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Alhawari HH, Abuhamdan RM, Alrashdan M, Al Thaher Y, Shraideh ZA, Abulateefeh SR. Development and In Vivo Evaluation of Sustained Release Microparticles Loaded with Levothyroxine for Hypothyroidism Treatment. J Pharm Sci 2024; 113:1566-1571. [PMID: 38232803 DOI: 10.1016/j.xphs.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 01/19/2024]
Abstract
Hypothyroidism is a chronic condition combated by a daily oral supplementation of levothyroxine. In addition to the need for frequent dosing, oral administration may result in variable absorption of the drug leading to a failure in achieving normal thyroid function. Therefore, the development of a long-acting injectable system capable of delivering the drug is necessary. This work was aimed at developing sustained release microparticles loaded with levothyroxine. The microparticles were produced through the emulsification-solvent evaporation method using 2 grades of biocompatible and biodegradable polyesters: poly(ᴅ,ʟ-lactide-co-glycolide) (PLGA) and poly(ᴅ,ʟ-lactide) (PLA). Both polymers produced microparticles with very similar sizes (1.9 µm) and zeta potential values (around -22.0 mV). However, PLA microparticles had a significantly higher drug loading (6.1% vs. 4.4%, respectively) and encapsulation efficiency (36.8%, vs. 26.1%, respectively) when compared to PLGA counterparts. While both types of microparticles displayed a biphasic release pattern in vitro, a slower rate of release was observed with PLA microparticles. Moreover, a similar biphasic release pattern was found in vivo, with an initial phase of rapid release followed by a slower phase in the subsequent 10 days. These results indicate the possibility of developing levothyroxine loaded polyester microparticles as a potential long-acting thyroid hormone replacement therapy.
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Affiliation(s)
| | | | - Majd Alrashdan
- School of Pharmacy, The University of Jordan, Amman 11942, Jordan
| | - Yazan Al Thaher
- Faculty of Pharmacy, Philadelphia University, Amman 19392, Jordan
| | - Ziad A Shraideh
- School of Science, The University of Jordan, Amman 11942, Jordan
| | - Samer R Abulateefeh
- School of Pharmacy, The University of Jordan, Amman 11942, Jordan; Faculty of Pharmacy, Al-Zaytoonah University of Jordan, Amman 11733, Jordan.
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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:S1530-891X(24)00471-3. [PMID: 38554774 DOI: 10.1016/j.eprac.2024.03.388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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Jee SB, Sawal A. Physiological Changes in Pregnant Women Due to Hormonal Changes. Cureus 2024; 16:e55544. [PMID: 38576690 PMCID: PMC10993087 DOI: 10.7759/cureus.55544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
Pregnancy affects many organ systems and causes significant physiological changes that are mainly caused by changes in hormone levels. This review explores the complex interactions between pregnancy-related hormonal changes and renal function, providing insights into the practical applications of these relationships. Extensive literature searches were conducted, combining data from several sources to produce thorough knowledge. Essential discoveries include changes in renal hemodynamics, calcium/phosphorus level variations, thyroid gland hypertrophy, changed function, and cardiovascular adaptations. The review also addresses how sex hormones affect immunological responses, emphasizing their importance for conditions like multiple sclerosis. Additionally impacted is the gastrointestinal tract, which results in symptoms like nausea and heartburn. Comprehending these physiological changes is essential for proficient therapeutic handling, guaranteeing the best possible health for both the mother and the fetus. The study emphasizes the importance of specialized medical treatment during pregnancy and calls for more investigation to clarify the intricacies of these physiological changes.
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Affiliation(s)
- Sohan B Jee
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Sawangi (Meghe) Wardha, Wardha, IND
| | - Anupama Sawal
- Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Sawangi (Meghe) Wardha, Wardha, IND
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Gezer E. Morning exercise affects the absorption of oral levothyroxine: a single center pilot study. Endocrine 2024:10.1007/s12020-024-03698-3. [PMID: 38280145 DOI: 10.1007/s12020-024-03698-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 01/12/2024] [Indexed: 01/29/2024]
Abstract
PURPOSE Levothyroxine (LT4) is the first-line hormone replacement therapy for hypothyroidism. Several factors which have an influence on oral LT4 absorption have been previously described; however, the influence of exercise on oral LT4 absorption has not been reported, yet. It was aimed to investigate the possible effect of morning exercise, right after LT4 ingestion, on the absorption of LT4 tablets in this study. PATIENTS AND METHODS Patients with primary hypothyroidism who fulfilled the inclusion criteria were offered to participate in a 6-week morning exercise programme and those who agreed to participate were enrolled in our study. Patients were required to have a walk for 30 min with a regular speed right after taking their daily LT4 treatments and start having breakfast the first hour after LT4 intake. Pre- and post-exercise TSH levels were recorded and TSH percentage change was calculated. RESULTS All patients had decreased TSH levels after the exercise programme. There was a significant decrease in TSH levels (p < 0.001). A significant positive correlation between TSH percentage change and daily dose of LT4 per kg of body weight was also shown. CONCLUSIONS This is the first study which demonstrates the significant positive effect of morning exercise on the absorption of LT4 tablets. In addition to that, it was also found that as the daily dose of LT4 increases, the percentage decrease of TSH level becomes greater.
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Affiliation(s)
- Emre Gezer
- Darica Farabi Training and Research Hospital, Division of Endocrinology and Metabolism, Kocaeli, Turkey.
