Study of serum 3,5,3'-triiodothyronine sulfate concentration in patients with systemic non-thyroidal illness

Levothyroxine: Conventional and novel drug delivery formulations

Despite the fact that levothyroxine is one of the most prescribed medications in the world, its bioavailability has been reported to be impaired by many factors, including interfering drugs or foods and concomitant diseases, and persistent hypothyroidism with a high dose of levothyroxine is thus elicited. Persistent hypothyroidism can also be induced by noninterchangeability between formulations and poor compliance. To address these issues, some strategies have been developed. Novel formulations (liquid solutions and soft-gel capsules) have been designed to eliminate malabsorption. Some other delivery routes (injections, suppositories, sprays, and sublingual and transdermal administrations) are aimed at circumventing different difficulties in dosing, such as thyroid emergencies and dysphagia. Moreover, nanomaterials have been used to develop delivery systems for the sustained release of levothyroxine to improve patient compliance and reduce costs. Some delivery systems encapsulating nanoparticles show promising release profiles. In this review, we first summarize the medical conditions that interfere with the bioavailability of oral levothyroxine and discuss the underlying mechanisms and treatments. The efficacy of liquid solutions and soft-gel capsules are systematically evaluated. We further summarize the novel delivery routes for levothyroxine and their possible applications. Nanomaterials in the levothyroxine field are then discussed and compared based on their load and release profile. We hope the article provides novel insights into the drug delivery of levothyroxine.

Treatment of Hypothyroid Patients With L-Thyroxine (L-T4) Plus Triiodothyronine Sulfate (T3S). A Phase II, Open-Label, Single Center, Parallel Groups Study on Therapeutic Efficacy and Tolerability

Sodium salt of levothyroxine (L-T4) is the treatment of choice of hypothyroidism. Yet, L-T4 monotherapy produces supoptimal 3,5,3'-triiodothyronine (T3)/T4 ratio in serum, as compared to normal subjects, and a minority of hypothyroid individuals on L-T4 complain for an incomplete well-being. Orally administered 3,5,3'-triiodothyronine sulfate (T3S) can be converted to T3 in humans, resulting in steady-state serum T3 concentrations for up to 48 h. In this study (EudraCT number 2010-018663-42), 36 thyroidectomized hypothyroid patients receiving 100 (group A), 125 (group B), or 150 μg (group C) L-T4 were enrolled in a 75 days study in which 25 μg L-T4 were replaced by 40 μg of T3S. A significant, progressive reduction in mean FT4 values was observed, being the largest in the group A and the smallest in group C, while no relevant variations in FT3 and total T3 serum values were observed in the three groups. TSH serum levels increased in all groups, the highest value being observed in group A. Lipid parameters did not show clinically significant changes in all groups. No T3S-related changes in the safety laboratory tests were recorded. No adverse event was judged as related to experimental treatment, and no patient discontinued the treatment. Twelve patients judged the L-T4+T3S treatment better than L-T4 alone, while no patient reported a preference for L-T4 over the combined treatment. In conclusion, the results of this study indicate that a combination of L-T4+T3S in hypothyroid subjects may allow mainteinance of normal levels of serum T3, with restoration of a physiological FT4/FT3 ratio and no appearance of adverse events. Further studies are required to verify whether the LT4+T3S chronic combined treatment of hypothyroidism is able to produce additional benefits over L-T4 monotherapy.

Leptin regulation of core body temperature involves mechanisms independent of the thyroid axis

