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Seng Yue C, Scarsi C, Bettazzi E, Mautone G, Celi FS, Ducharme M. Proton Pump Inhibitors Do Not Affect the Bioavailability of a Novel Liquid Formulation of Levothyroxine. Endocr Pract 2024; 30:513-520. [PMID: 38554774 DOI: 10.1016/j.eprac.2024.03.388] [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: 01/12/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE This study evaluates the impact of a representative proton pump inhibitor (PPI) (omeprazole), administered simultaneously or staggered, on the pharmacokinetics of levothyroxine (LT4) solution (Tirosint-SOL). METHODS This was a randomized, 3-way crossover, comparative bioavailability study in 36 healthy adults under fasting conditions. Omeprazole 40 mg delayed-release capsule was administered once daily from Day 1 to 6 (mornings, Treatment-A; evenings, Treatment-B; none, Treatment-C) to increase and stabilize gastric pH. In the morning of Day 5, a single dose of LT4 solution 600 mcg was administered. Blood samples were collected 0 to 48 hours post-LT4 administration. Noncompartmental pharmacokinetic parameters were calculated for total serum thyroxine using baseline-corrected data. Maximum concentration (Cmax) and area under the concentration-time curve (AUC0-48) were included in an analysis of variance to obtain geometric mean ratios and 90% confidence intervals. RESULTS For both comparisons (A/C and B/C), geometric mean ratios and 90% confidence intervals for all parameters were within the equivalence boundaries (80%-125%), indicating bioequivalence: for A/C, AUC0-48 98.98% [94%-104%], and Cmax 91.68% [87%-97%]; for B/C, AUC0-48 98.94% [95%-103%], and Cmax 94.90% [90%-100%]. Median Tmax (time associated with Cmax) was similar across treatments. CONCLUSION This study demonstrated that Tirosint-SOL bioavailability is unaffected by coadministration of a representative PPI, given simultaneously or staggered by about 12 hours, compared to administration of LT4 solution alone. For hypothyroid patients on PPI therapy, administration of LT4 solution may reduce variations in thyroid stimulating hormone levels related to intermittent use of acid-reducing drugs and consequently the need for dose adjustments.
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Affiliation(s)
| | | | | | | | - Francesco S Celi
- Department of Medicine at University of Connecticut Health, Farmington, Connecticut
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Xu GM, Hu MX, Li SY, Ran X, Zhang H, Ding XF. Thyroid disorders and gastrointestinal dysmotility: an old association. Front Physiol 2024; 15:1389113. [PMID: 38803365 PMCID: PMC11129086 DOI: 10.3389/fphys.2024.1389113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/18/2024] [Indexed: 05/29/2024] Open
Abstract
Gastrointestinal motility symptoms may be closely related to thyroid diseases. Sometimes, such symptoms are the only thyroid disease-related clue although the degree of the symptoms may vary. The exact mechanism of action of thyroid hormones on gastrointestinal motility is not completely understood, however, a clue lies in the fact that muscle cell receptors can be directly acted upon by thyroxines. Both hypo- and hyperthyroidism can cause impairment of gastrointestinal motility, modifying structure and function of pharynx and esophagus, and regulating esophageal peristalsis through neuro-humoral interaction. In hyperthyroid patients, alterations of postprandial and basic electric rhythms have been observed at gastro-duodenal level, often resulting in slower gastric emptying. Gastric emptying may also be delayed in hypothyroidism, but an unrelated gastric mucosa-affecting chronic modification may also cause such pattern. Hyperthyroidism commonly show malabsorption and diarrhoea, while hypothyroidism frequently show constipation. In summary, it can be stated that symptoms of gastrointestinal motility dysfunction can be related to thyroid diseases, affecting any of the gastrointestinal segment. Clinically, the typical thyroid disease manifestations may be missing, borderline, or concealed because of intercurrent sicknesses. Motility-linked gastrointestinal problems may easily conceal a misdetected, underlying dysthyroidism that should be carefully analyzed. Here, we aim to elaborate on the associations between thyroid disorders and GI dysmotility and the common clinical manifestations associated with GI dysmotility.
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Affiliation(s)
- Guang-Meng Xu
- Department of Colorectal and Anal Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Ming-Xin Hu
- Department of Thyroid Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Si-Yu Li
- Department of Thyroid Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Xuan Ran
- Department of Thyroid Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Hao Zhang
- Department of Thyroid Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Xiang-Fu Ding
- Department of Thyroid Surgery, The Second Hospital of Jilin University, Changchun, China
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Schnedl WJ, Michaelis S, Mangge H, Enko D. One sip of water with LT-4 supplementation-a key to euthyroidism in Hashimoto's thyroiditis. Endocrine 2024:10.1007/s12020-024-03829-w. [PMID: 38635065 DOI: 10.1007/s12020-024-03829-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE Recommended pharmacotherapy for hypothyroidism in Hashimoto's thyroiditis (HT) is oral supplementation with levothyroxine (LT-4). However, serum thyrotropin (TSH) levels within normal range are not consistently achieved with LT-4 medication. PATIENTS AND METHODS We report on 35 HT patients with LT-4 therapy in this retrospective evaluation. In general, we recommend that a maximum of two sips of water, which would then amount to < 50 mL, be ingested at the same time as LT-4. We report on follow up examinations measuring TSH and antibodies against thyroid peroxidase (TPOAb) after 6 months to five years. RESULTS After median time of 643 days (range 98-1825) we found in 35 HT patients a statistical significant reduction of serum TSH (p < 0.001) and TPOAb (p = 0.006). The patients median body weight was 71 kg (range 48-98) and a daily LT-4 dosage was used with median 69.1 µg (range 25-150). This results in a daily LT-4 dose of median 1.01 µg/kg bodyweight (range 0.3-2.3). CONCLUSIONS The reduction of water ingestion to a maximum of two sips, which is <50 mL, combined with LT-4 supplementation helps to achieve euthyroidism in HT. In addition, it reduces the L-T4 medication dosage needed to lower TSH serum levels and decreases TPO antibodies in HT.
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Affiliation(s)
- Wolfgang J Schnedl
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.