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Almukainzi M, AlQahtani R, Alanazi R, Alamri R, Alayed H. Insight of the Biopharmaceutical Implication of Sleeve Gastrectomy on Levothyroxine Absorption in Hypothyroidism Patients. Obes Surg 2024; 34:192-197. [PMID: 38091193 DOI: 10.1007/s11695-023-06970-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE The growing rate of obesity led to an increased number of bariatric surgeries (BS) as a treatment option for obesity. The gastrointestinal tract (GIT) changes following BS can impact many drugs' absorption. Levothyroxine (LT4) is a synthetic thyroxine (T4) replacement used commonly as tablets to manage hypothyroidism disorder, which is more prevalent among patients with obesity. This study aims to examine the LT4 oral tablet form therapy after sleeve gastrectomy. MATERIALS AND METHODS A retrospective cohort study was conducted in multi-center. The LT4 doses and TSH and T4 levels were compared before and after BS. The post-surgery readings were categorized into three periods: (one to three months), (four to six months), and (> six ) months after surgery. ANOVA test was used for analysis. RESULTS A total of 14374 patients who underwent BS from (1/2019 to 3/2022) were screened for eligibility, and n = 101 participants matched the inclusion criteria. The TSH and T4 were not statistically significant differences before and after surgery (P-values of 0.4864 and 0.5970, respectively). However, the doses significantly differed before and after surgery in all the follow-up time point periods (P < 0.002). CONCLUSION The LT4 required doses significantly reduced after sleeve gastrectomy, which can be related to the improved endogenous thyroid production in patients with obesity. However, the abnormality of the GIT induced by the sleeve gastrectomy may affect the exogenous LT4 absorption. Using liquid forms of LT4 while monitoring the thyroid function parameters can optimize the treatment after the procedure.
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Affiliation(s)
- May Almukainzi
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, 11671, Riyadh, Saudi Arabia.
| | - Reem AlQahtani
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, 11671, Riyadh, Saudi Arabia
| | - Rimah Alanazi
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, 11671, Riyadh, Saudi Arabia
| | - Rawan Alamri
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, 11671, Riyadh, Saudi Arabia
| | - Hajar Alayed
- Pharmaceutical Care, Dr. Suliman AlHabib Medical Group, Riyadh, Saudi Arabia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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Cherchir F, Oueslati I, Mouelhi Y, Talbi E, Feki M, Yazidi M, Chihaoui M. Levothyroxine liquid oral substitution as an alternative treatment for refractory hypothyroidism due to gastrointestinal malabsorption: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231209229. [PMID: 37927364 PMCID: PMC10623934 DOI: 10.1177/2050313x231209229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Tablets of levothyroxine (LT4) are the most used form for the treatment of hypothyroidism. Some patients may present with refractory hypothyroidism despite a high daily LT4 dose. We report the case of a 49-year-old woman who was admitted to our department for refractory hypothyroidism. She was treated with 300 μg oral LT4 tablets daily (3.9 μg/kg/day). Despite good compliance and regular intake of high doses of LT4, she had persistent symptoms of hypothyroidism and a thyroid-stimulating hormone level of 92.4 mIU/L. LT4 absorption test was consistent with the diagnosis of malabsorption. Etiological investigations revealed Helicobacter pylori gastritis. Helicobacter infection was adequately treated, but symptoms of hypothyroidism and elevated thyroid-stimulating hormone persisted. Increased LT4 doses (400 μg) failed to normalize thyroid-stimulating hormone levels. Thus, she was put on LT4 liquid form at a dose of 80 drops/day per day (400 µg). Two weeks later, she presented with clinical and biological improvement with a normal free thyroxine level of 1.14 ng/dL. Patients with gastrointestinal disorders may present with refractory hypothyroidism despite increasing doses of LT4. Switching to liquid formulation may resolve this problem.
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Affiliation(s)
- Faten Cherchir
- Faculty of Medicine of Tunis, Department of Endocrinology, La Rabta University Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Faculty of Medicine of Tunis, Department of Endocrinology, La Rabta University Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Yasmine Mouelhi
- Faculty of Medicine of Tunis, Department of Endocrinology, La Rabta University Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Emna Talbi
- Faculty of Medicine of Tunis, Laboratory of Biochemistry, La Rabta University Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Moncef Feki
- Faculty of Medicine of Tunis, Laboratory of Biochemistry, La Rabta University Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Faculty of Medicine of Tunis, Department of Endocrinology, La Rabta University Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Melika Chihaoui
- Faculty of Medicine of Tunis, Department of Endocrinology, La Rabta University Hospital, University of Tunis El Manar, Tunis, Tunisia
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Gatta E, Maltese V, Cavadini M, Anelli V, Bambini F, Buoso C, Facondo P, Pirola I, Delbarba A, Cappelli C. Interference or Noninterference Between Soy and Levothyroxine: That Is the Question. A Narrative Review of Literature. Endocr Pract 2023; 29:897-901. [PMID: 37633413 DOI: 10.1016/j.eprac.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE To evaluate the effect of soy intake on levothyroxine (L-T4) absorption among different L-T4 formulations. METHODS A PubMed/MEDLINE, Web of Science, and Scopus research was performed. Case reports, case series, and original studies written in English and published online up to November 30, 2022, were selected and reviewed. The final reference list was defined based on the relevance of each study to the scope of this review. RESULTS Few data, mainly case reports, seemed to suggest a possible interference of soy products on L-T4 tablets absorption. However, the only prospective randomized cross-over study showed no differences in L-T4 absorption when L-T4 and soy isoflavones were assumed concomitantly. The very little data available on liquid L-T4 formulations did not allow for any conclusions to be made, even if a double-blind placebo-controlled trial showed no impaired L-T4 absorption. CONCLUSION The inference of soy products on L-T4 absorption, if present, seems to have little clinical impact. Considering this fact, the Hamlet-like question whether soy milk interferes with L-T4 absorption remains unanswered.
