conjunctivitis***, provide | | | eye drops prophylactically. | | | | | | - Monitor ***CBC*** and assess | | | for signs of infection. | | | | | | - Hydrate the patient well to | | | reduce renal toxicity. | +-----------------------------------+-----------------------------------+ | **Antitumor Antibiotics** | **Mechanism of Action**: These | | | drugs intercalate between DNA | | | base pairs, inhibiting DNA | | | synthesis and generating free | | | radicals that cause DNA strand | | | breaks. | +-----------------------------------+-----------------------------------+ | **Doxorubicin (Adriamycin)** | **Specific Use:** Breast cancer, | | | ovarian cancer, lymphomas, and | | | leukemias.\ | | | **Route:** Intravenous (IV)\ | | | **Nursing Care:** | | | | | | - Monitor for | | | ***cardiotoxicity*** | | | (echocardiograms, EKG), limit | | | cumulative lifetime dose. | | | | | | - Educate the patient about | | | ***red discoloration of | | | urine***, sweat, and tears. | | | | | | - Monitor ***CBC*** for bone | | | marrow suppression. | | | | | | - Ensure good oral hygiene and | | | monitor for ***mucositis***. | +-----------------------------------+-----------------------------------+ | **Bleomycin** | **Specific Use:** Hodgkin\'s | | | lymphoma, testicular cancer, head | | | and neck cancers.\ | | | **Route:** Intravenous (IV), | | | Intramuscular (IM), Subcutaneous | | | (SubQ)\ | | | **Nursing Care:** | | | | | | - Monitor for ***pulmonary*** | | | ***toxicity***; conduct | | | regular pulmonary function | | | tests. | | | | | | - Assess for ***skin | | | changes***, as it may cause | | | hyperpigmentation. | | | | | | - Monitor for signs of | | | ***allergic reactions***. | | | | | | - Educate the patient about | | | avoiding ***smoking*** and | | | exposure to pollutants. | +-----------------------------------+-----------------------------------+ | **Plant Alkaloids (Mitotic | **Mechanism of Action**: These | | Inhibitors)** | drugs interfere with the mitotic | | | spindle, preventing cancer cells | | | from dividing. | +-----------------------------------+-----------------------------------+ | **Vincristine** | **Specific Use:** Leukemia, | | | lymphomas (Hodgkin's and | | | non-Hodgkin's), breast cancer.\ | | | **Route:** Intravenous (IV)\ | | | **Nursing Care:** | | | | | | - Monitor for ***peripheral | | | neuropathy*** (numbness, | | | tingling in hands/feet). | | | | | | - Assess for ***phlebitis*** | | | and monitor the IV site | | | carefully to prevent tissue | | | damage. | | | | | | - Ensure proper dosage | | | calculation to avoid ***fatal | | | intrathecal | | | administration***. | | | | | | - Administer stool softeners to | | | prevent ***constipation*** | | | due to neuropathy. | +-----------------------------------+-----------------------------------+ | **Paclitaxel (Taxol)** | **Specific Use:** Breast cancer, | | | ovarian cancer, non-small cell | | | lung cancer.\ | | | **Route:** Intravenous (IV)\ | | | **Nursing Care:** | | | | | | - Monitor for ***peripheral | | | neuropathy*** and | | | ***hypersensitivity | | | reactions*** (administer | | | premedications such as | | | antihistamines and steroids). | | | | | | - Assess for ***bone marrow | | | suppression*** and monitor | | | CBC regularly. | | | | | | - Educate the patient on | | | avoiding tight-fitting | | | clothing or shoes to minimize | | | nerve damage. | +-----------------------------------+-----------------------------------+ | **Topoisomerase Inhibitors** | **Mechanism of Action**: These | | | drugs inhibit topoisomerase | | | enzymes that are necessary for | | | unwinding and winding DNA during | | | replication, leading to DNA | | | damage and cell death. | +-----------------------------------+-----------------------------------+ | **Etoposide** | **Specific Use:** Testicular | | | cancer, small-cell lung cancer, | | | lymphomas.\ | | | **Route:** Intravenous (IV), | | | Oral\ | | | **Nursing Care:** | | | | | | - Monitor for ***hypotension*** | | | during IV administration | | | (administer slowly). | | | | | | - Monitor ***CBC*** for bone | | | marrow suppression. | | | | | | - Administer ***antiemetics*** | | | for nausea and vomiting. | | | | | | - Educate the patient about | | | possible ***alopecia***. | +-----------------------------------+-----------------------------------+ | **Irinotecan** | **Specific Use:** Colorectal | | | cancer, pancreatic cancer.