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Liu H, Lu M, Hu J, Fu G, Feng Q, Sun S, Chen C. Medications and Food Interfering with the Bioavailability of Levothyroxine: A Systematic Review. Ther Clin Risk Manag 2023; 19:503-523. [PMID: 37384019 PMCID: PMC10295503 DOI: 10.2147/tcrm.s414460] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
Purpose Levothyroxine is a common prescribed drug. Many medications and food, however, can interfere with its bioavailability. The aim of this review was to summarize the medications, food and beverages that interact with levothyroxine and to assess their effects, mechanisms and treatments. Methods A systematic review on interfering substances that interact with levothyroxine was performed. Web of Science, Embase, PubMed, the Cochrane library, grey literature from other sources and the lists of references were searched for human studies comparing the levothyroxine efficacy with and without interfering substances. The patient characteristics, drug classes, effects and mechanism were extracted. The NHLBI study quality assessment tools and the JBI critical appraisal checklist were used to assess the quality of included studies. Results A total of 107 articles with 128 studies were included. Drugs interactions were revealed in calcium and iron supplements, proton pump inhibitors, bile acid sequestrants, phosphate binders, sex hormones, anticonvulsants and other drugs. Some food and beverage could also induce malabsorption. Proposed mechanisms included direct complexing, alkalization, alteration of serum thyroxine-binding globulin levels and acceleration of levothyroxine catabolism via deiodination. Dose adjustment, administration separation and discontinuation of interfering substances can eliminate the interactions. Liquid solutions and soft-gel capsules could eliminate the malabsorption due to chelation and alkalization. The qualities of most included studies were moderate. Conclusion Lots of medications and food can impair the bioavailability of levothyroxine. Clinicians, patients and pharmaceutical companies should be aware of the possible interactions. Further well-designed studies are needed to provide more solid evidence on treatment and mechanisms.
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Affiliation(s)
- Hanqing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Man Lu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Jiawei Hu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Guangzhao Fu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Qinyu Feng
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
| | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
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Ding S, Xie L, Wang L, Zhou C, Zhou S, Chen J, Zhu B, Liu Y, Zhu J, Zhang Z, Li T, Wang L, Zhang Z, Shao F. Pharmacokinetic Interaction of Anaprazole, Amoxicillin and Clarithromycin after Single-Dose Simultaneous Administration and the Effect of Adding Bismuth on Their Pharmacokinetics in Healthy Male Chinese Subjects. Eur J Drug Metab Pharmacokinet 2023; 48:121-132. [PMID: 36520316 DOI: 10.1007/s13318-022-00810-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Helicobacter pylori-positive ulcers are treated with a proton pump inhibitor (PPI) + two antibiotics with/without bismuth. The objective of this study was to investigate the pharmacokinetic interaction of the novel PPI anaprazole, amoxicillin and clarithromycin with/without bismuth. METHODS This single-centre, randomised, open-label phase 1 pharmacokinetic study included healthy Chinese male participants, comprising two cohorts (cohort 1, 4 × 4 crossover design; cohort 2, 2 × 2 crossover design). In cohort 1, 24 participants received four treatment cycles with a different treatment in each cycle; the washout period between cycles was 9 days. Participants were randomly assigned to one of the following four treatment sequences (1:1:1:1): anaprazole sodium enteric-coated tablet 20 mg monotherapy, amoxicillin 1000 mg monotherapy, clarithromycin 500 mg monotherapy, and a three-drug combination (anaprazole 20 mg, amoxicillin 1000 mg and clarithromycin 500 mg). During each treatment cycle, study drugs were administered twice daily for four consecutive days and once in the morning on the fifth day. Cohort 2 participants were administered a single dose of the three-drug combination and a single dose of a four-drug combination (three-drug combination + bismuth 0.6 g) with a washout period of 11 ± 2 days between treatments. Blood samples were collected for pharmacokinetic analysis. RESULTS Twenty-nine of 32 enrolled participants (cohort 1, n = 24; cohort 2, n = 8) completed the study. There were no significant differences in exposure or time to reach maximum concentration (Tmax) between each single drug or the three-drug combination (cohort 1) or between the three- and four-drug combinations (cohort 1) for any of the drugs/metabolites. CONCLUSIONS Dose adjustments for individual drugs are not necessary with combined dosing of anaprazole, amoxicillin, clarithromycin and bismuth.