- General Internal Medicine Practice, Dr. Theodor Körnerstrasse 19b, A-8600, Bruck, Austria.
| | - Simon Michaelis
- Institute of Clinical Chemistry and Laboratory Medicine, Hospital Hochsteiermark, Vordernberger Straße 42, A-8700, Leoben, Austria
| | - Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, A-8036, Graz, Austria
| | - Dietmar Enko
- Institute of Clinical Chemistry and Laboratory Medicine, Hospital Hochsteiermark, Vordernberger Straße 42, A-8700, Leoben, Austria
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, A-8036, Graz, Austria
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Quiroz-Aldave JE, Concepción-Zavaleta MJ, Durand-Vásquez MDC, Concepción-Urteaga LA, Gamarra-Osorio ER, Suárez-Rojas J, Rafael-Robles LDP, Paz-Ibarra J, Román-González A. Refractory Hypothyroidism: Unraveling the Complexities of Diagnosis and Management. Endocr Pract 2023; 29:1007-1016. [PMID: 37714332 DOI: 10.1016/j.eprac.2023.09.003] [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: 07/16/2023] [Revised: 08/20/2023] [Accepted: 09/04/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Refractory hypothyroidism (RH) represents a challenge in the diagnosis and treatment within the field of thyroidology. It is defined as the inability to achieve disease control despite using levothyroxine (LT4) doses of 1.9 μg/kg/d or higher. METHODS A comprehensive review, encompassing 103 articles, was conducted using the Scielo, Scopus, and EMBASE databases, providing an approach to evaluation and diagnosis of this condition. RESULTS LT4 disintegrates and dissolves within an acidic gastric environment before being absorbed in the jejunum and ileum. It then extensively binds to serum transporter proteins and undergoes deiodination to yield tri-iodothyronine, the biologically active hormone. There are various nonpathological causes of RH, such as noncompliance with treatment, changes in the brand of LT4, food and drug interferences, as well as pregnancy. Pathological causes include lactose intolerance, Helicobacter pylori infection, giardiasis, among others. The diagnosis of RH involves conducting a thorough medical history and requesting relevant laboratory tests to rule out causes of treatment resistance. The LT4 absorption test allows for the identification of cases of malabsorption. The treatment of RH involves identifying and addressing the underlying causes of noncompliance or malabsorption. In cases of pseudomalabsorption, supervised and weekly administration of LT4 may be considered. DISCUSSION Early recognition of RH and correction of its underlying cause are of utmost importance, as this avoids the use of excessive doses of LT4 and prevents cardiovascular and bone complications associated with this condition.
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Affiliation(s)
- Juan Eduardo Quiroz-Aldave
- Division of Non-Communicable Diseases, Endocrinology Research Line, Hospital de Apoyo Chepén, Chepén, Perú
| | | | | | | | | | | | | | - José Paz-Ibarra
- Department of Medicine, School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Perú
| | - Alejandro Román-González
- Division of Endocrinology, Hospital Universitario de San Vicente Fundación, Medellín, Colombia; Division of Internal Medicine, Universidad de Antioquia, Medellín, Colombia
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Sachmechi I, Lucas KJ, Stonesifer LD, Ansley JF, Sack P, Celi FS, Scarsi C, Lanzi G, Wartofsky L, Burman KD. Efficacy of Levothyroxine Sodium Soft Gelatin Capsules in Thyroidectomized Patients Taking Proton Pump Inhibitors: An Open-Label Study. Thyroid 2023; 33:1414-1422. [PMID: 37885233 PMCID: PMC10754356 DOI: 10.1089/thy.2023.0382] [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] [Indexed: 10/28/2023]
Abstract
Background: Treatment with proton pump inhibitors (PPIs) and antacids affects the gastrointestinal absorption of levothyroxine sodium (LT4) tablets. Patients with hypothyroidism taking LT4 and PPIs or antacids, thus, require appropriate monitoring. The objective of this study was to determine whether a soft gelatin capsule of LT4 (Tirosint®) would obviate the effect of PPIs on LT4 absorption. The objective was achieved by assessing the effects of a switch from a conventional LT4 tablet form to the same dose as soft capsules in thyroidectomized patients on treatment with LT4 and PPIs. Methods: Patients with history of hypothyroidism due to total thyroidectomy on stable treatment with LT4 tablets, and with gastrointestinal disease treated with PPIs, were switched to a 12-week treatment with Tirosint at the same dose of the LT4 tablets, while maintaining treatment with PPIs. Serum thyrotropin (TSH) levels were the primary endpoint of the study. Secondary efficacy endpoints were: serum levels of free thyroxine (fT4), total thyroxine (TT4), free triiodothyronine (fT3), total triiodothyronine (TT3), creatine-phosphokinase (CPK), sex-hormone binding globulin, ferritin, angiotensin converting enzyme, and a lipid panel. Results: Forty-seven patients (36 females and 11 males, mean age 55.4 years) were enrolled and 45 of them completed the study (2 patients withdrew consent). During treatment with Tirosint, mean TSH levels demonstrated a statistically significant decrease (mean changes from baseline: -0.32 mIU/L at week 6 and -0.68 mIU/L at week 12) and concomitant increases in thyroid hormone (TH) levels from baseline to week 12, which were statistically significant for fT3 and TT3 (mean changes from baseline: 0.26 pmol/L and 0.10 nmol/L, respectively). Significant decreases of serum low-density lipoprotein, total cholesterol, and CPK levels were observed at week 12. No signs/symptoms arose during the study that could be specifically correlated to either hypo- or hyperthyroidism. Conclusions: In thyroidectomized patients taking PPIs and replacement LT4, a switch from conventional LT4 tablets to LT4 soft capsules at the same dose was associated with a significant decrease in TSH and increase in TH, indicating that LT4 absorption may be less affected by PPIs when given in the form of soft capsules. Clinical Trial Registration: NCT03094416.