\ | | | **Route:** Intravenous (IV)\ | | | **Nursing Care:** | | | | | | - Monitor for ***severe | | | diarrhea*** ("I run to the | | | can" mnemonic for | | | irinotecan). | | | | | | - Administer ***atropine*** for | | | early diarrhea and | | | ***loperamide*** for delayed | | | diarrhea. | | | | | | - Ensure hydration and | | | electrolyte balance due to | | | diarrhea. | | | | | | - Monitor ***CBC*** for signs | | | of bone marrow suppression. | +-----------------------------------+-----------------------------------+ | **Hormonal Agents** | **Mechanism of Action**: Hormonal | | | agents either block hormone | | | receptors or inhibit hormone | | | production, interfering with | | | hormone-driven cancer growth. | +-----------------------------------+-----------------------------------+ | **Tamoxifen** | **Specific Use:** Estrogen | | | receptor-positive breast cancer.\ | | | **Route:** Oral\ | | | **Nursing Care:** | | | | | | - Monitor for signs of | | | ***thromboembolism*** (e.g., | | | DVT, PE). | | | | | | - Educate the patient about | | | ***hot flashes*** and other | | | menopausal-like symptoms. | | | | | | - Regular ***gynecologic | | | exams*** are necessary due to | | | the risk of ***endometrial | | | cancer.*** | | | | | | - Monitor ***calcium levels*** | | | and bone density, as it may | | | increase osteoporosis risk. | +-----------------------------------+-----------------------------------+ | **Anastrozole** | **Specific Use:** Postmenopausal | | | women with breast cancer.\ | | | **Route:** Oral\ | | | **Nursing Care:** | | | | | | - Monitor for | | | ***osteoporosis*** and | | | suggest ***calcium*** and | | | ***vitamin D supplements***. | | | | | | - Assess for ***joint pain*** | | | (common side effect) and | | | educate about exercise to | | | maintain bone health. | | | | | | - Monitor ***lipid levels*** | | | due to potential | | | dyslipidemia. | +-----------------------------------+-----------------------------------+ | **Targeted Therapies** | **Mechanism of Action**: Targeted | | | therapies interfere with specific | | | molecules involved in cancer | | | growth, limiting damage to normal | | | cells. | +-----------------------------------+-----------------------------------+ | **Trastuzumab (Herceptin)** | **Specific Use:** HER2-positive | | | breast cancer and gastric | | | cancer.\ | | | **Route:** Intravenous (IV)\ | | | **Nursing Care:** | | | | | | - Monitor for | | | ***cardiotoxicity*** (e.g., | | | heart failure); perform | | | regular echocardiograms. | | | | | | - Watch for ***infusion-related | | | reactions*** (e.g., fever, | | | chills). | | | | | | - Educate the patient on the | | | importance of ***reporting | | | shortness of breath*** or | | | ***palpitations***. | +-----------------------------------+-----------------------------------+ | **Imatinib (Gleevec)** | **Specific Use:** Chronic myeloid | | | leukemia (CML), gastrointestinal | | | stromal tumors (GIST).\ | | | **Route:** Oral\ | | | **Nursing Care:** | | | | | | - Monitor ***liver function | | | tests*** due to | | | hepatotoxicity risk. | | | | | | - Assess for ***fluid | | | retention*** (e.g., weight | | | gain, edema). | | | | | | - Ensure regular ***blood | | | counts*** to monitor for bone | | | marrow suppression. | +-----------------------------------+-----------------------------------+ | **Immunotherapy (Biologic | **Mechanism of Action**: | | Agents)** | Immunotherapy boosts the body's | | | immune system to target and | | | destroy cancer cells. | +-----------------------------------+-----------------------------------+ | **Interferon Alpha** | **Specific Use:** Leukemias, | | | melanomas, viral infections.\ | | | **Route:** Intramuscular (IM), | | | Subcutaneous (SubQ)\ | | | **Nursing Care:** | | | | | | - Monitor for ***flu-like | | | symptoms*** (e.g., fever, | | | chills, fatigue). | | | | | | - Educate the patient on | | | managing side effects with | | | ***antipyretics*** and rest. | | | | | | - Monitor ***liver function*** | | | and ***CBC*** regularly. | +-----------------------------------+-----------------------------------+ | **Pembrolizumab (Keytruda)** | **Specific Use:** Melanoma, | | | non-small cell lung cancer, head | | | and neck cancers.\ | | | **Route:** Intravenous (IV)\ | | | **Nursing Care:** | | | | | | - Monitor for | | | ***immune-mediated | | | reactions*** (e.g., colitis, | | | pneumonitis, thyroiditis). | | | | | | - Educate patients to report | | | any new ***respiratory | | | symptoms*** or | | | ***diarrhea***. | | | | | | - Check ***thyroid function*** | | | regularly due to the risk of | | | hypothyroidism. | +-----------------------------------+-----------------------------------+