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Affiliation(s)
- Sijia Ding
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Lijun Xie
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Lu Wang
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Chen Zhou
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Sufeng Zhou
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Juan Chen
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Bei Zhu
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Yun Liu
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Jinying Zhu
- Department of Clinical Pharmacology, School of Pharmacy College, Nanjing Medical University, Nanjing, 211166, China
| | - Zeru Zhang
- Department of Clinical Pharmacology, School of Pharmacy College, Nanjing Medical University, Nanjing, 211166, China
| | - Tongtong Li
- Department of Clinical Pharmacology, School of Pharmacy College, Nanjing Medical University, Nanjing, 211166, China
| | - Li Wang
- Xuanzhu Technology Co., Ltd., Shijiazhuang, 050000, China
| | - Zhen Zhang
- Xuanzhu Technology Co., Ltd., Shijiazhuang, 050000, China
| | - Feng Shao
- Phase I Clinical Trial Unit, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
- Department of Clinical Pharmacology, School of Pharmacy College, Nanjing Medical University, Nanjing, 211166, China.
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Virili C, Capriello S, Stramazzo I, Brusca N, Santaguida MG, Gargano L, Bagaglini MF, Bruno G, Severi C, Centanni M. Daily requirement of softgel thyroxine is independent from gastric juice pH. Front Endocrinol (Lausanne) 2022; 13:1002583. [PMID: 36225208 PMCID: PMC9549358 DOI: 10.3389/fendo.2022.1002583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Softgel levothyroxine (LT4) preparation showed a better in vitro dissolution profile at increasing pH as compared to tablet LT4 preparation. Clinical studies suggested a better performance of softgel LT4 preparation in patients with gastric disorders but whether this finding is related to gastric juice pH variation in vivo is not known. METHODS Twenty-eight hypothyroid patients (24F/4M; median age=50 treated with tablet LT4 (median dose= 1.65 µg/kg/day) and with stable thyroid stimulating hormone (TSH) values on target (<0.8-2.5> mU/l) have been shifted to softgel LT4 preparation. The dose of softgel LT4 has been titrated to obtain a similar individual serum TSH value. All subjects followed a specific treatment schedule, taking LT4 in fasting condition and then abstaining from eating or drinking for at least 1 hour. Owing to the presence of long-lasting dyspepsia or of already known gastric disorders, all patients underwent endoscopy, upon informed consent. Gastric juice has been collected during endoscopy to measure gastric pH. Then we plotted the dose of LT4 with the gastric pH obtained in vivo, before and after the switch tablet/softgel preparation in all patients. RESULTS Upon the switch tablet/softgel preparation, the therapeutic LT4 dose was very slightly reduced (-6%) in the whole sample. However, the individual variations revealed the existence of two populations, one without any dose reduction (A) and the other showing a dose reduction >20% (B). Upon matching with the actual gastric pH, patients with normal pH (A: n=17; 14F/3M, median 1.52) no showed a lower softgel LT4 requirement. Instead, among patients with reduced gastric acid production (B: n=11; 10F/1M, median pH 5.02) the vast majority (10/11; 91%, p<0.0001) benefited from a lower dose of softgel LT4 (median = -23%, p<0.0001). Interestingly, the dose of LT4 in tablet correlated with pH value (Spearman's ρ =0.6409; p = 0.0002) while softgel dose was independent from gastric juice pH (Spearman's ρ =1.952; p = 0.3194). CONCLUSIONS These findings provide evidence that softgel LT4 preparation is independent from the actual gastric pH in humans and may represent a significant therapeutic option in patients with increased LT4 requirement, owed to disorders impairing the gastric acidic output.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Silvia Capriello
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Ilaria Stramazzo
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Nunzia Brusca
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
| | | | - Lucilla Gargano
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
| | - Maria Flavia Bagaglini
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Giovanni Bruno
- Department of Translational and Precision Medicine, Gastroenterology Unit, ‘‘Sapienza’’ University of Rome, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Gastroenterology Unit, ‘‘Sapienza’’ University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