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Affiliation(s)
- Issac Sachmechi
- Mount Sinai Services—NYC Health+Hospitals/Queens, Jamaica, New York, USA
| | - Kathryn Jean Lucas
- LucasResearch, Inc., Diabetes & Endocrinology Consultants, Morehead City, North Carolina, USA
| | | | | | - Paul Sack
- MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Francesco S. Celi
- Division of Endocrinology and Metabolism, Department of Medicine, UConn Health, Farmington, Connecticut, USA
| | | | | | - Leonard Wartofsky
- MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Kenneth D. Burman
- Endocrine Section, MedStar Washington Hospital Center, Washington, District of Columbia, USA
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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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Awasthi A, Chakraborty PP, Agrawal N, Sinha A, Pandey AK, Maiti A. Effect of morning versus night-time administration of proton pump inhibitor (pantoprazole) on thyroid function test in levothyroxine-treated primary hypothyroidism: a prospective cross-over study. Thyroid Res 2023; 16:15. [PMID: 37259094 DOI: 10.1186/s13044-023-00156-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND One of the common causes of suboptimal control of thyroid stimulating hormone (TSH) in levothyroxine-treated hypothyroidism is coadministration of proton pump inhibitors (PPIs). Morning administration of pantoprazole has been shown to suppress intragastric pH to a greater extent. We therefore aimed to determine the effect of pantoprazole at different time points of the day on thyroid function test (TFT) in levothyroxine-treated overt primary hypothyroidism. METHODS In this single centre, hospital based, prospective, two arm cross-over study (AB, BA), participants were randomized into 2 groups based on morning (6:00 am - 7:00 am simultaneously with the scheduled levothyroxine tablet) (group M) and evening (30 min before dinner) intake of 40 mg pantoprazole tablet (group N). After the initial 6 weeks (period 1), a washout period of 1 week for pantoprazole was given, and then both the groups crossed over for another 6 weeks (period 2). Patients were instructed to continue the same brand of levothyroxine tablet at empty stomach 1-hour before breakfast. Serum TSH was measured at baseline, week 6, and week 13. RESULTS Data from 30 patients, who completed the study with 100% compliance, were analysed. Mean TSH values of the study participants were significantly higher both at week 6 and week 13 compared to the baseline. Mean baseline serum TSH concentrations for groups M and N were 2.70 (± 1.36), and 2.20 (± 1.06) µlU/mL, respectively. Mean serum TSH concentrations at the end periods 1 and 2 for group M were 3.78 (± 4.29), and 3.76 (± 2.77) while the levels in group N were 3.30 (± 1.90), and 4.53 (± 4.590) µlU/mL, respectively. There was a significant rise in serum TSH concentration across periods 1 and 2 in both the groups (F2, 58 = 3.87, p = 0.03). Within group changes in TSH across periods 1 and 2 were not statistically significant. Similarly difference in TSH between the groups, either at 6 weeks or at 13 weeks, were also not statistically significant. CONCLUSIONS Concomitant use of pantoprazole, even for 6 weeks, leads to significant elevation in serum TSH in levothyroxine-treated patients who are biochemically euthyroid, irrespective of timing of pantoprazole intake. Early morning and night-time administration of pantoprazole have similar effect on TFT in these patients.
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Affiliation(s)
- Avivar Awasthi
- Department of Endocrinology, Kasturba Medical College, Manipal, Karnataka, India
| | - Partha Pratim Chakraborty
- Department of Endocrinology & Metabolism, Medical College, Kolkata, MCH 4th floor, 88 College Street, Kolkata, West Bengal, 700073, India.
| | - Neeti Agrawal
- Department of Endocrinology & Metabolism, Medical College, Kolkata, MCH 4th floor, 88 College Street, Kolkata, West Bengal, 700073, India
| | - Anirban Sinha
- Department of Endocrinology & Metabolism, Medical College, Kolkata, MCH 4th floor, 88 College Street, Kolkata, West Bengal, 700073, India
| | - Anuj Kumar Pandey
- Department of Paediatrics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Animesh Maiti
- Department of Endocrinology & Metabolism, Medical College, Kolkata, MCH 4th floor, 88 College Street, Kolkata, West Bengal, 700073, India
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Liu H, Li W, Zhang W, Sun S, Chen C. Levothyroxine: Conventional and novel drug delivery formulations. Endocr Rev 2022; 44:393-416. [PMID: 36412275 PMCID: PMC10166268 DOI: 10.1210/endrev/bnac030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/18/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Hanqing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wei Li
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wen Zhang
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
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Trimboli P, Mouly S. Pharmacokinetics and Clinical Implications of Two Non-Tablet Oral Formulations of L-Thyroxine in Patients with Hypothyroidism. J Clin Med 2022; 11:jcm11123479. [PMID: 35743549 PMCID: PMC9224574 DOI: 10.3390/jcm11123479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Increased knowledge of the pharmacokinetic characteristics of orally administered levothyroxine (L-T4) has improved individualization of dosing regimens. However, up to 40-45% of patients, depending on the leading cause of hypothyroidism, are still over- or, more often, undertreated. Unintentional non-adherence to L-T4 replacement therapy includes all situations of unintended drug-drug and drug-food interactions as well as fasting conditions that are not necessarily respected by patients. RESULTS In this specific context, the overall information concerning those factors with the potential to affect L-T4 absorption refers only to tablet formulation. Indeed, this is the reason why new non-tablet formulations of L-T4 were introduced some years ago. In this regard, the current literature review was designed to summarize pharmacokinetic, drug and food interactions and clinical data focusing on two new oral L-T4 formulations, i.e., liquid and soft-gel capsule in healthy volunteers and patients with primary hypothyroidism. The non-tablet L-T4 soft-gel capsules and solution have proven bioequivalence with the usual L-T4 tablet Princeps and generic formulations. Clinical studies have suggested higher performance of non-tablet formulations than tablet in those patients with suboptimal adherence. The impact of gastrointestinal conditions and variation of gastric pH was lower with either soft gel/solution than with tablets. In addition, the extent of drug-drug and drug-food interactions remains low and of uncertain clinical relevance. CONCLUSIONS Pending further studies allowing one to extend the use of soft-gel/solution preparations in unselected patients, non-tablet L-T4 formulations should be considered as a first-line choice, especially in those patients with moderate-to-high potential of suboptimal tablet performance.
