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BMJ 2012; 344 doi: (Published 22 February 2012) Cite this as: BMJ 2012;344:e1199

When a woman with hypothyroidism had her dose of thyroxine increased she felt worse, not better. She was tired and developed headaches, nipple discharge, and weight gain. Her thyroid stimulating hormone level was found to be over 100 mIU/L (normal range 0.27-4.2), with low free thyroxine and raised prolactin levels. A scan showed an enlarged pituitary gland. The new dose of thyroxine had been dispensed with a decimal point error—the patient had received a tenth of the appropriate dose. Severe hypothyroidism had over-stimulated the pituitary, causing it to become hyperplastic. It shrank back to normal with the correct dose of thyroxine (Can Med Assoc J 2012;184:210, doi:10.1503/cmaj.111883).

Clopidogrel is converted to its active form through the cytochrome P450 pathway, which also metabolises calcium channel blockers. Some studies conclude that calcium blockers reduce the efficacy of clopidogrel, but results from the CREDO trial suggest otherwise. Patients who were taking calcium channel …

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