- *Correspondence: Marco Centanni,
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Gatta E, Bambini F, Buoso C, Gava M, Maltese V, Anelli V, Delbarba A, Pirola I, Cappelli C. Liquid levothyroxine formulations in patients taking drugs interfering with L-T4 absorption. Front Endocrinol (Lausanne) 2022; 13:1080108. [PMID: 36561558 PMCID: PMC9764388 DOI: 10.3389/fendo.2022.1080108] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To describe the current knowledge on thyroid hormonal profile in patients on liquid L-T4 therapy and drugs known to interfere with L-T4 absorption. METHODS A PubMed/MEDLINE, Web of Science, and Scopus research was performed. Case reports, case series, original studies and reviews written in English and published online up to 31 August 2022 were selected and reviewed. The final reference list was defined based on the relevance of each paper to the scope of this review. RESULTS The available data showed that novel levothyroxine formulations circumvent gastric pH impairment due to multiple interfering drugs such as proton pump inhibitors, calcium or iron supplements, sevelamer, aluminum/magnesium hydroxide and sodium alginate. CONCLUSION New formulations can be taken simultaneously with drugs interfering with L-T4 absorption, in particular liquid formulations. Softgel capsules need more studies to support these data.
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Pecikoza U. Functional thyroid disorders in the pharmacy setting: How can we help our patients? ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-39858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Functional thyroid disorders (hypothyroidism and hyperthyroidism) are amongst the most common endocrine disorders pharmacists encounter on a daily basis. They are highly prevalent in iodine-replete areas, and affect women about 10 times more often than man. Hypothyroidism (thyroid hormone deficiency) is usually caused by Hashimoto's thyroiditis, an autoimmune disorder that leads to gradual thyroid destruction. The drug-of-choice for treating hypothyroidism is levothyroxine, a synthetic form of thyroxine. Key points which need to be discussed with patients who are prescribed levothyroxine for the first time are when/how to administer this drug, how its effects are monitored, what drugs may affect its efficacy, and the importance of properly treating hypothyroidism during pregnancy. Hyperthyroidism (increased production of thyroid hormones) is most often caused by Graves' disease, another thyroid autoimmune disorder in which stimulatory autoantibodies against the TSH receptor lead to increased thyroid function. Graves' disease is most commonly treated with thionamide drugs (thiamazole, carbimazole or propylthiouracil) and patients using these drugs should be advised on the monitoring requirements, duration of treatment, and how to recognize possible serious adverse effects (agranulocytosis and hepatotoxicity), and informed that these drugs must be used during pregnancy in order to reduce the risk of adverse outcomes for the mother and baby.
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Schiavo L, Giosuè A, Izzo V, Piaz FD, Filippelli A, Pilone V. Liquid levothyroxine sodium therapy improves pharmacologic thyroid-stimulating hormone homeostasis in patients with reduced efficacy for tablet levothyroxine sodium after sleeve gastrectomy. A case report. Obes Surg 2021; 31:4649-4652. [PMID: 34142312 DOI: 10.1007/s11695-021-05518-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/27/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Luigi Schiavo
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy. .,Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Mercato San Severino, Salerno, Italy. .,Unit of Clinical Pharmacology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy.
| | - Annalisa Giosuè
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Mercato San Severino, Salerno, Italy.,Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Viviana Izzo
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy.,Unit of Clinical Pharmacology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Fabrizio Dal Piaz
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy.,Unit of Clinical Pharmacology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy.,Unit of Clinical Pharmacology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Vincenzo Pilone
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy.,Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Mercato San Severino, Salerno, Italy
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