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Affiliation(s)
- Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ente Ospedaliero Cantonale (EOC), 6500 Bellinzona, Switzerland;
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Stéphane Mouly
- Assistance Publique-Hôpitaux de Paris Nord, Département Médico-Universitaire (DMU) INVICTUS, Département de Médecine Interne, Hôpital Lariboisière, INSERM UMRS-1144, Université de Paris Cité, 75010 Paris, France
- Correspondence: ; Tel.: +33-1-49-95-81-26; Fax: +33-1-49-95-84-46
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Virili C, Bruno G, Santaguida MG, Gargano L, Stramazzo I, De Vito C, Cicenia A, Scalese G, Porowska B, Severi C, Centanni M. Levothyroxine treatment and gastric juice pH in humans: the proof of concept. Endocrine 2022; 77:102-111. [PMID: 35477833 PMCID: PMC9242941 DOI: 10.1007/s12020-022-03056-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/04/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE Despite the absorption of oral thyroxine (T4) occurs in the small bowel, several patients with gastric disorders show an increased need for T4. In vitro evidence suggested that medium pH variations interfere with T4 dissolution. This study was aimed at finding the proof of concept of a direct relationship between the minimal effective dose of T4 and the actual gastric juice pH. PATIENTS AND METHODS Among 311 consecutively thyroxine-treated patients, 61 bearing Hashimoto's thyroiditis (52 F/9 M; median age = 51 years) who complained persistent dyspepsia and/or upper abdominal symptoms following a noninvasive workup for gastrointestinal disorders, underwent EGDS with multiple biopsies and gastric juice pH measurement. All patients accepted to take thyroxine in fasting conditions, abstaining from eating or drinking for one hour. RESULTS Thyroxine requirement increased along with the rising gastric pH (ρ = 0.4229; p = 0.0007). A multivariate analysis revealed that gastric pH was, beside body mass index, the far more important independent variable in determining the effective dose of T4 (p = 0.001). The ROC curve revealed that the pH threshold for an increased thyroxine requirement was at 2.28, being the AUC by 78%. Subdividing patients by the histologic findings, it appeared a significant increase (p = 0.0025) along with the progressive damage of gastric mucosa. CONCLUSION The in vivo measurement of gastric pH highlighted its key role in determining the minimal effective dose of oral T4 and may explain the interference of food, of some drugs and gut disorders on levothyroxine treatment.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Giovanni Bruno
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | | | | | - Ilaria Stramazzo
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, University of Rome, Rome, Italy
| | - Alessia Cicenia
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Giulia Scalese
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Barbara Porowska
- General and Specialistic Surgery 'Paride Stefanini', University of Rome, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.
- Endocrine Unit, AUSL Latina, Latina, Italy.
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11
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Virili C, Capriello S, Stramazzo I, Brusca N, Santaguida MG, Gargano L, Bagaglini MF, Bruno G, Severi C, Centanni M. Daily requirement of softgel thyroxine is independent from gastric juice pH. Front Endocrinol (Lausanne) 2022; 13:1002583. [PMID: 36225208 PMCID: PMC9549358 DOI: 10.3389/fendo.2022.1002583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Softgel levothyroxine (LT4) preparation showed a better in vitro dissolution profile at increasing pH as compared to tablet LT4 preparation. Clinical studies suggested a better performance of softgel LT4 preparation in patients with gastric disorders but whether this finding is related to gastric juice pH variation in vivo is not known. METHODS Twenty-eight hypothyroid patients (24F/4M; median age=50 treated with tablet LT4 (median dose= 1.65 µg/kg/day) and with stable thyroid stimulating hormone (TSH) values on target (<0.8-2.5> mU/l) have been shifted to softgel LT4 preparation. The dose of softgel LT4 has been titrated to obtain a similar individual serum TSH value. All subjects followed a specific treatment schedule, taking LT4 in fasting condition and then abstaining from eating or drinking for at least 1 hour. Owing to the presence of long-lasting dyspepsia or of already known gastric disorders, all patients underwent endoscopy, upon informed consent. Gastric juice has been collected during endoscopy to measure gastric pH. Then we plotted the dose of LT4 with the gastric pH obtained in vivo, before and after the switch tablet/softgel preparation in all patients. RESULTS Upon the switch tablet/softgel preparation, the therapeutic LT4 dose was very slightly reduced (-6%) in the whole sample. However, the individual variations revealed the existence of two populations, one without any dose reduction (A) and the other showing a dose reduction >20% (B). Upon matching with the actual gastric pH, patients with normal pH (A: n=17; 14F/3M, median 1.52) no showed a lower softgel LT4 requirement. Instead, among patients with reduced gastric acid production (B: n=11; 10F/1M, median pH 5.02) the vast majority (10/11; 91%, p<0.0001) benefited from a lower dose of softgel LT4 (median = -23%, p<0.0001). Interestingly, the dose of LT4 in tablet correlated with pH value (Spearman's ρ =0.6409; p = 0.0002) while softgel dose was independent from gastric juice pH (Spearman's ρ =1.952; p = 0.3194). CONCLUSIONS These findings provide evidence that softgel LT4 preparation is independent from the actual gastric pH in humans and may represent a significant therapeutic option in patients with increased LT4 requirement, owed to disorders impairing the gastric acidic output.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Silvia Capriello
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Ilaria Stramazzo
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Nunzia Brusca
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
| | | | - Lucilla Gargano
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
| | - Maria Flavia Bagaglini
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Giovanni Bruno
- Department of Translational and Precision Medicine, Gastroenterology Unit, ‘‘Sapienza’’ University of Rome, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Gastroenterology Unit, ‘‘Sapienza’’ University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
- *Correspondence: Marco Centanni,
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12
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Guzman-Prado Y, Vita R, Samson O. Concomitant Use of Levothyroxine and Proton Pump Inhibitors in Patients with Primary Hypothyroidism: a Systematic Review. J Gen Intern Med 2021; 36:1726-1733. [PMID: 33469743 PMCID: PMC8175524 DOI: 10.1007/s11606-020-06403-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to assess the effect of concomitant use of levothyroxine (LT4) and proton pump inhibitors (PPIs) on thyroid-stimulating hormone (TSH) levels in patients with primary hypothyroidism. METHODS A systematic review of interventional and observational studies that compared the TSH levels before and after concomitant use of LT4 and PPI was performed. Articles published in English up to September 1, 2019, were included. PubMed, EMBASE, and Cochrane Library databases. Gray literature was also searched in repositories, websites OpenGrey and Google Scholar, and abstracts of major international congresses. Study quality was assessed with the Newcastle-Ottawa quality assessment scale for observational studies and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool was used. RESULTS Five thousand twelve discrete articles were identified. Following assessment and application of eligibility criteria, seven studies were included. There was a considerable heterogeneity among the included studies in design, sample size, inclusion and exclusion criteria, treatment regimen, and baseline demographics. Each of the included studies showed an increase in TSH levels following LT4 and PPI consumption, and in the majority of these, the increase was statistically significant. DISCUSSION The concomitant use of LT4 and PPI showed a significant increase in TSH concentration. However, given the small number of studies, further research is needed to clarify the interfering role of PPI on LT4 intestinal absorption. PROSPERO REGISTRATION NUMBER CRD42020047084.