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Affiliation(s)
- Elisa Gatta
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Virginia Maltese
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Maria Cavadini
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Valentina Anelli
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Bambini
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Caterina Buoso
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Paolo Facondo
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Ilenia Pirola
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Andrea Delbarba
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy
| | - Carlo Cappelli
- Department of Clinical and Experimental Sciences, SSVD Endocrinologia, University of Brescia, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili di Brescia, Brescia, Italy.
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Dempsey AL, Wang GHM, Singh Ospina N, Vouri SM. Concomitant use of levothyroxine and interacting medications in U.S. ambulatory care visits. J Am Pharm Assoc (2003) 2023; 63:1553-1557.e3. [PMID: 37329957 PMCID: PMC10976856 DOI: 10.1016/j.japh.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/19/2023] [Accepted: 06/11/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Levothyroxine (LT4) is the third most commonly prescribed medication in the United States. It is a narrow therapeutic index medication, and thus can be impacted by drug-drug interactions, which are primarily available over-the-counter. The prevalence and associated factors with concomitant interacting drugs with LT4 is limited since over-the-counter products are not routinely captured in many drug databases. OBJECTIVE This study aimed to characterize the concomitant use of LT4 with interacting drugs at ambulatory care visits in the United States. DESIGN A cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2018 was completed. SETTING AND PARTICIPANTS Ambulatory care visits in the United States involving adult patients with a LT4 prescription were included in the analysis. OUTCOME MEASURES The primary outcome was initiation or continuation of a selected concomitant interacting drug which impacts LT4 absorption (e.g., proton pump inhibitor) in a patient visit in conjunction with LT4. RESULTS The authors analyzed 372,942,000 visits (weighted from a sample of 14,880) with a reported LT4 prescription. Concomitant use of interacting drugs with LT4 occurred in 24.4% of visits in which 80% of interacting drugs were proton pump inhibitors. Ages 35-49 years (adjusted odds ratio [aOR], 1.59), 50-64 years (aOR, 2.27), and ≥65 years (aOR, 2.87) compared to 18-34 years, female (aOR 1.37) versus males, and visits in 2014 or later (aOR, 1.27) versus 2006-2009 were associated with increased odds of concomitant interacting drug use in multivariable analysis. CONCLUSION At ambulatory care visits between 2006 and 2018, concomitant use of LT4 and interacting drugs impacted one-quarter of patient visits. Increased age, females, and visits later in the study period were associated with increased odds for concomitant interacting drugs. Additional work is needed to identify downstream consequences of concomitant use.
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Coiffard J, Aubry A, Bleibtreu A, Fourniols E, Junot H. Impact of clinical pharmacist interventions in a bone and joint infection orthoseptic surgery unit. Ann Pharm Fr 2023; 81:826-832. [PMID: 37075975 DOI: 10.1016/j.pharma.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 02/09/2023] [Accepted: 04/13/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES To assess the impact of interventions of a clinical pharmacist in a unit of orthopedic surgery specialized in bone and joint infections. METHODS Daily, in routine, a clinical pharmacist analyzed medication prescribed to inpatients via a computerized physician order entry (CPOE) (Phedra software). His attention was particularly focused on the impact of antibiotics on other medications. For this study, all of the pharmacist interventions (PI) have been retrospectively collected, then anonymized, and assessed over a two-month period. RESULTS Thirty-eight patients were hospitalized during the study period, with a mean age of 63 years old. Forty-five interventions were identified which represents a mean of 1.18 pharmaceutical interventions per patient. Most of them concerned lack of follow-up (24%) and drug-drug interactions (22%) and widely non-anti-infectious medication (35 interventions) with levothyroxine (10 interventions) as the most involved non-anti-infectious molecule. Among antibiotics, with respectively 9 and 8 interventions, rifampicin and fluoroquinolones (6 interventions for moxifloxacin) were the most concerned notably for drug-drug interactions with usual treatment. CONCLUSION In this observational retrospective study, 1.18 pharmacist interventions (PI) per patient were observed. Most of them are lack of follow-up and drug-drug interactions especially with usual treatment of patients. Moxifloxacin and rifampicin were the most antibiotics involved. Patients' characteristics (older, polypharmacy), long-term hospitalization and surgery are known to be predictive factors of medication errors and this study highlights the importance of the presence of clinical pharmacist in orthopedic surgery wards.
