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Nicol C, Jacquot J, Chebane L, Combret S, Pecquet PE, Massy N, Bagheri H. [Bariatric surgery and drugs: Review of the literature and Adverse Drug Reactions analysis in French National Pharmacovigilance Database]. Therapie 2024:S0040-5957(24)00033-7. [PMID: 38458944 DOI: 10.1016/j.therap.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/09/2024] [Accepted: 02/22/2024] [Indexed: 03/10/2024]
Abstract
INTRODUCTION Bariatric surgery is the only treatment for severe obesity (BMI>35kg/m2) currently recognized as effective both in achieving tangible and lasting weight loss, and in improving obesity-related comorbidities such as type 2 diabetes, hypertension, and cardiovascular complications. Bariatric surgery, like any other surgery of the digestive tract, can have an impact on nutrient absorption, as well as on drug absorption. The literature on drug management in bariatric surgery patients concerned mainly of case reports and retrospective studies involving a small number of patients. No official guidelines are available. METHODS We conducted a literature search on the consequences of bariatric surgery in terms of drug bioavailability and/or effect. The Medline® (PubMed) database was searched using the following keywords: "bariatric surgery", "bioavailability", "gastric bypass", and "obesity". We completed this review with an analysis of reports of adverse drug reactions (ADRs) in post-bariatric surgery patients for obesity registered in the National pharmacovigilance database (PVDB). We selected all cases with the mention of "bariatric surgery and/or gastrectomy" as "medical history". After reading the cases, we excluded those in which the patient had undergone surgery for an indication other than obesity, where the route of administration was other than oral, and cases in which ADRs resulted from voluntary overdose, attempted suicide, allergy, switch to Levothyrox® new formulation, meningioma under progestative drugs, inefficacy related to generic substitution and medication error. RESULTS The literature search identified mainly "case report" about the impact of bariatric surgery on so-called "narrow therapeutic window" drugs. We identified 66 informative cases out of a total of 565 cases selected (11%) in the PVDB. Nevertheless, the information does not allow a clear relationship between the occurrence of the ADR and the influence of bariatric surgery. CONCLUSION There is a lack of official information and/or recommendations on medication use in subjects who have undergone bariatric surgery. Apart from under-reporting, ADRs reports remain largely uninformative. Health professional and patients would be awareness for improving, quantitatively and qualitatively the reporting of ADRs in this population.
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Affiliation(s)
- Carole Nicol
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France
| | - Julien Jacquot
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France
| | - Leila Chebane
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France
| | - Sandrine Combret
- Centre régional de pharmacovigilance de Bourgogne, CHU de Dijon, 21000 Dijon, France
| | - Pauline-Eva Pecquet
- Service de pharmacologie clinique, centre de pharmacovigilance d'Amiens, CHU d'Amiens, 80000 Amiens, France
| | - Nathalie Massy
- Centre régional de pharmacovigilance de Rouen, CHU de Rouen, 76000 Rouen, France
| | - Haleh Bagheri
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France.
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Gatta E, Maltese V, Cavadini M, Anelli V, Bambini F, Buoso C, Facondo P, Pirola I, Delbarba A, Cappelli C. Interference or Noninterference Between Soy and Levothyroxine: That Is the Question. A Narrative Review of Literature. Endocr Pract 2023; 29:897-901. [PMID: 37633413 DOI: 10.1016/j.eprac.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE To evaluate the effect of soy intake on levothyroxine (L-T4) absorption among different L-T4 formulations. METHODS A PubMed/MEDLINE, Web of Science, and Scopus research was performed. Case reports, case series, and original studies written in English and published online up to November 30, 2022, were selected and reviewed. The final reference list was defined based on the relevance of each study to the scope of this review. RESULTS Few data, mainly case reports, seemed to suggest a possible interference of soy products on L-T4 tablets absorption. However, the only prospective randomized cross-over study showed no differences in L-T4 absorption when L-T4 and soy isoflavones were assumed concomitantly. The very little data available on liquid L-T4 formulations did not allow for any conclusions to be made, even if a double-blind placebo-controlled trial showed no impaired L-T4 absorption. CONCLUSION The inference of soy products on L-T4 absorption, if present, seems to have little clinical impact. Considering this fact, the Hamlet-like question whether soy milk interferes with L-T4 absorption remains unanswered.
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Affiliation(s)
- Elisa Gatta
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Virginia Maltese
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Maria Cavadini
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Valentina Anelli
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Bambini
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Caterina Buoso
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Paolo Facondo
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Ilenia Pirola
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Andrea Delbarba
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Carlo Cappelli
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy.
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Lau C, van Kesteren C, Smeenk R, Huitema A, Knibbe CAJ. Impact of Bariatric Surgery in the Short and Long Term: A Need for Time-Dependent Dosing of Drugs. Obes Surg 2023; 33:3266-3302. [PMID: 37594672 PMCID: PMC10514130 DOI: 10.1007/s11695-023-06770-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/19/2023]
Abstract
Sparse information is available on pharmacokinetic changes of drugs over time after bariatric surgery. By reviewing the literature on the short- and long-term pharmacokinetic changes of drugs, several patterns were identified for 39 drugs. No relevant pharmacokinetic changes were identified for roughly a third of the drugs. Of the remaining drugs, levels were variable and partly unpredictable shortly after the surgery. In the long term, most of the drug levels remain altered, but in some cases they returned to preoperative values. Based on the changes and the efficacy-safety balance of each drug, clinicians may need to perform additional clinical monitoring for specific drugs, including measuring drug levels. This review provides suggestions for clinicians and pharmacists for specific time-dependent drug dosing advice.
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Affiliation(s)
- Cedric Lau
- Department of Clinical Pharmacy, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT, Dordrecht, the Netherlands.
- Department of Pharmacy and Pharmacology, Antoni Van Leeuwenhoek Hospital/The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
| | - Charlotte van Kesteren
- Department of Clinical Pharmacy, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT, Dordrecht, the Netherlands
| | - Robert Smeenk
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT, Dordrecht, the Netherlands
| | - Alwin Huitema
- Department of Pharmacy and Pharmacology, Antoni Van Leeuwenhoek Hospital/The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, Sint Antonius Hospital, Nieuwegein & Utrecht, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Wassenaarseweg 76, 2333 AL, Leiden, The Netherlands
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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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Trimboli P, Ossola N, Torre A, Mongelli F, Quarenghi M, Camponovo C, Lucchini B, Rotondi M, Ruinelli L, Garofalo F. The performance of levothyroxine tablet is impaired by bariatric surgery. Endocrine 2022; 80:563-569. [PMID: 36581744 PMCID: PMC10199827 DOI: 10.1007/s12020-022-03289-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/16/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim was to evaluate if bariatric surgery can affect the LT4 performance. The endpoints were the following: 1) difference between LT4 daily dose before and 1 year after surgery, 2) difference between LT4 dose per weight before and 1 year after surgery, 3) difference among LT4 preparations. METHODS The study period was between January 2018 and May 2022. Inclusion criteria were a) adults undergone bariatric surgery, b) with proven autoimmune hypothyroidism, c) on LT4 therapy before bariatric surgery, d) using any commercialized LT4 preparation. Excluded were patients a) proven to have or suspected for pre-surgical intestinal malabsorption, b) with other potential interfering factors on LT4 absorption; c) with heart, renal, and/or hepatic failure, d) with recent/current infection/inflammation, e) in pregnancy, f) with incomplete data about LT4 therapy. RESULTS According to the selection criteria, 40 patients were included. Both TSH and LT4 daily doses were not significantly different with respect to baseline values. On the contrary, the LT4 dose per weight was significantly increased, especially in RYGB patients. An increased LT4 dose per weight was observed with the reduction of weight. CONCLUSION One year after bariatric surgery 1) the daily dose of LT4 remains unchanged, and 2) despite the significant weight reduction, LT4 dose per weight increases. Most data are referred to LT4 tablet and the performance of LT4 caps should be further investigated.
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Affiliation(s)
- Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland.
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana (USI), Lugano, Switzerland.
| | - Nicola Ossola
- Servizio di Nutrizione Clinica e Dietetica, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Alessandro Torre
- Servizio di Chirurgia, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Francesco Mongelli
- Servizio di Chirurgia, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Massimo Quarenghi
- Servizio di Nutrizione Clinica e Dietetica, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Chiara Camponovo
- Servizio di Endocrinologia e Diabetologia, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
- Servizio di Nutrizione Clinica e Dietetica, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Barbara Lucchini
- Servizio di Endocrinologia e Diabetologia, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Mario Rotondi
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Lorenzo Ruinelli
- Team Data Science & Research, Area ICT, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Fabio Garofalo
- Servizio di Chirurgia, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
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Marabotto E, Ferone D, Sheijani AD, Vera L, Ziola S, Savarino E, Bodini G, Furnari M, Zentilin P, Savarino V, Giusti M, Navarro Rojas FA, Bagnasco M, Albertelli M, Giannini EG. Prevalence of Lactose Intolerance in Patients with Hashimoto Thyroiditis and Impact on LT4 Replacement Dose. Nutrients 2022; 14:nu14153017. [PMID: 35893871 PMCID: PMC9331471 DOI: 10.3390/nu14153017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: to determine lactose intolerance (LI) prevalence in women with Hashimoto’s thyroiditis (HT) and assess the impact of LI on LT4 replacement dose. Methods. consecutive patients with HT underwent Lactose Breath Test and clinical/laboratory data collection. Unrelated gastrointestinal disorders were carefully ruled out. Lactose-free diet and shift to lactose-free LT4 were proposed to patients with LI. Results: we enrolled 58 females (age range, 23−72 years) with diagnosis of HT. In total, 15 patients were euthyroid without treatment, and 43 (74%) euthyroid under LT4 (30 of them with a LT4 formulation containing lactose). Gastrointestinal symptoms were present in 84.5% of patients, with a greater prevalence in change in bowel habits in lactose-intolerant patients (p < 0.0001). The cumulative LT4 dose required did not differ in patients with or without LI. No significant difference in both TSH values and LT4 dose were observed in patients shifted to lactose-free LT4 and diet at 3 and 6 months compared to baseline. Conclusion: the prevalence of LI in patients with HT was 58.6%, not different from global prevalence of LI. In the absence of other gastrointestinal disorders, LI seems not to be a major cause of LT4 malabsorption and does not affect the LT4 required dose in HT patients.