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Affiliation(s)
| | - Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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13
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Nagy EV, Perros P, Papini E, Katko M, Hegedüs L. New Formulations of Levothyroxine in the Treatment of Hypothyroidism: Trick or Treat? Thyroid 2021; 31:193-201. [PMID: 33003978 DOI: 10.1089/thy.2020.0515] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Levothyroxine (LT4) as a medication is used by up to 5.3% of the adult population. For optimal efficacy, the traditional tablet formulation (LT4tab) requires that patients avoid concomitant ingestion with food, drinks, and certain medications, as well as excellent patient compliance. Some comorbidities influence bioavailability of LT4 and may mandate repeated dose adjustments. Summary: New LT4 formulations (soft gel [LT4soft] and liquid [LT4liq]) containing predissolved LT4 are claimed to improve bioavailability, presumably by facilitating absorption. Thus, these formulations may well be more suitable than LT4tab for patients whose daily requirements are subjected to variations in bioavailability. Here, we review the evidence and indications for use of new LT4 formulations and highlight areas of uncertainty that are worthy of further investigation. While bioequivalence is established for LT4soft and LT4liq administered to healthy volunteers compared with LT4tab in pharmacokinetic (PK) studies, therapeutic equivalence of the new formulations seems to be different in several clinical settings. Some evidence suggests that new formulations of LT4 may mitigate against the strict requirements relating to concomitant ingestion with food, drinks, and certain medications, which apply to traditional LT4 tablets. The principal indication is in selected patients with disease fluctuations and intermittent therapies with interfering medications, where the need for frequent dose adjustments and office visits may be diminished. Whether the use of LT4soft or LT4liq in patients with impaired gastric acid secretion results in better control of hypothyroidism than LT4tab remains unclear. Conclusions: The evidence in favor of using LT4soft and LT4liq in clinical practice over LT4tab is weak, and the underlying putative PK mechanisms unclear. Additional studies to investigate these potential benefits, define the cost-effectiveness, and understand the PK mechanisms involved with new LT4 formulations are needed.
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Affiliation(s)
- Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - Monika Katko
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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14
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Concordet D, Gandia P, Montastruc JL, Bousquet-Mélou A, Lees P, Ferran A, Toutain PL. Levothyrox ® New and Old Formulations: Are they Switchable for Millions of Patients? Clin Pharmacokinet 2020; 58:827-833. [PMID: 30949873 PMCID: PMC6584220 DOI: 10.1007/s40262-019-00747-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In France, more than 2.5 million patients are currently treated with levothyroxine, mainly as the marketed product Levothyrox®. In March 2017, at the request of French authorities, a new formulation of Levothyrox® was licensed, with the objective of avoiding stability deficiencies of the old formulation. Before launching this new formulation, an average bioequivalence trial, based on European Union recommended guidelines, was performed. The implicit rationale was the assumption that the two products, being bioequivalent, would also be switchable, allowing substitution of the new for the old formulation, thus avoiding the need for individual calibration of the dosage regimen of thyroxine, using the thyroid-stimulating hormone level as the endpoint, as required for a new patient on initiating treatment. Despite the fact that both formulations were shown to be bioequivalent, adverse drug reactions were reported in several thousands of patients after taking the new formulation. In this opinion paper, we report that more than 50% of healthy volunteers enrolled in a successful regulatory average bioequivalence trial were actually outside the a priori bioequivalence range. Therefore, we question the ability of an average bioequivalence trial to guarantee the switchability within patients of the new and old levothyroxine formulations. We further propose an analysis of this problem using the conceptual framework of individual bioequivalence. This involves investigating the bioavailability of the two formulations within a subject, by comparing not only the population means (as established by average bioequivalence) but also by assessing two variance terms, namely the within-subject variance and the variance estimating subject-by-formulation interaction. A higher within individual variability for the new formulation would lead to reconsideration of the appropriateness of the new formulation. Alternatively, a possible subject-by-formulation interaction would allow a judgement on the ability, or not, of doctors to manage patients effectively during transition from the old to the new formulation.
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Affiliation(s)
| | - Peggy Gandia
- INTHERES, Université de Toulouse, INRA, ENVT, Toulouse, France
| | - Jean-Louis Montastruc
- Service de Pharmacologie Médicale et Clinique, INSERM UMR 1027, CIC INSERM 1436, Faculté de Médecine, Centre Hospitalier Universitaire de Toulouse, Université de Toulouse, Toulouse, France
| | | | - Peter Lees
- Royal Veterinary College, University of London, London, UK
| | - Aude Ferran
- INTHERES, Université de Toulouse, INRA, ENVT, Toulouse, France
| | - Pierre-Louis Toutain
- INTHERES, Université de Toulouse, INRA, ENVT, Toulouse, France. .,Royal Veterinary College, University of London, London, UK.
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15
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Pottel J, Armstrong D, Zou L, Fekete A, Huang XP, Torosyan H, Bednarczyk D, Whitebread S, Bhhatarai B, Liang G, Jin H, Ghaemi SN, Slocum S, Lukacs KV, Irwin JJ, Berg EL, Giacomini KM, Roth BL, Shoichet BK, Urban L. The activities of drug inactive ingredients on biological targets. Science 2020; 369:403-413. [PMID: 32703874 DOI: 10.1126/science.aaz9906] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 05/18/2020] [Indexed: 12/22/2022]
Abstract
Excipients, considered "inactive ingredients," are a major component of formulated drugs and play key roles in their pharmacokinetics. Despite their pervasiveness, whether they are active on any targets has not been systematically explored. We computed the likelihood that approved excipients would bind to molecular targets. Testing in vitro revealed 25 excipient activities, ranging from low-nanomolar to high-micromolar concentration. Another 109 activities were identified by testing against clinical safety targets. In cellular models, five excipients had fingerprints predictive of system-level toxicity. Exposures of seven excipients were investigated, and in certain populations, two of these may reach levels of in vitro target potency, including brain and gut exposure of thimerosal and its major metabolite, which had dopamine D3 receptor dissociation constant K d values of 320 and 210 nM, respectively. Although most excipients deserve their status as inert, many approved excipients may directly modulate physiologically relevant targets.