The ability to maintain core temperature within a narrow range despite rapid and dramatic changes in environmental temperature is essential for the survival of free-living mammals, and growing evidence implicates an important role for the hormone leptin. Given that thyroid hormone plays a major role in thermogenesis and that circulating thyroid hormone levels are reduced in leptin-deficient states (an effect partially restored by leptin replacement), we sought to determine the extent to which leptin's role in thermogenesis is mediated by raising thyroid hormone levels. To this end, we 1) quantified the effect of physiological leptin replacement on circulating levels of thyroid hormone in leptin-deficient ob/ob mice, and 2) determined if the effect of leptin to prevent the fall in core temperature in these animals during cold exposure is mimicked by administration of a physiological replacement dose of triiodothyronine (T₃). We report that, as with leptin, normalization of circulating T₃ levels is sufficient both to increase energy expenditure, respiratory quotient, and ambulatory activity and to reduce torpor in ob/ob mice. Yet, unlike leptin, infusing T₃ at a dose that normalizes plasma T₃ levels fails to prevent the fall of core temperature during mild cold exposure. Because thermal conductance (e.g., heat loss to the environment) was reduced by administration of leptin but not T₃, leptin regulation of heat dissipation is implicated as playing a uniquely important role in thermoregulation. Together, these findings identify a key role in thermoregulation for leptin-mediated suppression of thermal conduction via a mechanism that is independent of the thyroid axis.

A Review of the Pharmacokinetics of Levothyroxine for the Treatment of Hypothyroidism

Thyroxine hormone has been recognised since the early part of the nineteenth century and levothyroxine has been available since the mid-nineteenth century as a replacement for deficient thyroid hormones. While levothyroxine remains the staple treatment for hypothyroidism even to this day, its optimal use can be challenging. As is often the case with older drugs, the pharmacokinetics of levothyroxine is often under-appreciated or misunderstood and many factors influence the optimal dosing of levothyroxine. This article will review the pharmacokinetics of levothyroxine in the treatment of hypothyroidism and highlight major concepts that should aid both clinicians and researchers.

Identification of metabolic changes in genetically unstable stem cells by using model analysis of gene expression

Stem-cell research seeks to address many different questions related to fundamental stem-cell function with the ultimate goal of being able to control and utilize stem cells for a broad range of therapeutic needs. While a large amount of work is focused on discovering and controlling differentiation mechanisms in stem cells, an equally interesting and important area of work is to understand the basics of stem-cell propagation and self-renewal. With high-throughput genomics and transcriptomic information on hand, it is becoming possible to address some of the detailed mechanistic processes occurring in stem cells, though interpretation of these data is often difficult. In this work, stem cells with genetic abnormalities were compared to genetically normal stem cells using gene-expression array data integrated with a large-scale metabolic model to help interpret changes in metabolism resulting in the identification of several metabolic pathways that were different in the normal and abnormal cells.

Thyroid hormone abnormalities and frailty in elderly patients with chronic kidney disease: a hypothesis

Thyroid hormones play a crucial role in the metabolic activities of adults, affecting almost every organ system. All types of thyroid diseases are encountered in the elderly. As symptoms and signs of thyroid diseases may overlap with what is considered to be "normal aging," the presence of a thyroid disorder may go undiagnosed in the elderly. This potential problem is further compounded in elderly patients with chronic kidney disease (CKD), where the presence of an underlying hormonal problem such as hypothyroidism may be erroneously attributed to multiple comorbidities, the aging process, or the kidney disease. Frailty is being recognized as a contributing factor to the poor outcomes (hospitalization and high mortality) in elderly patients with CKD. Predisposing factors leading to frailty in elderly with CKD such as increased inflammatory markers, anemia, low testosterone, sarcopenia, and depression are associated with thyroid hormonal abnormalities. These associations are remarkable and raise the question of whether routine monitoring and screening for thyroid hormone changes in elderly CKD patients might be helpful in identifying reversible causes of frailty. In this review, we will focus on the associations between thyroid hormone abnormalities and the predisposing factors of frailty in elderly patients with CKD. If a cause-effect relationship of thyroid hormone abnormalities and factors predisposing to frailty in CKD patients is established, identification and treatment of thyroid abnormalities in this population would assume increased importance.

Nonthyroidal illness syndrome and euthyroid sick syndrome in intensive care patients

This article reviews the pathophysiology of non-thyroidal illness syndrome (NTIS) and euthyroid sick syndrome (ESS), a multifactorial phenomenon characterized by suppression of thyroid hormone levels that has been described in several disease states, probably due to different causes in different patients. It also describes the laboratory values of thyroid function tests (TFTs), relevant animal studies, the association of NTIS and ESS with cardiovascular problems and sepsis, and the rationale for treatment.