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Affiliation(s)
- Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 16132 Genoa, Italy; (D.F.); (L.V.); (M.G.); (F.A.N.R.); (M.B.)
| | - Afscin Djahandideh Sheijani
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
| | - Lara Vera
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 16132 Genoa, Italy; (D.F.); (L.V.); (M.G.); (F.A.N.R.); (M.B.)
| | - Sebastiano Ziola
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy;
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
| | - Massimo Giusti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 16132 Genoa, Italy; (D.F.); (L.V.); (M.G.); (F.A.N.R.); (M.B.)
| | - Fabiola Andrea Navarro Rojas
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 16132 Genoa, Italy; (D.F.); (L.V.); (M.G.); (F.A.N.R.); (M.B.)
| | - Marcello Bagnasco
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 16132 Genoa, Italy; (D.F.); (L.V.); (M.G.); (F.A.N.R.); (M.B.)
| | - Manuela Albertelli
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 16132 Genoa, Italy; (D.F.); (L.V.); (M.G.); (F.A.N.R.); (M.B.)
- Correspondence:
| | - Edoardo G. Giannini
- Division of Gastroenterology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (G.B.); (M.F.); (P.Z.); (V.S.); (E.G.G.)
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Iqbal S, Wan WY, Mitchell NE. It’s Not Lupus This Time! A Case of Worsening Hypothyroidism in a Patient With Nephrotic Syndrome. Cureus 2022; 14:e25355. [PMID: 35761923 PMCID: PMC9233522 DOI: 10.7759/cureus.25355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
Nephrotic syndrome can result in worsening of existing hypothyroidism in patients requiring thyroid hormone supplementation. The urinary loss of thyroxine-binding globulin, as well as increased gut edema, likely lead to reduced absorption and retention of exogenous thyroid hormone. Here, we present a case of a patient with Hashimoto’s thyroiditis, previously well-controlled on levothyroxine, who developed symptomatic hypothyroidism as a result of newly diagnosed nephrotic syndrome, whose symptoms improved with transition to an alternative formulation of levothyroxine and treatment of her underlying nephrotic syndrome. It is important to consider nephrotic syndrome as a cause of worsening hypothyroidism in a patient on a fixed dose of levothyroxine given the potential morbidity associated with a missed diagnosis and often need for escalation of dosage. There is no standardized therapy for hypothyroidism exacerbated by nephrotic syndrome, but liquid or gel formulations of levothyroxine may be more effective in patients with absorption problems.
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Alalwan AA, Friedman J, Alfayez O, Hartzema A. Drug absorption in bariatric surgery patients: A narrative review. Health Sci Rep 2022; 5:e605. [PMID: 35509385 PMCID: PMC9059175 DOI: 10.1002/hsr2.605] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/14/2022] [Accepted: 03/19/2022] [Indexed: 12/17/2022] Open
Abstract
Background Despite the increase in the number of bariatric surgeries performed, little is known about the impact of the surgery on drug absorption. Unpredictability is assumed with drugs, given the anatomical changes after surgery. Objective To evaluate the impact of bariatric surgery on drug absorption based on the type of procedure performed. Methods We conducted a comprehensive literature review searching PubMed/Medline for published studies (from inception to December 2017) that evaluate the use of drugs and the assessment of drug absorption after bariatric surgery. Pharmacokinetic/pharmacodynamic studies, case reports, and observational studies were included in our review. Results We found 60 studies addressing drug use after bariatric surgery. Twenty‐eight studies reported a decrease in drug absorption after bariatric surgery while only four studies showed an increase in drug absorption. Unchanged absorption of drugs was seen in 23 studies after the surgery. Conclusion The available information shows variations in drug absorption after bariatric surgery. The unpredictability may result from factors related to the patient, drug, and/or type of surgery. Therefore, pharmacists' involvement and close monitoring of patients after bariatric surgery could be effective to avoid sub‐/supratherapeutic responses.
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Affiliation(s)
- Abdullah Abdulaziz Alalwan
- Department of Pharmacy Practice, College of Pharmacy Qassim University Qassim Saudi Arabia
- Pharmaceutical Outcomes and Policy, College of Pharmacy University of Florida Gainesville Florida USA
| | - Jeffrey Friedman
- Department of Surgery, UF Health Bariatric Surgery Center University of Florida Gainesville Florida USA
| | - Osamah Alfayez
- Department of Pharmacy Practice, College of Pharmacy Qassim University Qassim Saudi Arabia
| | - Abraham Hartzema
- Pharmaceutical Outcomes and Policy, College of Pharmacy University of Florida Gainesville Florida USA
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Abstract
Hypothyroidism is a common endocrinopathy, and levothyroxine is frequently prescribed. Despite the basic tenets of initiating and adjusting levothyroxine being agreed on, there are many nuances and complexities to consistently maintaining euthyroidism. Understanding the impact of patient weight and residual thyroid function on initial levothyroxine dosage and consideration of age, comorbidities, thyrotropin goal, life stage, and quality of life as levothyroxine is adjusted can be challenging and continually evolving. Because levothyroxine is a lifelong medication, it is important to avoid risks from periods of overtreatment or undertreatment. For the subset of patients not restored to baseline health with levothyroxine, causes arising from all aspects of the patient's life (coexistent medical conditions, stressors, lifestyle, psychosocial factors) should be broadly considered. If such factors do not appear to be contributing, and biochemical euthyroidism has been successfully maintained, there may be benefit to a trial of combination therapy with levothyroxine and liothyronine. This is not supported by the majority of randomized clinical trials, but may be supported by other studies providing lower-quality evidence and by animal studies. Given this discrepancy, it is important that any trial of combination therapy be continued only as long as a patient benefit is being enjoyed. Monitoring for adverse effects, particularly in older or frail individuals, is necessary and combination therapy should not be used during pregnancy. A sustained-release liothyronine preparation has completed phase 1 testing and may soon be available for better designed and powered studies assessing whether combination therapy provides superior therapy for hypothyroidism.
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10
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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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11
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Ferrari SM, Ragusa F, Elia G, Paparo SR, Mazzi V, Baldini E, Benvenga S, Antonelli A, Fallahi P. Precision Medicine in Autoimmune Thyroiditis and Hypothyroidism. Front Pharmacol 2021; 12:750380. [PMID: 34867359 PMCID: PMC8635786 DOI: 10.3389/fphar.2021.750380] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
Autoimmune thyroid diseases (AITD) are T-cell-mediated organ specific autoimmune disorders, deriving from an altered response of the immune system that leads to the immune attack to the thyroid. Hashimoto’s thyroiditis (HT) and Graves’ disease (GD) are the two principal AITD clinical presentations. Hypothyroidism and thyrotoxicosis are, respectively, the clinical hallmarks of HT and GD. Patients with autoimmune thyroiditis are treated daily with synthetic L-thyroxine (L-T4) at the dose of 1.5–1.7 μg/kg. Various L-T4 formulations are commercially available (tablet, liquid solution, or soft gel capsule). L-T4 in tablets is generally prescribed to treat hypothyroidism, whereas the liquid formulation, or soft gel capsules, can be administered in hypothyroid patients in case of malabsorption or in patients in therapy with drugs interfering with L-T4 absorption. Furthermore, myoinositol has a crucial role in thyroid autoimmunity and function. Clinical studies reported a significant decline in TSH and antithyroid autoantibodies levels after treatment with myoinositol + selenium in patients with subclinical hypothyroidism and autoimmune thyroiditis. Moreover, thyroidectomy can be rarely recommended in patients with autoimmune thyroiditis, with cosmetic reasons for a goiter, or with important signs or symptoms of local compression, or nodular disease with a “suspicious” cytology for malignancy. Furthermore, a recent randomized trial suggested that total thyroidectomy can improve quality of life and fatigue, while medical therapy did not. In this review, we overview currently available evidence in personalized medicine in patients with autoimmune thyroiditis and hypothyroidism. Further research is needed in larger population to investigate the effect of these new treatments on quality of life.
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Affiliation(s)
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giusy Elia
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | | | - Valeria Mazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Enke Baldini
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women’s Endocrine Health, Azienda Ospedaliera Universitaria Policlinico “G. Martino”, I-98125, Messina, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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12
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Chen K, Lin Y, Luo P, Yang N, Yang G, Zhu L, Pei Q. Effect of laparoscopic sleeve gastrectomy on drug pharmacokinetics. Expert Rev Clin Pharmacol 2021; 14:1481-1495. [PMID: 34694169 DOI: 10.1080/17512433.2021.1997585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Given its feasibility and efficacy, laparoscopic sleeve gastrectomy (LSG) has become a widely accepted bariatric surgery for patients with clinically diagnosed severe obesity. LSG induces anatomical changes and subsequent weight loss which may affect drug pharmacokinetics (PK) and consequently impact dosing regimens. This review aims to examine the effect of LSG on drug PK and identify relevant gastrointestinal physiological alterations. AREAS COVERED PubMed, Embase, Scopus, and the Cochrane Library were searched for articles related to drug PK and LSG from inception to July 2021. Moreover, literature concerning postoperative physiological conditions in the gastrointestinal tract, such as gastric pH, gastric emptying, and small bowel transit time, etc., which may affect the PK profile of drug products was also reviewed. EXPERT OPINION Although LSG is classified as having restrictive property without malabsorptive bypass, postoperative changes in gastrointestinal physiology and subsequent weight loss may also lead to increased, decreased or unaltered drug exposure levels. General monitoring on drug efficacy or safety using biomarkers is proposed. In addition, therapeutic drug monitoring for those drugs when it is applicable and available is recommended to ensure efficient drug dosing and avoid adverse effects. Further research into many individual drugs are warranted.