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Affiliation(s)
- Joshua Pottel
- Department of Pharmaceutical Chemistry, University of California, San Francisco, CA 94158, USA
| | - Duncan Armstrong
- Preclinical Safety, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Ling Zou
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA 94158, USA
| | - Alexander Fekete
- Preclinical Safety, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Xi-Ping Huang
- Department of Pharmacology, University of North Carolina, Chapel Hill, NC 27759, USA
| | - Hayarpi Torosyan
- Department of Pharmaceutical Chemistry, University of California, San Francisco, CA 94158, USA
| | - Dallas Bednarczyk
- PK Sciences, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Steven Whitebread
- Preclinical Safety, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Barun Bhhatarai
- PK Sciences, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Guiqing Liang
- PK Sciences, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Hong Jin
- Preclinical Safety, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - S Nassir Ghaemi
- Translational Medicine, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA.,Tufts University School of Medicine, Boston, MA 02111, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Samuel Slocum
- Department of Pharmacology, University of North Carolina, Chapel Hill, NC 27759, USA
| | - Katalin V Lukacs
- National Heart and Lung Institute, Imperial College, London SW7 2AZ, UK
| | - John J Irwin
- Department of Pharmaceutical Chemistry, University of California, San Francisco, CA 94158, USA
| | - Ellen L Berg
- Eurofins, DiscoverX, South San Francisco, CA 94080, USA
| | - Kathleen M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA 94158, USA
| | - Bryan L Roth
- Department of Pharmacology, University of North Carolina, Chapel Hill, NC 27759, USA
| | - Brian K Shoichet
- Department of Pharmaceutical Chemistry, University of California, San Francisco, CA 94158, USA.
| | - Laszlo Urban
- Preclinical Safety, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA.
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16
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Virili C, Brusca N, Capriello S, Centanni M. Levothyroxine Therapy in Gastric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2020; 11:621616. [PMID: 33584549 PMCID: PMC7876372 DOI: 10.3389/fendo.2020.621616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/11/2020] [Indexed: 12/19/2022] Open
Abstract
Oral levothyroxine sodium is absorbed in the small intestine, mainly in the jejunum and the ileum being lower the absorption rate at duodenal level. The time interval between the ingestion of oral thyroxine and its appearance in the plasma renders unlike a gastric absorption of the hormone. However, several evidence confirm the key role of the stomach as a prerequisite for an efficient absorption of oral levothyroxine. In the stomach, in fact, occur key steps leading to the dissolution of thyroxine from the solid form, the process bringing the active ingredient from the pharmaceutical preparation to the aqueous solution. In particular, gastric juice pH, volume, viscosity, as well as gastric emptying time seem to be the most important limiting factors. These hypotheses are confirmed by the detection of an increased need for levothyroxine in patients with Helicobacter pylori infection, chronic atrophic gastritis, gastroparesis, or in simultaneous treatment with drugs interfering with gastric acidic output. The aim of the present article is to focus on the knowledge of pathophysiologic events that determine the absorptive fate of traditional (tablet) and alternative thyroxine preparations (softgel capsule and liquid solution) in patients bearing gastric disorders.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Nunzia Brusca
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Capriello
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
- *Correspondence: Marco Centanni,
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17
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Benvenga S. Liquid and softgel capsules of l-thyroxine results lower serum thyrotropin levels more than tablet formulations in hypothyroid patients. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2019; 18:100204. [PMID: 31844631 PMCID: PMC6896494 DOI: 10.1016/j.jcte.2019.100204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 12/14/2022]
Abstract
Objective Evidence indicates that L-T4 in liquid and softgel capsule are absorbed better than tablets in hypothyroid patients, even when patients are under medications that impair the intestinal absorption of L-T4. However, no study has evaluated all three L-T4 formulations in the same hypothyroid patients. This study aims to fill this gap. The outcome was the degree of TSH change in the liquid and softgel formulations, using tablet L-T4 as the reference, regardless of sequence of formulation and regardless of whether patients were co-ingesting with interfering medications. Methods We recorded serum TSH levels in two groups of L-T4 replaced patients with primary hypothyroidism (23 subjects who did not co-ingest interfering medications, and 20 subjects who did). Either group of patients took one formulation of L-T4 at a time with variable sequences. In the first group, the median durations of exposure to tablet, liquid or softgel L-T4 were 14, 9 and 10 months, respectively. In the second group the corresponding durations were 13, 11 and 10 months, during which patients co-ingested interfering medications. Results In the 23 patients, there were 78, 74 or 101 TSH determinations during liquid, softgel capsule or tablet L-T4 regimens. Serum TSH levels associated with liquid, capsule or tablet L-T4 were 1.62 ± 0.51, 1.77 ± 0.44 mU/L (P = 0.049 vs liquid) or 2.38 ± 0.69 mU/L (P < 0.0001 vs liquid or capsule). Rates of TSH ≤ 2.50 mU/L were 97.4% (liquid), 95.9% (softgel) or 64.4% (tablet, P < 0.0001 vs liquid or capsule). Rates of TSH ≤ 4.12 mU/L were 100%, 100% or 98.0%. In the 20 patients, the corresponding TSH determinations were 56, 57 and 41, and corresponding TSH levels were 2.74 ± 0.98, 2.70 ± 0.79 or 7.53 ± 2.82 mU/L. Rates of TSH ≤ 2.50 mU/L were 51.8% (liquid), 47.4% (capsule, P = 0.64) or 2.4% (tablet, P < 0.0001 vs liquid or capsule). Rates of TSH ≤ 4.12 mU/L were 92.8% (liquid), 94.7% (capsule, P = 0.68) or 12.2% (tablet, P < 0.0001 vs liquid or capsule). Conclusions L-T4 ingested as liquid solution or softgel capsule is more bioavailable compared to L-T4 ingested as tablet, and it is slightly superior to capsule L-T4 only in the absence of co-ingestion of interfering medications.