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Affiliation(s)
- Julie Coiffard
- Department of pharmacy, Pitié-Salpêtrière Hospital, Paris, France.
| | - Alexandra Aubry
- Laboratory of bacteriology, Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Bleibtreu
- Infectious and tropical diseases ward, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Fourniols
- Orthopaedic surgery ward, Pitié-Salpêtrière Hospital, Paris, France
| | - Helga Junot
- Department of pharmacy, Pitié-Salpêtrière Hospital, Paris, France
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Santos TP, da Silva Bastos PE, da Silva JF, de Medeiros Vieira SM, da Silva MCG, de Andrade ALC, Padilha RMO, Dos Santos Magnabosco AR, Cadena MRS, Cadena PG. Single and joint toxic effects of thyroid hormone, levothyroxine, and amiodarone on embryo-larval stages of zebrafish (Danio rerio). Ecotoxicology 2023; 32:525-535. [PMID: 37119427 DOI: 10.1007/s10646-023-02655-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 05/22/2023]
Abstract
This study evaluates single and joint endocrine disruptor toxicities of thyroid hormone, levothyroxine, and amiodarone in the embryo-larval stages of Danio rerio. Single toxicity experiments were carried out in concentrations based on the environmental concentration and increasing concentrations of 10, 100, and 1000 times the environmental concentration. Joint toxicity experiments evaluated the combined effects of these compounds. Toxic effects were examined during zebrafish embryonic development, and the parameters analyzed were apical sublethal, teratogenicity, mortality endpoints, and morphometry. Thyroid hormone exhibited the highest toxicity. However, the results showed that the environmental concentrations for all 3 compounds had low risk in relation to the parameters studied, such as teratogenic effects and morphometry. The larvae were more affected than embryos, where embryos needed higher concentrations in all experiments, possibly due to the absence of the chorion. The same type of effects were observed in the joint toxicity test, except that a possible antagonistic effect was detected. However, high concentrations showed stronger effects of these toxic compounds on fish development.
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Affiliation(s)
- Thamiris Pinheiro Santos
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
- Laboratório de Imunopatologia Keizo Asami (LIKA), Universidade Federal de Pernambuco (UFPE), Av. Prof. Moraes Rego, s/n, 50780-901, Recife, PE, Brazil
| | - Paulo Eduardo da Silva Bastos
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
| | - Jadson Freitas da Silva
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
| | - Stefânia Maria de Medeiros Vieira
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
| | - Marília Cordeiro Galvão da Silva
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
| | - André Lucas Corrêa de Andrade
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
- Laboratório de Imunopatologia Keizo Asami (LIKA), Universidade Federal de Pernambuco (UFPE), Av. Prof. Moraes Rego, s/n, 50780-901, Recife, PE, Brazil
| | - Renata Meireles Oliveira Padilha
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
| | - Amanda Rodrigues Dos Santos Magnabosco
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
| | - Marilia Ribeiro Sales Cadena
- Departamento de Biologia (DB), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil
| | - Pabyton Gonçalves Cadena
- Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco, Av. Dom Manoel de Medeiros s/n Dois Irmãos, 52171-900, Recife, PE, Brazil.
- Laboratório de Imunopatologia Keizo Asami (LIKA), Universidade Federal de Pernambuco (UFPE), Av. Prof. Moraes Rego, s/n, 50780-901, Recife, PE, Brazil.
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14
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Vandse S, Psarrakis Y, Washington K, Baron MA. Comparative Bioavailability of a Novel Solution and a Tablet Formulation of Levothyroxine. Clin Pharmacol Drug Dev 2023; 12:502-508. [PMID: 36876643 DOI: 10.1002/cpdd.1233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/23/2023] [Indexed: 03/07/2023]
Abstract
Levothyroxine (LT4) is the standard of care for treating hypothyroidism. Despite the established efficacy of LT4, 50% of treated patients fail to achieve normal thyrotropin levels. Oral formulations of LT4 that bypass the gastric phase of dissolution may offset some of the therapeutic shortcomings observed with tablets. An oral solution of LT4 can be administered to patients who are unable to swallow tablets; allows flexibility to individualize dosing; and may mitigate interference with LT4 absorption caused by food, coffee, increased gastric pH from atrophic gastritis, and malabsorption from bariatric surgery. The bioavailability of a novel LT4 oral solution and a reference LT4 tablet were compared in a randomized, laboratory-blinded, single-dose, 2-period, 2-sequence, crossover study in healthy euthyroid subjects. A single 600-μg oral dose of LT4 solution (30 mL × 100 μg/5 mL) or tablet (2 × 300-μg tablet) was administered under fasting conditions in each study period, and total thyroxine concentrations were measured for 72 hours after administration. The ratio of geometric least-squares means and 90% confidence intervals for area under the concentration-time curve from time 0 to 72 hours and maximum plasma concentration were calculated. Among 42 subjects in the pharmacokinetic population, the geometric least-squares mean ratio of area under the concentration-time curve from time 0 to 72 hours and maximum plasma concentration for baseline-adjusted thyroxine was 109.1% and 107.9%, respectively, meeting Food and Drug Administration bioequivalence criteria. Adverse events (AEs) were similar between treatment groups with no serious AEs or discontinuations for AEs. Comparable bioavailability was observed between the LT4 oral solution and reference tablet after a single oral 600-μg dose under fasting conditions.