Thyroid hormones, dementia, and atrophy of the medial temporal lobe

CONTEXT

Thyroid function has been related to Alzheimer disease (AD), but it remains unclear whether thyroid dysfunction results from or contributes to developing AD.

OBJECTIVE

The objective of the study was to determine the association between thyroid function and both medial temporal lobe atrophy on brain magnetic resonance imaging (MRI) as putative early sign of AD and risk of dementia.

DESIGN AND PARTICIPANTS

This was a population-based cohort study among 1077 elderly subjects aged 60-90 yr and dementia free at baseline (1995-1996).

MAIN OUTCOME MEASURES

Nonfasting serum levels of TSH, free T(4) (fT(4)), T(3), and rT(3) were available in 1025 subjects followed up for incident dementia until 2005. In a subset of 489 nondemented elderly, we assessed volumes of the hippocampus and amygdala on brain MRI. Subjects using thyroid medication were excluded.

RESULTS

During 5657 person-years of follow-up (mean 5.5 yr), 63 subjects were diagnosed with dementia (46 with AD). TSH and thyroid hormones were not associated with risk of dementia or AD. TSH and T(3) were also not related to brain atrophy, whereas nondemented subjects with higher fT(4) levels had more hippocampal and amygdalar atrophy on MRI. Similar associations were found for rT(3). Excluding subjects with thyroid disorders or incipient AD did not change the results.

CONCLUSION

In our study, TSH was related neither to risk of AD nor with early MRI markers thereof, arguing against an important role of thyroid function in the development of AD. Whether the association of higher fT(4) and rT(3) levels with brain atrophy on MRI has functional significance remains to be elucidated.

Detection and quantification of 3,5,3'-triiodothyronine and 3,3',5'-triiodothyronine by electrospray ionization tandem mass spectrometry

A novel and rapid method for identifying and quantifying 3,5,3'-triiodothyronine (T3) and 3,3',5'-triiodothyronine (rT3; reverse T3) has been introduced using electrospray ionization tandem mass spectrometry (ESI-MS/MS). MS(2) spectra in either negative ionization mode or positive ionization mode can be used to differentiate T3 and rT3. Quantification of the T3 and rT3 isomers under the negative ionization mode is also achieved without prior separation by HPLC.

Changes in thyroxine requirements in patients with hypothyroidism undergoing renal transplantation

Hypothyroidism is common in the renal failure population and is both influenced by the onset of renal failure and its correction with renal transplantation. We report a series of 20 consecutive patients on oral thyroxine, in which restoration of renal function following transplantation resulted in reduced thyroxine requirements. We speculate that iodide excess, reduced bioavailability, and drug interactions may have contributed both to their hypothyroidism and the increased requirements for thyroxine in these patients while on dialysis. Failure to recognize the changes following renal transplantation may result in significant morbidity.

Regulation of thyroid hormone metabolism during fetal development

Compared with adults, plasma T3 concentrations in the human fetus are decreased, whereas levels of rT3 and the different iodothyronine sulfates, T4S, T3S, rT3S and 3,3'-T2S, are increased. The low T3 and high rT3 concentrations reflect the preponderance of inner ring versus outer ring deiodinase activity due to high type III iodothyronine deiodinase (D3) expression in fetal tissues, such as liver and brain, the placenta, and perhaps also the uterus, in combination with still incomplete expression of hepatic type I iodothyronine deiodinase (D1) expression. In contrast to humans, D3 is hardly expressed in the fetal rat liver. However, high D3 expression is observed in the embryonic chicken liver which decreases dramatically towards the end of incubation, resulting in a marked increase in plasma T3. Thyroid hormone is essential for the development of the brain, in which local conversion of the prohormone T4 to the active hormone T3 by the type II iodothyronine deiodinase (D2) plays a very important role. In contrast to the rat, however, little is known about the ontogeny of D2 in different human brain areas. The cause of the high concentrations of sulfated iodothyronines in fetal plasma is unknown. In adults, the liver is an important site for the clearance of these conjugates, where they are rapidly degraded by D1. Although fetal human liver expresses significant D1 activity, clearance of iodothyronine sulfates may be defective due to the lack of transporters mediating their hepatic uptake. However, production of iodothyronine sulfates may also be increased in the human fetus, although the responsible sulfotransferases and their location remain to be identified. Sulfation may be a reversible pathway of thyroid hormone inactivation, depending on the recovery of free hormone by sulfatases. However, little is known at present about the characteristics and regulation of these enzymes in fetal human tissues. Further studies are required to increase our understanding of the tissue-specific and stage-dependent regulation of thyroid hormone bioactivity during human development.