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Affiliation(s)
- Kaifeng Chen
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China.,Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yaqi Lin
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China.,Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ping Luo
- Department of General Surgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Nan Yang
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guoping Yang
- Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Liyong Zhu
- Department of General Surgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qi Pei
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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13
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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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14
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Kingma JS, Burgers DMT, Monpellier VM, Wiezer MJ, Blussé van Oud-Alblas HJ, Vaughns JD, Sherwin CMT, Knibbe CAJ. Oral drug dosing following bariatric surgery: General concepts and specific dosing advice. Br J Clin Pharmacol 2021; 87:4560-4576. [PMID: 33990981 PMCID: PMC9291886 DOI: 10.1111/bcp.14913] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022] Open
Abstract
Bariatric or weight‐loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended‐release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advice for oral drug therapy after bariatric surgery, implying that a risk assessment on a case‐by‐case basis is required for each drug.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Valerie M Monpellier
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Huis ter Heide, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Janelle D Vaughns
- Department of Anesthesia and Pain Medicine, Children's National Health System, Washington, DC, USA.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Division of Systems Biomedicine & Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
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15
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Steenackers N, Vanuytsel T, Augustijns P, Tack J, Mertens A, Lannoo M, Van der Schueren B, Matthys C. Adaptations in gastrointestinal physiology after sleeve gastrectomy and Roux-en-Y gastric bypass. Lancet Gastroenterol Hepatol 2021; 6:225-237. [PMID: 33581761 DOI: 10.1016/s2468-1253(20)30302-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/19/2023]
Abstract
Linked to the growing obesity epidemic, demand for bariatric and metabolic surgery has increased, the most common procedures being sleeve gastrectomy and Roux-en-Y gastric bypass. Originally, bariatric procedures were described as purely restrictive, malabsorptive, or combined restrictive-malabsorptive procedures limiting food intake, nutrient absorption, or both. Nowadays, anatomical alterations are known to affect gastrointestinal physiology, which in turn affects the digestion and absorption of nutrients and drugs. Therefore, understanding gastrointestinal physiology is crucial to prevent postoperative nutritional deficiencies and to optimise postoperative drug therapy. Preclinical and clinical research indicates that sleeve gastrectomy accelerates liquid and solid gastric emptying and small intestinal transit, and increases bile acid serum levels, whereas its effects on gastrointestinal acidity, gastric and pancreatic secretions, surface area, and colonic transit remain largely unknown. Roux-en-Y gastric bypass diminishes gastric acid secretion, accelerates liquid gastric emptying, and increases bile acid serum levels, but its effects on intestinal pH, solid gastric emptying, intestinal transit time, gastric enzyme secretions, and surface area remain largely unknown. In this Review, we summarise current knowledge of the effects of these two procedures on gastrointestinal physiology and assess the knowledge gaps.
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Affiliation(s)
- Nele Steenackers
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Department of Chronic Diseases and Metabolism, and Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Ann Mertens
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Matthias Lannoo
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
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16
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Porat D, Vaynshtein J, Gibori R, Avramoff O, Shaked G, Dukhno O, Czeiger D, Sebbag G, Dahan A. Stomach pH before vs. after different bariatric surgery procedures: Clinical implications for drug delivery. Eur J Pharm Biopharm 2021; 160:152-157. [DOI: 10.1016/j.ejpb.2021.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 01/19/2023]
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17
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Antonelli A, Elia G, Ragusa F, Paparo SR, Cavallini G, Benvenga S, Ferrari SM, Fallahi P. The Stability of TSH, and Thyroid Hormones, in Patients Treated With Tablet, or Liquid Levo-Thyroxine. Front Endocrinol (Lausanne) 2021; 12:633587. [PMID: 33790863 PMCID: PMC8006411 DOI: 10.3389/fendo.2021.633587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/29/2021] [Indexed: 01/01/2023] Open
Abstract
Approximately, 5% of the population is affected by hypothyroidism, mainly women and persons aged more than 60 years. After the diagnosis of hypothyroidism the usual therapy is tablet levothyroxine (L-T4), with a monitoring of the thyroid-stimulating hormone (TSH) level in primary hypothyroidism every 6-8 weeks and L-T4 is adjusted as necessary to reach an euthyroid state. Once TSH is stabilized in the normal range, it is recommended to conduct annual testing in the treated subjects to warrant suitable replacement. More recently advances regarding L-T4 treatment are the introduction of new oral formulations: the liquid solution, and soft gel capsule. The soft gel capsule permits a quick dissolution in the acid gastric pH. The liquid preparation does not require an acid gastric environment. Many pharmacokinetic studies demonstrated a more rapid absorption for the liquid L-T4, or capsule, than with tablet. Many studies have shown that the liquid, or capsule, formulations can overcome the interaction with foods, drugs or malabsorptive conditions, that are able to impair the tablet L-T4 absorption. Lately studies have suggested that liquid L-T4 can permit to maintain more efficiently normal TSH levels in hypothyroid patients in the long-term follow-up, than tablet L-T4, both in patients with malabsorptive states, and in those without malabsorption. Further large, prospective, longitudinal studies are needed to evaluate the stability of TSH, in hypothyroid patients treated with different L-T4 formulations.
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Affiliation(s)
- Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Gabriella Cavallini
- Interdepartmental Research Centre on Biology and Pathology of Aging, University of Pisa, Pisa, Italy
| | - Salvatore Benvenga
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program on Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, A.O.U. Policlinico Gaetano Martino, Messina, Italy
| | | | - Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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18
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Fallahi P, Ferrari SM, Elia G, Ragusa F, Paparo SR, Antonelli A. L-T4 Therapy in Enteric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2021; 12:626371. [PMID: 33708175 PMCID: PMC7940821 DOI: 10.3389/fendo.2021.626371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
Levothyroxine (L-T4) absorption can be impaired by various causes: a) L-T4 ingestion during breakfast, or with food; b) conditions of reduced gastric acidity; c) intestinal procedures and diseases such as bariatric surgery, lactose intolerance (LI), celiac disease (CD), inflammatory bowel disease; d) drugs that alter L-T4 absorption, increasing the gastric pH, or preventing the dissolution of tablets. The development of new oral formulations, i.e. the liquid preparation and the soft gel capsule, represents the most recent advance regarding L-T4 therapy. Treating hypothyroidism with L-T4 tablets can lead to an improper control of thyroid-stimulating hormone (TSH) in ~10%-15% of patients. The improperly elevated TSH is usually managed by increasing the L-T4 daily dose, and revaluating TSH upon 2-6 months. The increase of the L-T4 dosage may cause iatrogenic hyperthyroidism, especially when the underlying disorders are cured. Liquid L-T4 can be administered in patients unable to swallow capsules or tablets, and this is one of its major benefits. Liquid L-T4 can: 1- overcome food and beverages interference; 2- bypass the malabsorption associated with an increased gastric pH; 3- circumvent the issue of malabsorption in patients who underwent bariatric surgery; 4-maintain TSH values under control better than L-T4 tablets in hypothyroid patients with typical or atypical CD, or in patients with LI. Few clinical studies evaluated soft gel L-T4 with encouraging findings in patients with gastric- or coffee-related malabsorption, or hypothyroid patients without malabsorption. Additional research is necessary to investigate liquid L-T4, or soft gel capsule, in other conditions of altered L-T4 absorption.
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Affiliation(s)
- Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- *Correspondence: Poupak Fallahi,
| | | | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
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19
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Liquid Levothyroxine Formulation Taken during Lunch in Italy: A Case Report and Review of the Literature. Case Rep Endocrinol 2020; 2020:8858887. [PMID: 32963845 PMCID: PMC7492953 DOI: 10.1155/2020/8858887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 12/27/2022] Open
Abstract
Levothyroxine (L-T4) is among the most widely prescribed medications in the world, and it is considered by the World Health Organization an essential medicine for basic health care. Replacement therapy has always been considered straightforward although different factors may interfere with intestinal absorption of L-T4, including food, dietary fibre, coffee, drugs, and gastrointestinal diseases. For these reasons, current guidelines recommend that L-T4 should be taken in a fasting state because its absorption is maximised when it is taken on an empty stomach, reflecting the importance of gastric acidity in the absorption process. In addition to sodium L-T4 in tablet form, various formulations (soft-gel capsules and liquid solutions) have become available for clinical use in the last years promising improved absorption. We described a 31-year-old Italian man who took liquid levothyroxine formulation during lunch. He was under replacement therapy with liquid levothyroxine 75 mcg daily for hypothyroidism due to Hashimoto thyroiditis for three years. During confirmation of the L-T4 replacement therapy, the patient stated that he was going to continue to “take liquid levothyroxine during (his) lunch every day.” We recommended taking the medication correctly in the morning at least thirty minutes before breakfast and repeating TSH, fT4, and fT3 after three months. The thyroid hormonal profiles taken after 3 and 6 months were comparable to those when the patient was taking the medication during lunch. In conclusion, liquid levothyroxine formulation should be preferred in case of malabsorption or potential malabsorption. Liquid formulation should be preferred due to the possibility of taking it during breakfast, which significantly improves the compliance of patients. Further studies are needed to evaluate the possibility of taking liquid L-T4 during lunch.
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20
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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21
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 233] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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22
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Fain K, Rojas AP, Peiris AN. Hypothyroidism following gastric sleeve surgery resolved by ingesting crushed thyroxine tablets. Proc AMIA Symp 2019; 33:38-39. [PMID: 32063762 DOI: 10.1080/08998280.2019.1669412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022] Open
Abstract
Bariatric procedures for weight loss have increased in the past few decades. Levothyroxine malabsorption has been reported following gastric bypass; however, few studies have addressed this issue after gastric sleeve procedures. Levothyroxine dosing is usually weight based and administered at approximately 1.6 μg/kg body weight. Absorption occurs mainly in the jejunum and upper ileum, which can be altered by gastric pH, other drugs, food, and other factors. We present a 35-year-old woman with longstanding iatrogenic hypothyroidism treated with thyroxine, whose thyroid-stimulating hormone level rose following a gastric sleeve procedure despite taking levothyroxine daily.
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Affiliation(s)
- Kristen Fain
- School of Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | - Alexsandra P Rojas
- School of Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | - Alan N Peiris
- Clinical Research Institute and Department of Internal Medicine, Texas Tech University Health Sciences CenterLubbockTexas
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23
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Virili C, Trimboli P, Centanni M. Novel thyroxine formulations: a further step toward precision medicine. Endocrine 2019; 66:87-94. [PMID: 31617168 DOI: 10.1007/s12020-019-02049-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/05/2019] [Indexed: 02/06/2023]
Abstract
Levothyroxine (T4) is a critical-dose drug, because little variations in the blood concentration may cause treatment failure as well as iatrogenic thyrotoxicosis. Despite the dose response of this drug being more carefully titrated nowadays, several papers still report that a significant fraction of patients treated with levothyroxine demonstrate a TSH which is not on target. Moreover, some widespread gastrointestinal disorders as well as interfering drugs and foods may cause the "refractoriness" of a significant number of patients to an expected dose of thyroxine. The increasing awareness of the mechanisms interfering with the oral thyroid hormone bioavailability and the body of evidence regarding the complexity of treatment in certain classes of patients prompted pharmaceutical research to identify new hormonal formulations to optimize the performance of this drug. In this brief review, the progression of the scientific knowledge of novel T4 formulations use has been analyzed.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Thyroid Center and Nuclear Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.