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Affiliation(s)
- Salvatore Benvenga
- Endocrinology Section, 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 & Clinical Endocrinology, and Women's Endocrine Health, University Hospital, AOU Policlinico G. Martino, Messina, Italy
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18
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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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19
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Authors' Reply to Castello-Bridoux et al.: "Comment on Levothyrox ® New and Old Formulations: Are they Switchable for Millions of Patients?". Clin Pharmacokinet 2019; 58:973-975. [PMID: 31187470 PMCID: PMC6584249 DOI: 10.1007/s40262-019-00786-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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20
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Tanguay M, Girard J, Scarsi C, Mautone G, Larouche R. Pharmacokinetics and Comparative Bioavailability of a Levothyroxine Sodium Oral Solution and Soft Capsule. Clin Pharmacol Drug Dev 2018; 8:521-528. [PMID: 30153382 PMCID: PMC6585626 DOI: 10.1002/cpdd.608] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/05/2018] [Indexed: 12/11/2022]
Abstract
A new formulation of levothyroxine sodium has been developed in the form of an oral solution contained in unit‐dose ampules. A study has been conducted to compare the bioavailability of levothyroxine sodium oral solution and levothyroxine sodium soft capsule in healthy volunteers under fasting conditions. The rate and extent of absorption of the new levothyroxine solution were also evaluated when administered on dilution in water or directly into the mouth without water. In each period, according to the randomization scheme, subjects were administered single oral doses of either test, as 4 × 150‐μg unit‐dose ampules, with or without water, or reference, as 4 × 150‐μg capsules in a crossover design. Thirty‐six subjects were randomized and dosed in this study; of these, 31 completed all study periods. When comparing the solution with the capsule (both products administered with water), the 90% confidence intervals for the ratio of log‐transformed values of AUC0‐48 and Cmax were within 90.00% and 111.11%, respectively, for baseline‐corrected levothyroxine. Moreover, the administration of levothyroxine oral solution without water did not affect the rate and extent of its absorption. In conclusion, levothyroxine oral solution unit‐dose ampules were bioequivalent to the levothyroxine capsule when administered with or without water. All formulations were well tolerated, with no major side effects.
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Affiliation(s)
- Mario Tanguay
- Syneos Health, Quebec City, Quebec, Canada.,Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, Canada
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21
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Trimboli P, Virili C, Centanni M, Giovanella L. Thyroxine Treatment With Softgel Capsule Formulation: Usefulness in Hypothyroid Patients Without Malabsorption. Front Endocrinol (Lausanne) 2018; 9:118. [PMID: 29619010 PMCID: PMC5871661 DOI: 10.3389/fendo.2018.00118] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 03/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Levothyroxine sodium (LT4) is the therapy of choice for hypothyroidism. In the last decade, new LT4 formulations, such as liquid and softgel capsules, became available. Even if some evidence has been reached in the efficacy of liquid LT4 in patients with suboptimal TSH on tablet LT4, the usefulness of softgel LT4 has been rarely studied. This study aimed at evaluating the effect of switching from tablet to softgel LT4 patients without increased need for LT4. TSH was used as proxy of LT4 bioavailability and effectiveness. METHODS During the period from April to August 2017, 19 patients on tablet LT4 treatment for hypothyroidism, mostly due to autoimmune thyroiditis, were enrolled. Subjects with causes of malabsorption or increased requirement of LT4 were previously excluded. Patients finally included were asked to switch from tablet to softgel LT4 formulation at unchanged dose and ingestion fashion (30 min before breakfast). TSH was measured with chemiluminescence immunoassays. RESULTS According to exclusion and inclusion criteria, 19 patients were finally selected. One of these had headache 4 days later and come back to tablet LT4, and 18 of them (16W/2M; mean age = 55 years; BMI 22.7 kg/m2) completed the study. They were treated with a median LT4 dose of 88 μg/day and showed a median TSH value of 3.33 mIU/L. The rate of cases with TSH ≤ 4.0 mIU/L was 61.1% (11/18 cases). When patients were re-evaluated after 3 months of softgel LT4, we observed that TSH reached levels under 4.0 mIU/L in 16/18 (88.9%) patients, TSH was lower in 11 cases, and in 6 out of 7 patients with pre-switch TSH values over the normal range. Overall, TSH values on softgel LT4 (median 1.90 mIU/L) was significantly lower from that observed during tablet LT4 (p = 0.0039). CONCLUSION These data show that hypothyroid patients with no proven malabsorption may have an improved TSH following 3 months from the switch from tablet to softgel LT4 preparation at unchanged dose.
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Affiliation(s)
- Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- *Correspondence: Pierpaolo Trimboli,
| | - Camilla Virili
- 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
| | - Luca Giovanella
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. Lancet 2017; 390:1550-1562. [PMID: 28336049 PMCID: PMC6619426 DOI: 10.1016/s0140-6736(17)30703-1] [Citation(s) in RCA: 540] [Impact Index Per Article: 77.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 01/15/2017] [Accepted: 01/19/2017] [Indexed: 12/19/2022]
Abstract
Hypothyroidism is a common condition of thyroid hormone deficiency, which is readily diagnosed and managed but potentially fatal in severe cases if untreated. The definition of hypothyroidism is based on statistical reference ranges of the relevant biochemical parameters and is increasingly a matter of debate. Clinical manifestations of hypothyroidism range from life threatening to no signs or symptoms. The most common symptoms in adults are fatigue, lethargy, cold intolerance, weight gain, constipation, change in voice, and dry skin, but clinical presentation can differ with age and sex, among other factors. The standard treatment is thyroid hormone replacement therapy with levothyroxine. However, a substantial proportion of patients who reach biochemical treatment targets have persistent complaints. In this Seminar, we discuss the epidemiology, causes, and symptoms of hypothyroidism; summarise evidence on diagnosis, long-term risk, treatment, and management; and highlight future directions for research.
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Affiliation(s)
- Layal Chaker
- Academic Centre for Thyroid Disease, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Antonio C Bianco
- Division of Endocrinology and Metabolism, Rush University Medical Center, Chicago, IL, USA
| | | | - Robin P Peeters
- Academic Centre for Thyroid Disease, Erasmus University Medical Centre, Rotterdam, Netherlands.
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Ernst FR, Sandulli W, Elmor R, Welstead J, Sterman AB, Lavan M. Retrospective Study of Patients Switched from Tablet Formulations to a Gel Cap Formulation of Levothyroxine: Results of the CONTROL Switch Study. Drugs R D 2017; 17:103-115. [PMID: 27943146 PMCID: PMC5318319 DOI: 10.1007/s40268-016-0150-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Medication changes involving levothyroxine-either dose titrations or switching formulations-occur frequently in patients with erratic thyroid-stimulating hormone (TSH) levels and persistent hypothyroid symptoms. We investigated whether switching patients from levothyroxine tablets to a gel cap formulation of levothyroxine might reduce dose adjustments and improve tolerability and efficacy outcomes. OBJECTIVES Primary study objectives included quantifying the percentage of patients achieving TSH levels within a pre-specified range, median dose changes experienced, and the percentage of patients with improved hypothyroid symptom control after switching from levothyroxine tablets to levothyroxine gel caps. METHODS A retrospective medical chart review was conducted among 99 randomly selected hypothyroid patients who were switched from a tablet to a gel cap formulation of levothyroxine. Patients were required to have been on levothyroxine monotherapy for ≥1 year prior to the medication switch. Data was collected for 6 months pre-switch and up to 6 months post-switch. RESULTS Of the 99 patients studied, the majority (51.5%) experienced no documented change in TSH status after the switch (P < 0.0001). However, there was a decrease in the mean number of dose changes experienced (1.61 ± 0.96 vs. 0.73 ± 0.96; P < 0.0001). Improved hypothyroid symptom control was reported among 61.6% of patients (61 of 99; P < 0.0001). CONCLUSION The results of CONTROL Switch support a strategy of switching patients who may experience tolerability or efficacy problems with standard levothyroxine tablets to the levothyroxine gel cap formulation.