Characterization of human iodothyronine sulfotransferases

Sulfation is an important pathway of thyroid hormone metabolism that facilitates the degradation of the hormone by the type I iodothyronine deiodinase, but little is known about which human sulfotransferase isoenzymes are involved. We have investigated the sulfation of the prohormone T4, the active hormone T3, and the metabolites rT3 and 3,3'-diiodothyronine (3,3'-T2) by human liver and kidney cytosol as well as by recombinant human SULT1A1 and SULT1A3, previously known as phenol-preferring and monoamine-preferring phenol sulfotransferase, respectively. In all cases, the substrate preference was 3,3'-T2 >> rT3 > T3 > T4. The apparent Km values of 3,3'-T2 and T3 [at 50 micromol/L 3'-phosphoadenosine-5'-phosphosulfate (PAPS)] were 1.02 and 54.9 micromol/L for liver cytosol, 0.64 and 27.8 micromol/L for kidney cytosol, 0.14 and 29.1 micromol/L for SULT1A1, and 33 and 112 micromol/L for SULT1A3, respectively. The apparent Km of PAPS (at 0.1 micromol/L 3,3'-T2) was 6.0 micromol/L for liver cytosol, 9.0 micromol/L for kidney cytosol, 0.65 micromol/L for SULT1A1, and 2.7 micromol/L for SULT1A3. The sulfation of 3,3'-T2 was inhibited by the other iodothyronines in a concentration-dependent manner. The inhibition profiles of the 3,3'-T2 sulfotransferase activities of liver and kidney cytosol obtained by addition of 10 micromol/L of the various analogs were better correlated with the inhibition profile of SULT1A1 than with that of SULT1A3. These results indicate similar substrate specificities for iodothyronine sulfation by native human liver and kidney sulfotransferases and recombinant SULT1A1 and SULT1A3. Of the latter, SULT1A1 clearly shows the highest affinity for both iodothyronines and PAPS, but it remains to be established whether it is the prominent isoenzyme for sulfation of thyroid hormone in human liver and kidney.

[Non-thyroid illness" or changed thyroid hormone parameter syndrome with non-thyroid illnesses]

BACKGROUND

The multiple effects of systemic illness on thyroid economy are commonly referred to "non-thyroidal illness" (NTI) or "sick euthyroid syndrome". The various aspects of this common syndrome are summarized in this article.

STUDIES

Results of the relevant studies published during the past 25 years were evaluated. The influence of the underlying illness and of drug administration was especially emphasized.

RESULTS

The most common abnormalities in NTI are 1. the "low-T3 syndrome" due to a decreased T3 generation from T4 by a reduced activity of 5'-deiodinase (a selenoprotein); 2. the "low-T3 low-T4 state", which is associated with a poor prognosis. The low T4-levels are related to a binding inhibitor that displaces T4 from its binding proteins. However, there exists some controversy regarding the character of this binding inhibitor. 3. The high-T4 state is often found in acute psychiatric and liver diseases. The nutritional status of the patients and drugs known to influence thyroid hormone parameters have to be considered when patients with NTI are evaluated. Some difficulties may arise, when there is evidence of coexisting thyroid disease. Here aside from further biochemical evaluation such as thyroid antibodies, thyroid ultrasound and a thyroid scan have to be performed.

CONCLUSION

NTI is associated with various alterations in thyroid hormone parameters when no intrinsic thyroid hormone disease exists. The severity of NTI reflects clinical outcome and clinical amelioration is associated with normalization of thyroid hormone parameters. There is no need for specific therapeutic intervention such as the administration of thyroid hormones in patients with the various forms of the NTI-syndrome.