- Endocrinology Unit, AUSL Latina, Latina, Italy.
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24
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Changes in Thyroid Replacement Therapy after Bariatric Surgery: Differences between Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy. Obes Surg 2019; 29:2593-2599. [DOI: 10.1007/s11695-019-03890-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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25
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Virili C, Antonelli A, Santaguida MG, Benvenga S, Centanni M. Gastrointestinal Malabsorption of Thyroxine. Endocr Rev 2019; 40:118-136. [PMID: 30476027 DOI: 10.1210/er.2018-00168] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/12/2018] [Indexed: 02/07/2023]
Abstract
Levothyroxine, a largely prescribed drug with a narrow therapeutic index, is often a lifelong treatment. The therapeutic efficacy of T4 may be marred by behavioral, pharmacologic, and pathologic issues acting as interfering factors. Despite a continuous search for an optimal T4 treatment, a significant number of patients fail to show a complete chemical and/or clinical response to this reference dose of T4. Gastrointestinal malabsorption of oral T4 represents an emerging cause of refractory hypothyroidism and may be more frequent than previously reputed. In this review, we examine the pharmacologic features of T4 preparations and their linkage with the intestinal absorption of the hormone. We have stressed the major biochemical and pharmacologic characteristics of T4 and its interaction with the putative transporter at the intestinal level. We have examined the interfering role of nutrients, foods, and drugs on T4 absorption at the gastric and intestinal levels. The impact of gastrointestinal disorders on T4 treatment efficacy has been also analyzed, in keeping with the site of action and the interfering mechanisms. Based on the evidence obtained from the literature, we also propose a schematic diagnostic workup for the most frequent and often hidden gastrointestinal diseases impairing T4 absorption.
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Affiliation(s)
- Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Interdepartmental Program of Molecular and Clinical Endocrinology, and Women's Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
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26
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Azran C, Porat D, Fine-Shamir N, Hanhan N, Dahan A. Oral levothyroxine therapy postbariatric surgery: Biopharmaceutical aspects and clinical effects. Surg Obes Relat Dis 2019; 15:333-341. [PMID: 30704913 DOI: 10.1016/j.soard.2019.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/13/2018] [Accepted: 01/04/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bariatric surgery can lead to changes in the oral absorption of many drugs. Levothyroxine is a narrow therapeutic drug for hypothyroidism, a common condition among patients with obesity. OBJECTIVE The purpose of this work was to provide a mechanistic overview of levothyroxine absorption, and to thoroughly analyze the expected effects of bariatric surgery on oral levothyroxine therapy. METHODS We performed a systematic review of the relevant literature reporting the effects of bariatric surgery on oral levothyroxine absorption and postoperative thyroid function. A PubMed search for relevant keywords resulted in a total of 14 articles reporting levothyroxine status before versus after bariatric surgery. RESULTS Different mechanisms may support opposing trends as to levothyroxine dose adjustment postsurgery. On the one hand, based on impaired drug solubility/dissolution attributable to higher gastric pH as well as reduced gastric volume, compromised levothyroxine absorption is expected. On the other hand, the great weight loss, and altered set-point of thyroid hormone homeostasis with decreased thyroid-stimulating hormone after the surgery, may result in a decreased dose requirement. CONCLUSIONS For patients after bariatric surgery, close monitoring of both the clinical presentation and plasma thyroid-stimulating hormone and T4 levels is strongly advised. Better understanding and awareness of the science presented in this article may help to avoid preventable complications and provide optimal patient care.
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Affiliation(s)
| | - Daniel Porat
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Noa Fine-Shamir
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nirvana Hanhan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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27
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Santamaría MM, Villafranca JJA, Abilés J, López AF, Rodas LV, Goitia BT, Navarro PU. Systematic review of drug bioavailability following gastrointestinal surgery. Eur J Clin Pharmacol 2018; 74:1531-1545. [PMID: 30136101 DOI: 10.1007/s00228-018-2539-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 08/07/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE Inter- and intraindividual pharmacokinetics variability in humans affects the way in which drugs act on the body. Gastrointestinal surgery has an impact on this variability and significantly alters the kinetics of drugs in post-surgical patients. The way in which pharmacokinetic profiles are modified depends on the type of operative procedure performed. The extent to which the absorption of different groups of drugs is affected varies according to the site and length of intestinal resections. METHODS A literature search was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Three databases were searched: MEDLINE, Embase, and the Cochrane Library. For each drug, potential changes in absorption were described, including recommendations extracted from the results of the studies and collected according to authors' criteria as practical conclusions, and grades of recommendation were determined by levels of evidence using the Oxford Centre for Evidence-Based Medicine scale. RESULTS Sixty-eight articles were collected during the selection process after the bibliographic search. The main outcomes for 60 drugs from the various studies were classified according to each type of surgery. CONCLUSIONS Modifications in the digestive tract secondary to gastrointestinal surgery may compromise the bioavailability of drugs. Decreased absorption surface, gastric emptying speed, and gastric pH alteration are factors to be taken into account in the management of pharmacological treatment after surgery. Evidence supported by data in clinical practice is scarce, but after studying the pharmacokinetic profile of some molecules, it is possible to offer recommendations for its adaptation to the patient's clinical situation.
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Affiliation(s)
- Manuela Moreno Santamaría
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain.
| | | | - Jimena Abilés
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain
| | - Alberto Fernández López
- Surgery Department, Quirónsalud Hospital, Edificio Arttysur, Avda. de los Empresarios, s/n, 11379, Palmones, Cádiz, Spain
| | - Lucia Visiedo Rodas
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain
| | - Begoña Tortajada Goitia
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain
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28
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Laurent I, Tang S, Astère M, Wang KR, Deng S, Xiao L, Li QF. Liquid L-thyroxine versus tablet L-thyroxine in patients on L- thyroxine replacement or suppressive therapy: a meta-analysis. Endocrine 2018; 61:28-35. [PMID: 29572710 DOI: 10.1007/s12020-018-1574-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/04/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To compare the effectiveness of liquid L-T4 (L-thyroxine) and tablet L-T4 in patients on L-T4 replacement or suppressive therapy. METHODS The Cochrane Library, PubMed, Embase, and Web of Science databases were searched to identify relevant articles. All prospective or randomized controlled studies (RCTs) comparing liquid L-T4 and tablet L-T4 in patients on L-T4 replacement or suppressive therapy were included in the analysis. RESULTS Overall, the initial search of the four databases identified 1278 published studies; of these, eight studies were ultimately included in the meta-analysis. TSH (thyroid stimulating hormone) levels were significantly suppressed in patients on liquid L-T4 compared with those on tablet L-T4, in patients on L-T4 suppressive therapy with L-T4 malabsorption (Mean Difference (MD) = -2.26, 95% Confidence Interval (CI): -3.59, -0.93; P = 0.0009)). However, liquid L-T4 and tablet L-T4 did not show a statistically significant difference in patients on L-T4 suppressive therapy without malabsorption (MD = 0.08, 95% CI: -0.31, 0.47; P = 0.69). TSH levels were significantly normalized in patients on liquid L-T4 compared with those on tablet L-T4, in Patients on L-T4 replacement therapy with L-T4 malabsorption (MD = -3.20, 95% CI: -5.08, -1.32; P = 0.0009). However, liquid L-T4 and tablet L-T4 did not show a statistically significant difference in patients on L-T4 replacement therapy without malabsorption (MD = 0.91, 95% CI: -0.03, 1.86; P = 0.06). CONCLUSION Liquid L-T4 is more efficient than tablet L-T4 in patients on L-T4 replacement or suppressive therapy with malabsorption. No significant differences were observed in patients without malabsorption. Further studies should be conducted to verify these findings.
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Affiliation(s)
- Irakoze Laurent
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Kabezi Hospital, Ministry of Public Health and Fighting AIDS, Kabezi, Burundi
| | - Siying Tang
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Manirakiza Astère
- Department of Oncology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kan Ran Wang
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuhua Deng
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ling Xiao
- Department of Nursing, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Fu Li
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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29
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Guglielmi V, Bellia A, Bianchini E, Medea G, Cricelli I, Sbraccia P, Lauro D, Cricelli C, Lapi F. Drug interactions in users of tablet vs. oral liquid levothyroxine formulations: a real-world evidence study in primary care. Endocrine 2018; 59:585-592. [PMID: 28905202 DOI: 10.1007/s12020-017-1412-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/28/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Several medications may interact with levothyroxine (LT4) intestinal absorption or metabolism, thus reducing its bioavailability. We investigated the variability of thyroid stimulating hormone (TSH) levels and prescribed daily dosages (PDDs) of LT4 before and during potential drug-drug interactions (DDIs) in users of tablets vs. oral liquid LT4 formulations. METHODS By using the Italian general practice Health Search Database (HSD), we retrospectively selected adult patients with at least one LT4 prescription from 2012 to 2015 and at least 1 year of clinical history recorded. The incident prescription of interacting medications (e.g., proton pump inhibitors, calcium or iron salts) was the index date. Analysis was carried out using a self-controlled study design. RESULTS Overall, 3965 users of LT4 formed the study cohort (84.1% women, mean age 56 ± 16.5 years). TSH variability on the entry date was greater among liquid LT4 users than in those prescribed with tablets as shown by the difference between 75th and 25th centile, which were 3.01 and 3.8, respectively. The incidence rate ratio (IRR) for TSH variability did not differ between groups, before and during exposure to DDIs. In contrast, PDDs less likely increased during the exposure to DDI with oral liquid LT4 compared with tablets (IRR = 0.84; 95% CI: 0.77-0.92), especially in patients with post-surgical hypothyroidism (IRR = 0.75; 95% CI: 0.64-0.85). CONCLUSIONS In clinical practice, the use of oral liquid LT4 is not associated with increased PDDs, compared with tablets formulation, during exposure to DDIs. These results support the need for individualizing LT4 formulation to prescribe, especially in patients with various comorbidities and complex therapeutic regimens.
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Affiliation(s)
- Valeria Guglielmi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Elisa Bianchini
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Gerardo Medea
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Iacopo Cricelli
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Paolo Sbraccia
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy.
