Gaps in Medication Monitoring May Contribute to Death

Hypothyroidism, a chronic condition resulting from low thyroid activity, affects up to 4% of the population. Symptoms of hypothyroidism include fatigue, weight gain, and cold intolerance.1,2 Levothyroxine, a synthetic form of a thyroid hormone, is the drug of choice for replacement therapy to treat this condition. Although levothyroxine is generally well tolerated, regular blood work is required to monitor thyroid hormone levels and prevent serious adverse events.3 As part of ongoing collaboration with several provincial offices of the Chief Coroner or Medical Examiner, ISMP Canada received a report about the death of a woman who was taking levothyroxine but had not undergone monitoring for an extensive period. This bulletin describes the suboptimal follow-up and monitoring of this patient’s hypothyroidism and suggests strategies to overcome the challenges associated with the management of patients with chronic disorders.