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Affiliation(s)
- Sunil Vandse
- Vertice Pharma, Berkeley Heights, New Jersey, USA
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15
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Santos Monteiro S, Santos TS, Lopes AM, Oliveira JC, Freitas C, Couto Carvalho A. Levothyroxine malabsorption or pseudomalabsorption? A question in the management of refractory hypothyroidism. Endocr Connect 2022; 11:EC-22-0355. [PMID: 36318199 PMCID: PMC9716372 DOI: 10.1530/ec-22-0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE The levothyroxine absorption test (LT4AT) is an important tool for distinguishing hypothyroidism due to malabsorption from 'pseudomalabsorption' conditions. Our aim was to review our institution's LT4AT results and assess its role in the management of patients with refractory hypothyroidism. METHODS We performed a retrospective study of all patients evaluated for refractory hypothyroidism who underwent LT4AT in our tertiary center between 2014 and 2020. Its results and the impact on thyroid function management during follow-up were assessed. RESULTS Ten female patients were included with a mean age of 40 years (min-max: 26-62). Mean weight was 72 kg (min-max: 43-88) and baseline LT4 dosage ranged from 2.5 to 5.3 µg/kg/day. The most common causes of hypothyroidism were postsurgical in 50% (n = 5) and autoimmune in 20% (n = 2). During LT4AT, normal LT4 absorption was found in all but one individual (mean FT4 increase of 231%, min-max: 85-668). The only patient with objective LT4 absorption impairment (maximal increase of 48% by hour 5) presented also Helicobacter pylori gastritis and prior history of 'intestinal surgery' during childhood. No adverse events were reported during any of the LT4ATs. During follow-up (median 11.5 months (IQR 23)), three patients obtained euthyroidism and six had improved their hypothyroidism state. CONCLUSIONS The LT4AT is an effective and safe way to assess refractory hypothyroidism and provides valuable information to distinguish LT4 malabsorption from 'pseudomalabsorption'. Our data suggest that most patients with suspicious LT4 malabsorption perform normally during LT4AT. This test provides relevant information for better management of patients with refractory hypothyroidism.
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Affiliation(s)
- Sílvia Santos Monteiro
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
- Correspondence should be addressed to S Santos Monteiro:
| | - Tiago Silva Santos
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
- Correspondence should be addressed to S Santos Monteiro:
| | - Ana Martins Lopes
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - José Carlos Oliveira
- Department of Clinical Pathology, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - Cláudia Freitas
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - André Couto Carvalho
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
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16
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Bai Q, Tan J, Chai J, Shen L, Li N, Wu C. Preparation of Levothyroxine Transdermal Gels and Preliminary
Pharmacokinetic Study in Hypothyroidism Rat Model. LETT DRUG DES DISCOV 2022. [DOI: 10.2174/1570180819666220322151350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Hypothyroidism is a common disorder due to inadequate thyroid hormone secretion.
In patients with hypothyroidism, levothyroxine (LT4) is the treatment of choice, and tablets are the
most common dosage form. However, the main limitation of tablet LT4 is malabsorption.
Objective:
This study intends to develop a new dosage form of percutaneous drug delivery for levothyroxine.
Absorption of levothyroxine sodium through the application of gel formulation was studied using
a hypothyroidism rat model.
Methods:
A formulation of levothyroxine sodium gel was developed and selected. In-vitro transdermal
experiments were performed using the vertical Franz diffusion pool method, and gel formulation was
used for animal research (hypothyroidism rats model). Total 30 rats were randomly divided into 6 groups,
and one was the normal control group. The other 5 groups were prepared as hypothyroidism models. After
applying different doses of gel preparation to the rat model, we measured serum total thyroxine (TT4),
free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) using fluorescence
determination of luminescence immunoassay.
Results:
The optimum formulation of levothyroxine gels comprised 20% polyvinyl alcohol (PVA), 5%
glycerol, 2% azone, and 6% oleic acid. The application of levothyroxine sodium gel resulted in quick and
smooth action so that the predicted level of the normal control group could be reached within 2 weeks,
and it lasted steadily for 8 weeks.
Conclusion:
This research study successfully developed and tested an optimal formulation of levothyroxine
gel with therapeutic benefit on hypothyroidism in rats.
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Affiliation(s)
- Qingshuang Bai
- Department of Nuclear Medicine, Tianjin Fourth Central Hospital, The Fourth Central Clinical College, Tianjin Medical
University, Tianjin, China
| | - Jian Tan
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin,
China
| | - Jinyan Chai
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin,
China
| | - Linna Shen
- Department of Oncology and Haematology, Tianjin Fourth Central Hospital, The Fourth Central Clinical
College, Tianjin Medical University, Tianjin, China
| | - Ning Li
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin,
China
| | - Cailan Wu
- Department of Nuclear Medicine, Tianjin Fourth Central Hospital, The Fourth Central Clinical College, Tianjin Medical
University, Tianjin, China
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17
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Ducharme M, Scarsi C, Bettazzi E, Mautone G, Lewis Y, Celi FS. A Novel Levothyroxine Solution Results in Similar Bioavailability Whether Taken 30 or Just 15 Minutes Before a High-Fat High-Calorie Meal. Thyroid 2022; 32:897-904. [PMID: 35469428 PMCID: PMC9419984 DOI: 10.1089/thy.2021.0604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Levothyroxine (LT4) sodium is a standard treatment for hypothyroidism. Its absorption and bioavailability when taken as a tablet have been shown to be significantly decreased with concomitant food ingestion. Therefore, LT4 formulations are recommended to be taken on an empty stomach, at least 30, ideally 60, minutes before breakfast, potentially affecting adherence to therapy. A novel LT4 solution (Tirosint®-SOL) has been shown to result in a faster absorption process than tablets or soft-gel capsule formulations. The objective of this trial was to evaluate the bioavailability of this preparation taken 15 minutes before a high-fat high-calorie meal in comparison with the minimally recommended 30-minute interval. Methods: Thirty-six (33 completers, 24 males and 9 females) healthy volunteers participating in the randomized study took 600 mcg of LT4 oral solution, single doses after a 10-hour fast, 15 or 30 minutes before a high-fat, high-calorie, FDA-approved standardized meal in a controlled research setting. We measured serum total thyroxine using Liquid Chromatography with Tandem Mass Spectrometry at baseline and multiple time points up to 72 hours after LT4 administration. The predefined equivalence boundaries for the extent of exposure reflected by the area under the curve (AUC) were 80-125%. The washout period was at least 35 days. Results: The geometric mean ratios and confidence intervals (CIs) for the baseline-adjusted extent of exposure represented by AUCs truncated at both 48 and 72 hours after dosing (AUC0-48: 90% [90% CI 86-94]; and AUC0-72: 92% [90% CI 87-97]) were within the prespecified equivalence boundaries. The baseline-adjusted peak concentration was also clinically similar (Cmax: 85% [90% CI 80-90]). The median tmax was 1.5 hours in each group. The rate of adverse events was similar between groups. Conclusions: We observed no significant difference in the pharmacokinetic properties of a novel LT4 solution administered 15 and 30 minutes before a high-fat high-calorie meal in normal subjects. Further research is needed to evaluate (a) the differences in overall bioavailability at other time points (including immediately premeal) and (b) the real-world effectiveness of this preparation in newly proposed administration conditions to optimize treatment outcomes in hypothyroid patients.