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30
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Benvenga S, Capodicasa G, Perelli S, Ferrari SM, Fallahi P, Antonelli A. Increased Requirement of Replacement Doses of Levothyroxine Caused by Liver Cirrhosis. Front Endocrinol (Lausanne) 2018; 9:150. [PMID: 29720960 PMCID: PMC5915540 DOI: 10.3389/fendo.2018.00150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/20/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Since hypothyroidism is a fairly common dysfunction, levothyroxine (L-T4) is one of the most prescribed medications. Approximately 70% of the administered L-T4 dose is absorbed. The absorption process takes place in the small intestine. Some disorders of the digestive system and some medicines, supplements, and drinks cause L-T4 malabsorption, resulting in failure of serum TSH to be normal. Only rarely liver cirrhosis is mentioned as causing L-T4 malabsorption. CASE REPORT In this study, we report increased requirement of daily doses of l-thyroxine in two patients with the atrophic variant of Hashimoto's thyroiditis and liver cirrhosis. In one patient, this increased requirement could have been contributed by the increased serum levels of the estrogen-dependent thyroxine-binding globulin (TBG), which is the major plasma carrier of thyroid hormones. In the other patient, we switched from tablet L-T4 to liquid L-T4 at the same daily dose. Normalization of TSH levels was achieved, but TSH increased again when she returned to tablet L-T4. CONCLUSION Liver cirrhosis can cause increased L-T4 requirements. In addition to impaired bile secretion, the mechanism could be increased serum TBG. A similar increased requirement of L-T4 is observed in other situations characterized by elevation of serum TBG. Because of better intestinal absorption, L-T4 oral liquid formulation is able to circumvent the increased need of L-T4 in these patients.
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Affiliation(s)
- Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Giovanni Capodicasa
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
- *Correspondence: Giovanni Capodicasa,
| | - Sarah Perelli
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
| | | | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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31
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Virili C, Giovanella L, Fallahi P, Antonelli A, Santaguida MG, Centanni M, Trimboli P. Levothyroxine Therapy: Changes of TSH Levels by Switching Patients from Tablet to Liquid Formulation. A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2018; 9:10. [PMID: 29434573 PMCID: PMC5790785 DOI: 10.3389/fendo.2018.00010] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/09/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In the last years, levothyroxine (LT4) has been commercialized also in liquid formulation, which is less sensitive to the factors known to reduce the absorption of tablet LT4. To date, there is no robust information that liquid LT4 can improve pharmacologic thyroid homeostasis of patients with reduced efficacy of tablet LT4. This analysis aimed at achieving solid evidence that switching thyroxine treatment from tablet to liquid preparation improves patients' TSH levels. METHODS The search was performed in PubMed/MEDLINE and Scopus database based on the terms "thyroid," "levothyroxine," and "liquid," and updated until September 25, 2017. Studies were included only if they described patients with suboptimal TSH on tablet LT4, subsequently switched to liquid LT4. RESULTS The literature search retrieved 462 articles and six were finally included. The pooled mean difference of TSH value between tablet and liquid LT4 was 4.23 mIU/L (95% CI from 3.69 to 4.77). Mild heterogeneity was found (I2 60%). Overall mean difference of TSH was significant (p < 0.0001). CONCLUSION The present meta-analysis showed that patients with suboptimal TSH on tablet LT4 can have a significantly improved TSH by switching to liquid LT4 formulation at unchanged dose.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- *Correspondence: Camilla Virili,
| | - Luca Giovanella
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Santaguida
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Abstract
BACKGROUND Based on the mechanisms of drug absorption, increased levothyroxine requirements are expected after bariatric surgery. However, there are conflicting data on this topic. This review evaluates the effects of bariatric surgery on levothyroxine dosing. METHODS Data were obtained from PubMed, Scopus, and review of published bibliographies. RESULTS Six of 10 studies demonstrated decreased postoperative requirements. Most demonstrated correlations between weight loss and dose. Only 3 case reports and 1 case series demonstrated increased levothyroxine requirements, attributed to malabsorption. CONCLUSIONS The loss of both fat and lean body mass may counteract malabsorptive effects from surgery, resulting in decreased postoperative levothyroxine requirements. In addition, the reversal of impaired levothyroxine pharmacokinetics and an altered set point of thyroid hormone homeostasis may also contribute to postoperative levothyroxine reductions.
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Affiliation(s)
- Silpa Gadiraju
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA.
| | - Clare J Lee
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
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Hachon L, Declèves X, Faucher P, Carette C, Lloret-Linares C. RYGB and Drug Disposition: How to Do Better? Analysis of Pharmacokinetic Studies and Recommendations for Clinical Practice. Obes Surg 2017; 27:1076-1090. [PMID: 28124236 DOI: 10.1007/s11695-016-2535-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An important issue in the follow-up of patients with bariatric surgery remains to determine whether their therapeutic management should be different after surgery. In this article, we first reviewed all pharmacokinetic studies involving at least four subjects who underwent the Roux-en-Y gastric bypass (RYGB) bariatric surgery. Twenty-five publications were selected and, overall, 25 drugs were studied. Drug solubility and permeability parameters for each drug were defined using different parameters or classifications. Increased rates of oral drug absorption were predominantly observed. Conversely, drug exposure differed from one drug to another. Considering the galenic formulation and the Biopharmaceutics Classification System (BCS) class may help the prediction of oral drug exposure outcome after RYGB. We propose a strategy aiming to guide prescription and drug monitoring in patients with RYGB. But further research is clearly needed due to the unique characteristics of the bariatric population. Priority should be given to drugs that do not have clinical or biological surrogates for dose adaptation.
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Affiliation(s)
- Lorry Hachon
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Therapeutic Research Unit, Department of Internal Medicine, Paris, F-75010, France.,Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France
| | - Xavier Declèves
- Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France.,Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Pharmacokinetics and Pharmacochemistry Unit, Paris, F-75014, France
| | - Pauline Faucher
- Nutrition Department, Assistance Publique-Hôpitaux de Paris, Hôpital La Pitié Salpêtrière, Paris, France
| | - Claire Carette
- Nutrition Department, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Célia Lloret-Linares
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Therapeutic Research Unit, Department of Internal Medicine, Paris, F-75010, France. .,Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France.
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Ferrara R, Ientile V, Arcoraci V, Ferrajolo C, Piccinni C, Fontana A, Benvenga S, Trifirò G. Treatment pattern and frequency of serum TSH measurement in users of different levothyroxine formulations: a population-based study during the years 2009-2015. Endocrine 2017; 58:143-152. [PMID: 28155170 DOI: 10.1007/s12020-017-1242-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/17/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several conditions can modify the intestinal absorption of levothyroxine tablets, with potential consequences on their therapeutic effect. Pre-dosed ampoules and oral drops have been recently made available to overcome this limitation. AIMS To describe the pattern of use of different formulations of levothyroxine in a general population of Southern Italy and to perform an exploratory analysis investigating the effect of switching from levothyroxine tablets to oral liquid formulations. METHODS Data were extracted from the Caserta Local Health Unit database. All patients receiving at least one levothyroxine prescription during the years 2009-2015 were identified. 1-year incidence of use of formulation-specific levothyroxine was calculated. Switchers between levothyroxine tablets and oral liquid formulations were identified and the frequency of thyroid-stimulating hormone measurement within 2 years prior and after the switch date was explored. RESULTS Overall, 56,354 levothyroxine users were included in the study. Of these, 55,147 patients received at least one prescription for tablets (97.9%), 1867 pre-dosed ampoules (3.3%) and 1550 oral drops (2.8%). The proportion of levothyroxine users receiving oral liquid formulations slightly increased over time. Patients switching from tablets to oral liquid formulations showed a statistically significant reduction in the number of thyroid-stimulating hormone measurements after switching from tablets, especially in presence of drugs interacting with levothyroxine potentially altering its absorption. CONCLUSIONS Use of levothyroxine oral liquid formulations is increasing over time even though their use is still limited in a general population of Southern Italy. Our exploratory analysis showed that the frequency of thyroid-stimulating hormone measurement was reduced in patients switching from levothyroxine tablet to new formulations.
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Affiliation(s)
- Rosarita Ferrara
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
| | - Valentina Ientile
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
| | - Vincenzo Arcoraci
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmen Ferrajolo
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Carlo Piccinni
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gianluca Trifirò
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy.
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy.
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Ribichini D, Fiorini G, Repaci A, Castelli V, Gatta L, Vaira D, Pasquali R. Tablet and oral liquid L-thyroxine formulation in the treatment of naïve hypothyroid patients with Helicobacter pylori infection. Endocrine 2017; 57:394-401. [PMID: 27848196 DOI: 10.1007/s12020-016-1167-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/01/2016] [Indexed: 12/20/2022]
Abstract
To compare the clinical efficacy of tablet and oral liquid L-thyroxine (LT4) formulation in naïve hypothyroid subjects with Helicobacter pylori infection. Forty-seven adult naïve hypothyroid subjects with dyspeptic symptoms were investigated with upper endoscopy and divided into: 28 patients with Helicobacter pylori infection (Group A); 15 patients without gastric alterations (group B); 4 patients with autoimmune gastritis were excluded from the study. Subjects were randomly treated with a same dose of LT4 tablet (TAB) or oral liquid formulation (SOL), for 9 months on group A and 6 months on group B. Helicobacter pylori infection was eradicated after 3 months of LT4 treatment. On group A, after 3 months (before Helicobacter pylori eradication), subjects treated with SOL showed a greater thyroid-stimulating hormone reduction (ΔTSH3-0: TAB = -4.1 ± 4.6 mU/L; SOL = -7.7 ± 2.5 mU/L; p = 0.029) and a greater homogeneity in the thyroid-stimulating hormone values (TSH3mo: TAB = 5.7 ± 4.9 mU/L; SOL = 4.1 ± 2.0 mU/L; p = 0.025), compared to LT4 tablet. At 9 months (after 6 months of Helicobacter pylori eradication) mean thyroid-stimulating hormone values were lower in subjects treated with LT4 tablet (TSH9mo: TAB = 1.8 ± 1.2 mU/L; SOL = 3.2 ± 1.7 mU/L; p = 0.006). On group B no difference were observed, at each time point, in the mean thyroid-stimulating hormone values and thyroid-stimulating hormone variations between two LT4 formulations. LT4 liquid formulation may produce a better clinical response compared to the tablet formulation in hypothyroid subjects with Helicobacter pylori infection.