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Affiliation(s)
- Frank R Ernst
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA.
| | | | - Riad Elmor
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA
| | - Jennifer Welstead
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA
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Cristofoletti R, Patel N, Dressman JB. Assessment of Bioequivalence of Weak Base Formulations Under Various Dosing Conditions Using Physiologically Based Pharmacokinetic Simulations in Virtual Populations. Case Examples: Ketoconazole and Posaconazole. J Pharm Sci 2017; 106:560-569. [DOI: 10.1016/j.xphs.2016.10.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
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Benvenga S, Capodicasa G, Perelli S. l-Thyroxine in an Oral Liquid or Softgel Formulation Ensures More Normal Serum Levels of Free T4 in Patients with Central Hypothyroidism. Front Endocrinol (Lausanne) 2017; 8:321. [PMID: 29209276 PMCID: PMC5701926 DOI: 10.3389/fendo.2017.00321] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/01/2017] [Indexed: 12/20/2022] Open
Abstract
CONTEXT l-Thyroxine (l-T4) therapy of central hypothyroidism (CH) is guided by measurements of serum free thyroxine (FT4), which should be above the midnormal range value (MNRV). In some countries, novel formulations of oral l-T4 (liquid or softgel) are available further to the classic tablets. The intestinal absorption of either novel formulation is greater than tablets in patients with primary hypothyroidism. OBJECTIVE To evaluate whether new oral formulations of l-T4 could be considered optimal in patients with CH who do not reach the FT4 target using tablet l-T4. DESIGN Our observation of six patients with isolated CH and serum FT4 below MNRV under stable adequate doses of tablet l-T4 (median 1.51 μg/kg bw/day), prompted us to switch them to liquid (n = 4) or softgel (n = 3) l-T4 at the same dose, and verify whether FT4 increased above MNRV. A seventh patient with FT4 above MNRV was enrolled because she wanted a "more modern formulation." Postswitch FT4 was measured at least twice with the same kit as preswitch FT4. RESULTS In the first six patients, postswitch FT4 averaged 13.0 ± 1.6 pg/ml compared to 10.4 ± 1.8 preswitch FT4 (P = 0.00026), with 11/13 (85%) measurements above MNRV compared to 0/20. In the liquid or softgel l-T4 group, postswitch FT4 averaged 13.1 ± 1.6 vs. 10.6 ± 0.9 pg/ml preswitch (P = 0.0004) or 12.9 ± 2.1 vs. 10.3 ± 2.4 (P = 0.048), respectively. In the seventh patient (switched to liquid l-T4), averages were 18.3 vs. 15.2 pg/ml, and proportions 4/4 vs. 2/2. CONCLUSION In CH patients, oral liquid or softgel l-T4 administered at the same doses as tablet l-T4 ensures target serum FT4 levels above MNRV that tablet l-T4 may miss. In turn, this performance suggests the more favorable pharmacokinetics profile of either novel formulation compared with the tablet formulation.
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Affiliation(s)
- 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 on Molecular & Clinical Endocrinology, and Women’s Endocrine Health, Azienda Ospedaliera Universitaria Policlinico G. Martino, Messina, Italy
| | - Giovanni Capodicasa
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Sarah Perelli
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- *Correspondence: Sarah Perelli,
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Guglielmi R, Frasoldati A, Zini M, Grimaldi F, Gharib H, Garber JR, Papini E. ITALIAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS STATEMENT-REPLACEMENT THERAPY FOR PRIMARY HYPOTHYROIDISM: A BRIEF GUIDE FOR CLINICAL PRACTICE. Endocr Pract 2016; 22:1319-1326. [PMID: 27482609 DOI: 10.4158/ep161308.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Hypothyroidism requires life-long thyroid hormone replacement therapy in most patients. Oral levothyroxine (LT4) is an established safe and effective treatment for hypothyroidism, but some issues remain unsettled. METHODS The Italian Association of Clinical Endocrinologists appointed a panel of experts to provide an updated statement for appropriate use of thyroid hormone formulations for hypothyroidism replacement therapy. The American Association of Clinical Endocrinologists' protocol for standardized production of clinical practice guidelines was followed. RESULTS LT4 is the first choice in replacement therapy. Thyroid-stimulating hormone (TSH) should be maintained between 1.0 and 3.0 mIU/L in young subjects and at the upper normal limit in elderly or fragile patients. Achievement of biochemical targets, patient well-being, and adherence to treatment should be addressed. In patients with unstable serum TSH, a search for interfering factors and patient compliance is warranted. Liquid or gel formulations may be considered in subjects with hampered LT4 absorption or who do not allow sufficient time before or after meals and LT4 replacement. Replacement therapy with LT4 and L-triiodothyronine (LT3) combination is generally not recommended. A trial may be considered in patients with normal values of serum TSH who continue to complain of symptoms of hypothyroidism only after co-existent nonthyroid problems have been excluded or optimally managed. LT3 should be administered in small (LT4:LT3 ratio, 10:1 to 20:1) divided daily doses. Combined therapy should be avoided in elderly patients or those with cardiac risk factors and in pregnancy. CONCLUSION LT4 therapy should be aimed at resolution of symptoms of hypothyroidism, normalization of serum TSH, and improvement of quality of life. In selected cases, the use of liquid LT4 formulations or combined LT4/LT3 treatment may be considered to improve adherence to treatment or patient well-being. ABBREVIATIONS AACE = American Association of Clinical Endocrinologists FT3 = free triiodothyronine FT4 = free thyroxine LT3 = levotriiodothyronine LT4 = levothyroxine MeSH = medicine medical subject headings QoL = quality of life TSH = thyroid-stimulating hormone.
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