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Affiliation(s)
- Murray Ducharme
- Faculté de Pharmacie, University of Montreal and Learn and Confirm, Inc., St. Laurent, Quebec, Canada
- Address correspondence to: Murray Ducharme, PharmD, FCCP, FCP, Faculté de Pharmacie, University of Montreal, Learn and Confirm, Inc., 750 Marcel-Laurin, Suite 235, St. Laurent, QC H4M 2M4, Canada
| | | | | | | | - Yvette Lewis
- Learn and Confirm, Inc., St. Laurent, Quebec, Canada
| | - Francesco S. Celi
- Division of Endocrinology Diabetes and Metabolism, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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18
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Ward J, Gill S, Armstrong K, Fogarty T, Tan D, Scott A, Yahya A, Dhaliwal SS, Jacques A, Tang C. Randomised controlled trial on the effect of simethicone bowel preparation on rectal variability during image-guided radiation therapy for prostate cancer (SPoRT study). J Med Imaging Radiat Oncol 2022; 66:866-873. [PMID: 35322563 DOI: 10.1111/1754-9485.13404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The purpose of this study was to assess whether simethicone reduces the rectal volume (RV) and gas volume (GV), to increase treatment accuracy and to decrease toxicity of prostate radiation therapy. METHODS 30 patients were randomised to simethicone or no intervention. Cone-beam computed tomography (CBCT) scans were performed on Days 1-3 and weekly until completion of radiation. RV and GV were measured using volume delineation. Toxicity data were collected. RESULTS 264 CBCTs were analysed. RV and GV were not significantly different in the simethicone group compared with the control group at each time point (P >0.05) after adjusting for Week 0 values as a covariate. The simethicone group showed an average reduction in RV and GV of 10% and 21%, respectively, compared with the control group (P >0.05). Standard deviations were calculated over 10 time points, which were grouped to represent the first 2-3 weeks of radiation therapy versus subsequent weeks. These were not significantly different between the simethicone and control group. However, there was a statistically significant decrease in the variability of RV at time points 6-10 compared with time points 1-5 within the simethicone group (P = 0.012), but no significant difference was found between these grouped time points in the control group (P = 0.581). The toxicity questionnaires showed no significant difference between the groups. CONCLUSIONS Simethicone did not decrease the RV or GV overall. However, simethicone appeared to significantly decrease the RV variability from Week three onwards. This suggests that taking simethicone two to three weeks before starting radiation therapy may reduce RV variability, although a larger study is needed to confirm this.
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Affiliation(s)
- Jennifer Ward
- Department of Radiation Oncology, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Suki Gill
- Department of Radiation Oncology, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia.,Division of Internal Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Kevin Armstrong
- Department of Radiation Oncology, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tamara Fogarty
- Department of Radiation Oncology, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Daren Tan
- Department of Radiation Oncology, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia
| | - Alison Scott
- Radiation Oncology Medical Physics, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia
| | - Aylin Yahya
- Department of Radiation Oncology, Clinical Trials and Research Unit, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia
| | - Satvinder Singh Dhaliwal
- Department of Radiation Oncology, Clinical Trials and Research Unit, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia.,Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.,Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, George Town, Pulau Pinang, Malaysia
| | - Angela Jacques
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Institute for Health Research, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Colin Tang
- Department of Radiation Oncology, Sir Charles Gairdner Hospital Cancer Centre, Perth, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
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Abstract
Hypothyroidism is a common endocrinopathy, and levothyroxine is frequently prescribed. Despite the basic tenets of initiating and adjusting levothyroxine being agreed on, there are many nuances and complexities to consistently maintaining euthyroidism. Understanding the impact of patient weight and residual thyroid function on initial levothyroxine dosage and consideration of age, comorbidities, thyrotropin goal, life stage, and quality of life as levothyroxine is adjusted can be challenging and continually evolving. Because levothyroxine is a lifelong medication, it is important to avoid risks from periods of overtreatment or undertreatment. For the subset of patients not restored to baseline health with levothyroxine, causes arising from all aspects of the patient's life (coexistent medical conditions, stressors, lifestyle, psychosocial factors) should be broadly considered. If such factors do not appear to be contributing, and biochemical euthyroidism has been successfully maintained, there may be benefit to a trial of combination therapy with levothyroxine and liothyronine. This is not supported by the majority of randomized clinical trials, but may be supported by other studies providing lower-quality evidence and by animal studies. Given this discrepancy, it is important that any trial of combination therapy be continued only as long as a patient benefit is being enjoyed. Monitoring for adverse effects, particularly in older or frail individuals, is necessary and combination therapy should not be used during pregnancy. A sustained-release liothyronine preparation has completed phase 1 testing and may soon be available for better designed and powered studies assessing whether combination therapy provides superior therapy for hypothyroidism.