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Affiliation(s)
- Danilo Ribichini
- Division of Endocrinology (DE), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy.
| | - Giulia Fiorini
- Division of Internal Medicine (IM), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Andrea Repaci
- Division of Endocrinology (DE), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Valentina Castelli
- Division of Internal Medicine (IM), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Luigi Gatta
- Gastroenterogy & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Dino Vaira
- Division of Internal Medicine (IM), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Renato Pasquali
- Division of Endocrinology (DE), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy.
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TSH Normalization in Bariatric Surgery Patients After the Switch from L-Thyroxine in Tablet to an Oral Liquid Formulation. Obes Surg 2017; 27:78-82. [PMID: 27272506 DOI: 10.1007/s11695-016-2247-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Drug malabsorption is one of the potential troubles after bariatric surgery. Evidence for diminished levothyroxine (L-T4) absorption has been reported in patients after bariatric surgery. METHODS This study reports 17 cases of hypothyroid patients [who were well replaced with thyroxine tablets (for >1 year) to euthyroid thyrotropin (TSH) levels before surgery (13 Roux-en-Y gastric bypasses (RYGB); 4 biliary pancreatic diversions (BPD))]. From 3 to 8 months after surgery, these patients had elevated TSH levels. Patients were then switched from oral tablets to a liquid L-T4 formulation (with the same dosage, 30 min before breakfast). RESULTS Two-three months after the switch, TSH was significantly reduced both in patients treated with RYGB, as in those treated with BPD, while FT4 and FT3 levels were not significantly changed (RYGB group, TSH μIU/mL: 7.58 ± 3.07 vs 3.808 ± 1.83, P < 0.001; BPD group, TSH μIU/mL: 8.82 ± 2.76 vs 3.12 ± 1.33, P < 0.01). CONCLUSIONS These results first show that liquid L-T4 could prevent the problem of malabsorption in patients with BPD and confirm those of previous studies in patients submitted to RYGB, suggesting that the L-T4 oral liquid formulation could circumvent malabsorption after bariatric surgery.
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Hommel C, Delgrange E. Resistance to levothyroxine in a bariatric surgery patient: an indication for liquid formulation? Acta Clin Belg 2017; 72:72-75. [PMID: 27362875 DOI: 10.1080/17843286.2016.1196861] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We report the case of a 49-year-old female patient with hypothyroidism who underwent bariatric surgery and developed severe hypothyroidism despite high doses of oral levothyroxine (L-T4) tablets. Initially, a high-dose L-T4 tablets absorption test was performed to exclude pseudo-malabsorption. In view of a modest increase in serum T4 levels, L-T4 liquid formulation absorption test was performed, and showed faster and more efficient absorption of thyroid hormones. We discuss the issue of distinguishing malabsorption from pseudo-malabsorption, review the literature concerning the benefits of liquid L-T4 in cases of impaired absorption such as bariatric surgery and consider the socio-economic implications of different liquid formulations.
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Affiliation(s)
- Christophe Hommel
- Service d’Endocrinologie, CHU UcL Namur, Yvoir, Belgium
- Service de Médecine Interne, Université catholique de Louvain, Brussels, Belgium
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Skelin M, Lucijanić T, Amidžić Klarić D, Rešić A, Bakula M, Liberati-Čizmek AM, Gharib H, Rahelić D. Factors Affecting Gastrointestinal Absorption of Levothyroxine: A Review. Clin Ther 2017; 39:378-403. [PMID: 28153426 DOI: 10.1016/j.clinthera.2017.01.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/23/2016] [Accepted: 01/03/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Levothyroxine (LT4) is a drug with a narrow therapeutic index, applied in small amounts (micrograms), which makes interactions in the absorption phase clinically significant. The main aim of this article was to review and present the latest information on factors that affect the gastrointestinal absorption of this drug. METHODS Relevant data were collected by using the MEDLINE, PubMed, EMBASE, Web of Science, Science Direct, and Scopus databases with the key words levothyroxine and absorption. Searches were not limited to specific publication types, study designs, dates, or languages. The reports were highly variable in the amount of information provided regarding study design and methods. Because of the heterogeneity of studies, no statistical analysis was performed. FINDINGS Many gastrointestinal disorders, such as celiac disease, atrophic gastritis, lactose intolerance, and Helicobacter pylori infection, may impede the absorption of levothyroxine. During treatment of these disorders, it is necessary to monitor serum thyroid-stimulating hormone and free T4 values to reduce the risk of developing iatrogenic hyperthyroidism. Soybeans and coffee have the greatest impact on the reduction of absorption, whereas vitamin C has the ability to increase it. Conversely, the effect of dietary fiber on the absorption of LT4 is not yet fully understood; further research is needed on this topic. A decrease in the absorption of LT4 is established and clinically significant when administered concomitantly with cholestyramine, colesevelam, lanthanum, calcium carbonate, calcium citrate, calcium acetate, iron sulfate, ciprofloxacin, aluminum hydroxide, sevelamer, or proton pump inhibitors. This effect should be taken into consideration when prescribing these drugs concomitantly with LT4. The effects of Giardia lamblia infection and the influence of orlistat, polystyrene sulfonate, raloxifene, and simethicone on absorption of LT4 have been poorly documented. For bariatric surgery, sucralfate and H2-antagonist interactions are not well founded or contradictory evidence is available regarding their existence; additional research should be conducted. IMPLICATIONS The majority of the interactions are clinically significant. They are based on the LT4 adsorption on interfering substances in the digestive tract, as well as a consequently reduced amount of the drug available for absorption. These interactions can be avoided by separating the administration of LT4 and the interfering substance.
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Affiliation(s)
- Marko Skelin
- Pharmacy Department, General Hospital Šibenik, Šibenik, Croatia
| | - Tomo Lucijanić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Clinical Hospital Dubrava, Zagreb, Croatia
| | | | - Arnes Rešić
- Department of Paediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Miro Bakula
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh," Zagreb, Croatia
| | - Ana-Marija Liberati-Čizmek
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh," Zagreb, Croatia
| | - Hossein Gharib
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Dario Rahelić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Clinical Hospital Dubrava, Zagreb, Croatia
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Cappelli C, Pirola I, Gandossi E, Casella C, Lombardi D, Agosti B, Marini F, Delbarba A, Castellano M. TSH Variability of Patients Affected by Differentiated Thyroid Cancer Treated with Levothyroxine Liquid Solution or Tablet Form. Int J Endocrinol 2017; 2017:7053959. [PMID: 28572820 PMCID: PMC5441121 DOI: 10.1155/2017/7053959] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/13/2017] [Accepted: 03/22/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent guidelines from the American Thyroid Association (ATA) indicate that, in many patients affected by differentiated thyroid cancer (DTC), the serum TSH should be maintained between 0.1 and 0.5 mU/L. The purpose of this study was to evaluate the TSH variability of patients affected by DTC treated with liquid L-T4 formulation or in tablet form. PATIENTS AND METHODS Patients were eligible if (a) they were submitted to a total thyroidectomy and 131I remnant ablation for DTC in our institution and (b) they were classified low-risk patients according to ATA guidelines 2009. Patients were randomized (1 : 1) to receive treatment of hypothyroidism with liquid L-T4 or tablet form. The first check-up evaluation was made from 8 to 12 months after 131I remnant ablation. TSH values were established again after further 12 months. RESULTS A significant increase in TSH values (median) was observed in patients taking tablets [TSH (min-max): 0.28 (0.1-0.45) versus 0.34 (0.01-0.78) mIU/L, p = 0.041] as compared to those taking liquid formulation [TSH (min-max): 0.28 (0.1-0.47) versus 0.30 (0.1-0.55) mIU/L, p = 0.345]. CONCLUSIONS The use of L-T4 liquid formulation, as compared to that of tablets, resulted in a significantly higher number of DTC patients maintaining TSH values in range for the ATA risk score, reducing TSH variability over the time.
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Affiliation(s)
- Carlo Cappelli
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
- *Carlo Cappelli:
| | - Ilenia Pirola
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Elena Gandossi
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, 3rd Division of General Surgery, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Davide Lombardi
- Department of Otorhinolaryngology, Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Barbara Agosti
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Fiorella Marini
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Andrea Delbarba
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Maurizio Castellano
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
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Azran C, Wolk O, Zur M, Fine-Shamir N, Shaked G, Czeiger D, Sebbag G, Kister O, Langguth P, Dahan A. Oral drug therapy following bariatric surgery: an overview of fundamentals, literature and clinical recommendations. Obes Rev 2016; 17:1050-1066. [PMID: 27335140 DOI: 10.1111/obr.12434] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/08/2016] [Accepted: 05/09/2016] [Indexed: 12/14/2022]
Abstract
Bariatric surgery is the most effective solution for severe obesity and obesity with comorbidities, and the number of patients going through bariatric surgery is rapidly and constantly growing. The modified gastrointestinal anatomy of the patient may lead to significant pharmacokinetic alterations in the oral absorption of drugs after the surgery; however, because of insufficient available literature and inadequate awareness of the medical team, bariatric surgery patients may be discharged from the hospital with insufficient instructions regarding their medication therapy. In this article, we aim to present the various mechanisms by which bariatric surgery may influence oral drug absorption, to provide an overview of the currently available literature on the subject, and to draw guidelines for the recommendations bariatric surgery patients should be instructed before leaving the hospital. To date, and until more robust data are published, it is essential to follow and monitor patients closely for safety and efficacy of their medication therapies, both in the immediate and distant time post-surgery.