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20
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Cordido M, Juiz-Valiña P, Urones P, Sangiao-Alvarellos S, Cordido F. Thyroid Function Alteration in Obesity and the Effect of Bariatric Surgery. J Clin Med 2022; 11:jcm11051340. [PMID: 35268429 PMCID: PMC8911439 DOI: 10.3390/jcm11051340] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/26/2022] Open
Abstract
The most common endocrine disease in obesity is hypothyroidism and secondary endocrine alterations, including abnormal thyroid function, are frequent in obesity. It is unclear whether impaired thyroid function is the cause or the consequence of increased adiposity; furthermore, there are no clear data regarding the best way to dose levothyroxine for patients with both hypothyroidism and obesity, and the effect of bariatric surgery (BS). The aim of the present article is to review some controversial aspects of the relation between obesity and the thyroid: (1) Thyroid function in obesity and the effect of BS (2) Thyroid hormone treatment (THT) in obese patients with hypothyroidism and the effect of BS. In summary: In morbidly obese patients, TSH is moderately increased. Morbid obesity has a mild central resistance to the thyroid hormone, reversible with weight loss. In morbidly obese hypothyroid patients, following weight loss, the levothyroxine dose/kg of ideal weight did not change, albeit there was an increment in the levothyroxine dose/kg of actual weight. From a clinical practice perspective, in morbid obesity, diagnosing mild hypothyroidism is difficult, BS improves the altered thyroid function and THT can be adapted better if it is based on ideal weight.
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Affiliation(s)
- María Cordido
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Servicio Urgencias, Hospital Universitario A Coruña, 15006 A Coruña, Spain
| | - Paula Juiz-Valiña
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Paula Urones
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Susana Sangiao-Alvarellos
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981178127 (S.S.-A. & F.C.); Fax: +34-981178204 (S.S.-A. & F.C.)
| | - Fernando Cordido
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Servicio Endocrinología y Nutrición, Hospital Universitario A Coruña, 15006 A Coruña, Spain
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981178127 (S.S.-A. & F.C.); Fax: +34-981178204 (S.S.-A. & F.C.)
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Jamil MZZ, Salman S, Akhtar M, Iqbal S, Bhalli A, Farooq H. Determining the Association Between Helicobacter pylori Infection and Treatment-Refractory Hypothyroidism. Cureus 2022; 14:e21316. [PMID: 35186575 PMCID: PMC8848460 DOI: 10.7759/cureus.21316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Refractory hypothyroidism, despite weight-based thyroxine dosing, is a common endocrinology consultation in outpatients. Chronic Helicobacter (H.) pylori infection has been reported to be responsible for the poor absorption of thyroxine from the small gut leading to suboptimal response with contradictory evidence. This study was carried out to determine the association of chronic Helicobacter pylori infection with refractory hypothyroidism in outpatients presenting to a tertiary care hospital. Methods One hundred thirty patients with the diagnosis of hypothyroidism, visiting Jinnah Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) Jinnah Hospital Lahore, Pakistan, from January 2020 to February 2021, were included in the study after informed consent following the non-probability consecutive sampling technique. All of these patients were 15-70 years of age, non-pregnant, and receiving thyroxine treatment for at least six weeks. Patients with a history of gastric surgery, malabsorption syndrome, or poor compliance were excluded from the study. Patients’ age, sex, and body mass index (BMI) were recorded in a structured proforma. Patients were categorized into two groups, i.e. controls (biochemically euthyroid on thyroxine treatment with TSH < 4.5mU/L) and cases (refractory hypothyroidism despite 1.6 mcg/kg thyroxine treatment with TSH > 4.5 mU/L). The presence of chronic H. pylori infection was checked with serum immunoglobulin G (IgG) testing by enzyme-linked immunoassay (ELISA) from the hospital laboratory and data analysis was done by SPSS version 21.0 (IBM Corp., Armonk, NY). Results One hundred thirty patients were included in this study, with an age range from 15 to 70 years. Of these, 65/130 (50%) were euthyroid on treatment and 65/130 (50%) had treatment-refractory hypothyroidism. The mean age of patients in our study was 45.81 ± 11 years, with 118 (90.8%) female patients. The prevalence of positive H. pylori IgG antibody was 47/130 (36.2%) overall, with 23 patients (35.4%) in the control (euthyroid) group and 24 patients (36.9%) in the cases (refractory hypothyroidism) group. The difference between the two groups was not statistically significant with an odds ratio of 1.069 (CI 0.523 - 2.187) and a p-value of 0.855. Moreover, age, gender, and BMI had no effect on chronic H. pylori association with refractory hypothyroidism. Conclusion This study does not suggest any significant association between chronic H. pylori infection and treatment-refractory hypothyroidism. Other factors like poor compliance, drug-drug interactions, and malabsorption disorders should be preferably sought in case of refractory hypothyroidism.