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Affiliation(s)
- Carmil Azran
- Clinical Pharmacy, Herzliya Medical Center, Herzliya, Israel
| | - Omri Wolk
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Moran Zur
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Noa Fine-Shamir
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gad Shaked
- Department of Surgery B, Soroka University Medical Center, Beer Sheva, Israel
| | - David Czeiger
- Department of Surgery B, Soroka University Medical Center, Beer Sheva, Israel
| | - Gilbert Sebbag
- Department of Surgery B, Soroka University Medical Center, Beer Sheva, Israel
| | - Olga Kister
- Institute of Pharmacy, Biopharmaceutics and Pharmaceutical Technology, Johannes Gutenberg-University, Mainz, Germany
| | - Peter Langguth
- Institute of Pharmacy, Biopharmaceutics and Pharmaceutical Technology, Johannes Gutenberg-University, Mainz, Germany
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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Virili C, Trimboli P, Romanelli F, Centanni M. Liquid and softgel levothyroxine use in clinical practice: state of the art. Endocrine 2016; 54:3-14. [PMID: 27473098 DOI: 10.1007/s12020-016-1035-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/22/2016] [Indexed: 12/23/2022]
Abstract
Levothyroxine is recognized as the treatment of choice for hypothyroidism. So far, the tablet levothyroxine has been the formulation almost exclusively used, even though an optimal daily dose of levothyroxine has been unsuccessfully sought and a consensus not achieved. Due to progressive use of a more individually tailored levothyroxine dose, increasing evidence has instead displayed that many gastrointestinal disorders, polypharmacy, and food interference may raise the daily levothyroxine requirement. In recent years, alternative levothyroxine formulations have become available and have rapidly gained attention because of their pharmacokinetic properties. This study aims to provide an overview regarding the use of softgel capsule and/or liquid levothyroxine solution while performing a review of published studies about such topic. A comprehensive computer literature search of the PubMed/MEDLINE, Scopus, and Google Scholar databases has been conducted to find published articles on this topic. The search algorithm was based on the combinations of the following terms: "oral solution" or "soft gel" or "liquid", and "levothyroxine". The computer search resulted in 75 articles; through a critical review of such titles and abstracts and a screening of their references lists, the review included 18 original articles relating to 800 patients treated with alternative formulations. Despite some limits, the results obtained using softgel and liquid levothyroxine were consistent with each other. In selected categories of levothyroxine-treated patients (pediatric, suffering from hypo-achlorhydria, polypharmacy, undergone bariatric surgery, fed through enteric tube) these new formulations have shown promising attributes in improving a treatment that needs to be individually tailored.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Francesco Romanelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.
- Endocrinology Unit, AUSL Latina, Latina, Italy.
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Fallahi P, Ferrari SM, Ruffilli I, Ragusa F, Biricotti M, Materazzi G, Miccoli P, Antonelli A. Advancements in the treatment of hypothyroidism with L-T4 liquid formulation or soft gel capsule: an update. Expert Opin Drug Deliv 2016; 14:647-655. [PMID: 27552635 DOI: 10.1080/17425247.2016.1227782] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The most recent advance concerning levothyroxine (L-T4) therapy is the development of novel oral formulations: the liquid preparation, and the soft gel capsule. Areas covered: This review evaluates the most recent clinical studies about these new formulations. The liquid formulation has been shown to overcome: the food and beverages intereference with L-T4 tablets absorption, caused by food or coffee at breakfast; malabsorption induced by the increased gastric pH, resulting from atrophic gastritis, or due to proton-pump inhibitors; and malabsorption after bariatric surgery. The use of liquid L-T4 has been studied also in pregnancy, newborns and infants, suggesting a better bioequivalence than tablets. Finally, liquid L-T4 is more active than tablets in the control of thyroid-stimulating hormone (TSH) in hypothyroid patients without malabsorption, drug interference, or gastric disorders, leading to a hypothesized higher absorption of liquid L-T4 also in these patients. Few studies have evaluated soft gel L-T4 with promising results in patients with malabsorption related to coffee or gastritis. Expert opinion: Liquid L-T4 (and soft gel capsules) are more active than the tablet L-T4 in the control of TSH in hypothyroid patients with gastric disorders, malabsorption, or drug interference, but also in patients without absorption disorders.
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Affiliation(s)
- Poupak Fallahi
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | | | - Ilaria Ruffilli
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Francesca Ragusa
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Marco Biricotti
- b Department of Surgical, Medical, Molecular Pathology and Critical Area , University of Pisa , Pisa , Italy
| | - Gabriele Materazzi
- b Department of Surgical, Medical, Molecular Pathology and Critical Area , University of Pisa , Pisa , Italy
| | - Paolo Miccoli
- b Department of Surgical, Medical, Molecular Pathology and Critical Area , University of Pisa , Pisa , Italy
| | - Alessandro Antonelli
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
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Trimboli P, Centanni M, Virili C. Liquid liothyronine to obtain target TSH in differentiated thyroid cancer patients. Endocr J 2016; 63:563-7. [PMID: 27000530 DOI: 10.1507/endocrj.ej16-0040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In the last ten years a liquid formulation of liothyronine (L-T3) became available. To date, no studies on its systematic use have been reported. This study is aimed at assessing the reliability of liquid L-T3 in achieving target TSH in patients with differentiated thyroid cancers (DTC). Twenty-one high risk DTC patients in whom levothyroxine treatment up to 2.0 μg/kg/day did not suppress TSH levels (i.e. >0.1 mIU/L) were selected. Maintaining the same L-T4 dose, they started to assume liquid L-T3 at an initial fixed dose of 3.55 μg (5 drops). Further adjustments of L-T3 dose were tailored according to individual assessment. Initial serum TSH ranged from 0.8 to 12.0 mIU/L, when patients assumed high dose of L-T4 alone. Following the addition of a daily single dose of 3.55 μg L-T3, the target TSH was attained in five patients (23.8%). After increasing L-T3 dose up to a mean of 7.3±3.4 μg/day all patients reached target serum TSH (<0.1 mIU/L). The mean individual L-T3 dose was significantly correlated with the body weight and was 0.11±0.04 μg/kg/day (p=0.013). Mean L-T4:L-T3 ratio was 21:1. No patients showed skewed free-T3 or free-T4 values, neither experienced discomfort nor reported adverse events. Liquid L-T3 can be useful to achieve optimal TSH suppression in high risk DTC with not suppressed TSH on L-T4 alone. This formulation allows an individual tailoring of L-T3, minimizing risks of side effects as well as of overtreatment in these clinical conditions.
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Affiliation(s)
- Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Fallahi P, Ferrari SM, Antonelli A. Oral L-thyroxine liquid versus tablet in patients with hypothyroidism without malabsorption: a prospective study. Endocrine 2016; 52:597-601. [PMID: 26721663 DOI: 10.1007/s12020-015-0836-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/16/2015] [Indexed: 11/30/2022]
Abstract
No consistent data are present in literature about the effectiveness of levothyroxine (L-T4) liquid formulation in patients without malabsorption. The aim of this study is to compare the effectiveness of L-T4 liquid formulation, with L-T4 tablets, in hypothyroid patients without malabsorption or drug interference. One hundred and fifty two patients were recruited. Patients were switched from the L-T4 therapy in tablets, to liquid L-T4 at the same dosage, 30 min before breakfast. Serum thyrotropic hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) were re-evaluated after 1-3 months (first control) and 5-7 months (second control) from the switch. TSH values significantly declined with respect to the basal value after the switch to liquid L-T4 both at the first control (P < 0.05) and at the second control (P < 0.01); FT4 and FT3 levels were not significantly changed. We show that liquid L-T4 is more effective than L-T4 tablet in controlling TSH levels in hypothyroid patients without malabsorption, gastric disorders, or drug interference.
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Affiliation(s)
- Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy.
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Fierabracci P, Martinelli S, Tamberi A, Piaggi P, Basolo A, Pelosini C, Ricco I, Magno S, Querci G, Ceccarini G, Scartabelli G, Salvetti G, Vitti P, Santini F. Weight Loss and Variation of Levothyroxine Requirements in Hypothyroid Obese Patients After Bariatric Surgery. Thyroid 2016; 26:499-503. [PMID: 26895690 DOI: 10.1089/thy.2015.0473] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Obesity and hypothyroidism are both common disorders within the general population. Obese hypothyroid subjects require higher doses of levothyroxine (LT4) compared with normal weight individuals. Previous studies on the effects of bariatric surgery on LT4 dose requirements in hypothyroid subjects have provided conflicting results. The aim of this study was to evaluate the LT4 requirements in a group of obese subjects with acquired hypothyroidism, before and after weight loss achieved by bariatric surgery. METHODS Ninety-three obese hypothyroid subjects (mean age = 48 ± 9 years; mean body mass index = 45.9 ± 5.6 kg/m(2)), were evaluated before and 28 ± 8 months after bariatric surgery. Changes in the LT4 dose, anthropometric measures, and hormone values were evaluated. In 20 patients, data of body composition, assessed by dual energy X-ray absorptiometry, were also analyzed. RESULTS On average, after weight loss, a significant reduction of the total dose of LT4 was documented (from 130.6 ± 48.5 to 116.2 ± 38.6 μg/day; p < 0.001). The LT4 dose had to be reduced in 47 patients, was unchanged in 34, and had to be increased in 12 patients affected by autoimmune thyroiditis. Reduction of the LT4 dose was proportional to reduction of the lean body mass. CONCLUSIONS The weight loss achieved with modern surgical bariatric procedures is associated with a reduction of LT4 requirements in most hypothyroid subjects, which appears to be related to a decrease of the lean body mass. Occasionally, a concurrent decline of residual thyroid function, as it occurs in autoimmune thyroiditis, can counteract this phenomenon and eventually produce an increase of LT4 needs. It is believed that during the weight loss phase that follows bariatric surgery, there is no need for preventive adjustments of the LT4 dose, but serum thyroid hormones and thyrotropin should be periodically monitored in order to detect possible variations of LT4 requirements and to allow proper corrections of the therapy.
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Affiliation(s)
- Paola Fierabracci
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Silvia Martinelli
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Anna Tamberi
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Paolo Piaggi
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Alessio Basolo
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Caterina Pelosini
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Ilaria Ricco
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Silvia Magno
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Giorgia Querci
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Giovanni Ceccarini
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | | | - Guido Salvetti
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Paolo Vitti
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
| | - Ferruccio Santini
- Obesity Center, Endocrinology Unit 1, University Hospital of Pisa , Pisa, Italy
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Fallahi P, Ferrari SM, Ruffilli I, Antonelli A. Reversible normalisation of serum TSH levels in patients with autoimmune atrophic gastritis who received L-T4 in tablet form after switching to an oral liquid formulation: a case series. BMC Gastroenterol 2016; 16:22. [PMID: 26965518 PMCID: PMC4787146 DOI: 10.1186/s12876-016-0439-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background L-thyroxine (L-T4) malabsorption is a potential concern in patients with autoimmune atrophic gastritis. Methods We evaluated five patients with autoimmune gastritis, who showed high serum thyrotropin (TSH) levels (in the hypothyroid range) while in therapy with L-T4 in tablet. All patients were switched to receive an oral L-T4 liquid formulation maintaining the same dosage. Results In all patients who received L-T4 in tablet form after switching to an oral liquid formulation with the same L-T4 dosage, TSH circulating levels were normalized. In four patients who were switched back again to receive L-T4 in tablets, maintaining the dosage, TSH levels worsened again reaching levels in the hypothyroid range. Conclusions The fact that the change from tablets to liquid oral formulation normalised serum TSH levels, and that switching back to tablets caused thyrotropin levels to worsen, leads us to believe that absorption of L-T4 is greater with oral liquid formulations in these patients. These results suggest that the L-T4 oral liquid formulation could circumvent the pH alteration resulting from atrophic gastritis.
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Affiliation(s)
- Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Ilaria Ruffilli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Alessando Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy.
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Cappelli C, Pirola I, Daffini L, Formenti A, Iacobello C, Cristiano A, Gandossi E, Agabiti Rosei E, Castellano M. A Double-Blind Placebo-Controlled Trial of Liquid Thyroxine Ingested at Breakfast: Results of the TICO Study. Thyroid 2016; 26:197-202. [PMID: 26586610 DOI: 10.1089/thy.2015.0422] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Levothyroxine (LT4) is the recommended treatment for millions of hypothyroid patients. Current guidelines recommend that LT4 tablets be taken in a fasting state, but inability to adhere to this often leads to poor therapy compliance. METHODS A randomized, double-blind, placebo-controlled, crossover trial was conducted in previously untreated hypothyroid patients randomly assigned to receive an oral solution of LT4 either at least 30 minutes before breakfast or directly at breakfast time. Each patient completed two six-week treatment periods, with different timing of active LT4 administration: placebo before breakfast and active LT4 at breakfast, or vice versa. At the end of each period, thyrotropin (TSH), free thyroxine (fT4), and free triiodothyronine (fT3) were measured. The primary endpoint was to verify any difference in serum TSH levels whether consuming liquid LT4 at breakfast or 30 minutes prior to breakfast. RESULTS A total of 77 patients (64 females; median age 45.4 ± 3.7 years) completed the study. No statistically significant differences in serum TSH, fT4, or fT3 levels were observed whether LT4 was taken at breakfast or 30 minutes before, in a fasting state. No significant effect from the sequence of regimens, breakfast composition, and/or concomitantly administered drugs was observed on the dose of LT4 administered, or on the post-treatment serum TSH values. CONCLUSIONS The TICO study suggests that a liquid LT4 formulation can be ingested directly at breakfast, thus potentially improving therapeutic compliance. This observation is of considerable clinical relevance, since non-adherence to LT4 therapy requirements is more likely to cause variability in serum TSH concentrations.
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Affiliation(s)
- Carlo Cappelli
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
| | - Ilenia Pirola
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
| | - Linda Daffini
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
| | - Annamaria Formenti
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
| | - Carmelo Iacobello
- 2 Department of Molecular and Translational Medicine, University of Brescia , Brescia, Italy
| | - Alessandra Cristiano
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
| | - Elena Gandossi
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
| | - Enrico Agabiti Rosei
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
| | - Maurizio Castellano
- 1 Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, University of Brescia , Brescia, Italy
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Cappelli C, Negro R, Pirola I, Gandossi E, Agosti B, Castellano M. Levothyroxine liquid solution versus tablet form for replacement treatment in pregnant women. Gynecol Endocrinol 2016; 32:290-2. [PMID: 26585420 DOI: 10.3109/09513590.2015.1113518] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the need and the magnitude of levothyroxine (LT4) increase in hypothyroid pregnant women on liquid compared to tablet formulations. METHODS Patients were recruited by searching our "thyroid patients" database. The selection criteria were as follows: a) pregnant women on treatment for hypothyroidism (both liquid and tablet LT4) who gave birth at our hospital between February 2012 and January 2014; b) thyroid stimulating hormone (TSH) and free thyroxine (FT4) levels obtained at least 3 months before missed menstrual cycle, with a TSH value less than 2.5 mIU/L and c) TSH and FT4 obtained within 12 weeks of pregnancy, and each month subsequently. RESULTS During pregnancy, 8/31 (25.5%) of the women had to increase the dosage of LT4. Of these, 7/17 (41.2%) were on LT4 replacement therapy with tablets, and 1/14 (7.1%) with liquid formulation (p = 0.038). Daily LT4 was significantly increased in the liquid group only (52.9 ± 19.5 versus 67.5 ± 19.2 mcg/day (p = 0.013). A logistic regression analysis showed that the treatment with LT4 tablets was the only predictor of LT4 increase (OR: 0.44; 95% CI: 0.04-0.83; p = 0.031). CONCLUSION Pregnant women on optimal replacement therapy before pregnancy require an increase of LT4 dosage more often when on a tablet than liquid formulation.
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Affiliation(s)
- Carlo Cappelli
- a Department of Clinical and Experimental Sciences , Endocrine and Metabolic Unit, University of Brescia , Brescia , Italy and
| | - Roberto Negro
- b Division of Endocrinology , "V. Fazzi" Hospital , Lecce , Italy
| | - Ilenia Pirola
- a Department of Clinical and Experimental Sciences , Endocrine and Metabolic Unit, University of Brescia , Brescia , Italy and
| | - Elena Gandossi
- a Department of Clinical and Experimental Sciences , Endocrine and Metabolic Unit, University of Brescia , Brescia , Italy and
| | - Barbara Agosti
- a Department of Clinical and Experimental Sciences , Endocrine and Metabolic Unit, University of Brescia , Brescia , Italy and
| | - Maurizio Castellano
- a Department of Clinical and Experimental Sciences , Endocrine and Metabolic Unit, University of Brescia , Brescia , Italy and
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Santaguida MG, Virili C, Del Duca SC, Cellini M, Gatto I, Brusca N, De Vito C, Gargano L, Centanni M. Thyroxine softgel capsule in patients with gastric-related T4 malabsorption. Endocrine 2015; 49:51-7. [PMID: 25595886 DOI: 10.1007/s12020-014-0476-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/04/2014] [Indexed: 02/06/2023]
Abstract
The key role of an intact gastric acid secretion for subsequent intestinal T4 absorption is supported by an increased requirement of thyroxine in patients with gastric disorders. A better pH-related dissolution profile has been described in vitro for softgel T4 preparation than for T4 tablets. Our study was aimed at comparing softgel and tablet T4 requirements in patients with gastric disorders. A total of 37 patients with gastric-related T4 malabsorption were enrolled, but only 31 (28F/3M; median age = 50 years; median T4 dose = 2.04 μg/kg/day) completed the study. All patients were in long-lasting treatment (>2 years) with the same dose of T4 tablets when treatment was switched to a lower dose of softgel T4 capsules (-17 %; p = 0.0002). Assessment of serum FT4 and TSH was carried out at baseline and after 3, 6, 12, and 18 months after the treatment switch. In more than 2/3 of patients (good-responders n = 21), despite the reduced dose of T4, median TSH values were similar at each time point (p = 0.3934) with no change in FT4 levels. In the remaining patients (poor-responders n = 10), TSH levels were significantly higher at each time point than at baseline (p < 0.0001). To note, in five of them intestinal comorbidity was subsequently detected. Comorbidity associated with poor-responders status was the only significant predictor in multivariate analysis (OR = 11.333). Doses of softgel T4 capsules lower than T4 tablet preparation are required to maintain the therapeutic goal in 2/3 of patients with impaired gastric acid secretion.
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Affiliation(s)
- Maria Giulia Santaguida
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
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Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670-751. [PMID: 25266247 PMCID: PMC4267409 DOI: 10.1089/thy.2014.0028] [Citation(s) in RCA: 940] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND A number of recent advances in our understanding of thyroid physiology may shed light on why some patients feel unwell while taking levothyroxine monotherapy. The purpose of this task force was to review the goals of levothyroxine therapy, the optimal prescription of conventional levothyroxine therapy, the sources of dissatisfaction with levothyroxine therapy, the evidence on treatment alternatives, and the relevant knowledge gaps. We wished to determine whether there are sufficient new data generated by well-designed studies to provide reason to pursue such therapies and change the current standard of care. This document is intended to inform clinical decision-making on thyroid hormone replacement therapy; it is not a replacement for individualized clinical judgment. METHODS Task force members identified 24 questions relevant to the treatment of hypothyroidism. The clinical literature relating to each question was then reviewed. Clinical reviews were supplemented, when relevant, with related mechanistic and bench research literature reviews, performed by our team of translational scientists. Ethics reviews were provided, when relevant, by a bioethicist. The responses to questions were formatted, when possible, in the form of a formal clinical recommendation statement. When responses were not suitable for a formal clinical recommendation, a summary response statement without a formal clinical recommendation was developed. For clinical recommendations, the supporting evidence was appraised, and the strength of each clinical recommendation was assessed, using the American College of Physicians system. The final document was organized so that each topic is introduced with a question, followed by a formal clinical recommendation. Stakeholder input was received at a national meeting, with some subsequent refinement of the clinical questions addressed in the document. Consensus was achieved for all recommendations by the task force. RESULTS We reviewed the following therapeutic categories: (i) levothyroxine therapy, (ii) non-levothyroxine-based thyroid hormone therapies, and (iii) use of thyroid hormone analogs. The second category included thyroid extracts, synthetic combination therapy, triiodothyronine therapy, and compounded thyroid hormones. CONCLUSIONS We concluded that levothyroxine should remain the standard of care for treating hypothyroidism. We found no consistently strong evidence for the superiority of alternative preparations (e.g., levothyroxine-liothyronine combination therapy, or thyroid extract therapy, or others) over monotherapy with levothyroxine, in improving health outcomes. Some examples of future research needs include the development of superior biomarkers of euthyroidism to supplement thyrotropin measurements, mechanistic research on serum triiodothyronine levels (including effects of age and disease status, relationship with tissue concentrations, as well as potential therapeutic targeting), and long-term outcome clinical trials testing combination therapy or thyroid extracts (including subgroup effects). Additional research is also needed to develop thyroid hormone analogs with a favorable benefit to risk profile.
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Affiliation(s)
| | - Antonio C. Bianco
- Division of Endocrinology, Rush University Medical Center, Chicago, Illinois
| | - Andrew J. Bauer
- Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kenneth D. Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Anne R. Cappola
- Division of Endocrinology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Francesco S. Celi
- Division of Endocrinology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - David S. Cooper
- Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian W. Kim
- Division of Endocrinology, Rush University Medical Center, Chicago, Illinois
| | - Robin P. Peeters
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M. Sara Rosenthal
- Program for Bioethics, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, Ontario, Canada
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