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Stagi S, Municchi G, Ferrari M, Wasniewska MG. An Overview on Different L-Thyroxine (l-T 4) Formulations and Factors Potentially Influencing the Treatment of Congenital Hypothyroidism During the First 3 Years of Life. Front Endocrinol (Lausanne) 2022; 13:859487. [PMID: 35757415 PMCID: PMC9218053 DOI: 10.3389/fendo.2022.859487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022] Open
Abstract
Congenital hypothyroidism (CH) is a relatively frequent congenital endocrine disorder, caused by defective production of thyroid hormones (THs) at birth. Because THs are essential for the development of normal neuronal networks, CH is also a common preventable cause of irreversible intellectual disability (ID) in children. Prolonged hypothyroidism, particularly during the THs-dependent processes of brain development in the first years of life, due to delays in diagnosis, inadequate timing and dosing of levothyroxine (l-thyroxine or l-T4), the non-compliance of families, incorrect follow-up and the interference of foods, drugs and medications affecting the absorption of l-T4, may be responsible for more severe ID. In this review we evaluate the main factors influencing levels of THs and the absorption of l-T4 in order to provide a practical guide, based on the existing literature, to allow optimal follow-up for these patients.
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Affiliation(s)
- Stefano Stagi
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
- *Correspondence: Stefano Stagi,
| | - Giovanna Municchi
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
| | - Marta Ferrari
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
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Wang J, Liu D, Xie Y. Association between Helicobacter pylori infection and serum thyroid stimulating hormone in the National Health and Nutrition Examination Survey 1999-2000. Front Endocrinol (Lausanne) 2022; 13:1018267. [PMID: 36440202 PMCID: PMC9691638 DOI: 10.3389/fendo.2022.1018267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/26/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Current evidence on the associations between plasma thyroid stimulating hormone and Helicobacter pylori infection is conflicting. Therefore, our study aimed to examine TSH in relation to H. pylori infection. METHODS Based on the US National Health and Nutrition Examination Survey (NHANES) 1999-2000, a cross-sectional study was conducted with 948 participants aged 30 to 85 years. The associations between H. pylori seropositivity and TSH were evaluated using binary logistic regression models. A subgroup analysis stratified by sex, age, and body mass index was conducted. RESULTS A higher serum TSH level was found in subjects with H. pylori seropositive than in subjects with H. pylori seronegative. A significant positive association was found between H. pylori seropositivity and TSH with increasing quartiles of hormonal levels in univariate regression models (Q4 vs Q1: OR = 1.659; 95% CI, 1.152-2.389) and in multivariate regression models (Q4 vs Q1: OR = 1.604; 95% CI, 1.087-2.367). In stratified analyses, the adjusted association of serum TSH with H. pylori seropositivity was statistically significant in male (Q4 vs Q1: OR = 1.894; 95% CI, 1.109-3.235), normal BMI (Q4 vs Q1: OR = 1.894; 95% CI, 1.109-3.235), overweight (Q4 vs Q1: OR = 2.124; 95% CI, 1.047-4.308);, obese (Q4 vs Q1: OR = 0.429; 95% CI, 0.220-0.837), and age over 60 years (Q4 vs Q1: OR = 1.999; 95% CI, 1.118-3.575). CONCLUSION High TSH levels were associated with H. pylori infection, especially among male, overweight and elderly adults.
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Affiliation(s)
- Jinyun Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Gastroenterology, JiangXi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dingwei Liu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Gastroenterology, JiangXi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yong Xie
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Gastroenterology, JiangXi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Yong Xie,
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Abstract
Levothyroxine (LT4) is a convenient treatment for hypothyroidism. Coffee, however, prevents the body from efficaciously absorbing LT4. It is unknown whether the intake of tea interferes with LT4 absorption. Thirty-seven hypothyroidism patients with the following types of consumption were recruited: 1) only tea, 2) tea and coffee, and 3) only coffee. The concentrations of thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) were recorded before and 3 months after changing the consumption. The patients had reductions in the concentration of TSH to varying degrees after 3 months (p < 0.001 or p < 0.05). The natural logarithms of the differences between the concentrations of TSH before and after the change in the consumption (Δln-TSH) of tea and coffee, only coffee, and only tea were 1.94, 2.00, and 2.18, respectively. Long-term consumption of tea, like coffee, interfered with the absorption of LT4. We believe that avoiding tea when taking LT4 will reduce malabsorption.
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Ettleson MD, Papaleontiou M. Evaluating health outcomes in the treatment of hypothyroidism. Front Endocrinol (Lausanne) 2022; 13:1026262. [PMID: 36329885 PMCID: PMC9623066 DOI: 10.3389/fendo.2022.1026262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Clinical hypothyroidism is defined by the inadequate production of thyroid hormone from the thyroid gland to maintain normal organ system functions. For nearly all patients with clinical hypothyroidism, lifelong treatment with thyroid hormone replacement is required. The primary goal of treatment is to provide the appropriate daily dose of thyroid hormone to restore normal thyroid function for each individual patient. In current clinical practice, normalization of thyrotropin (TSH) level is the primary measure of effectiveness of treatment, however the use of a single biomarker to define adequate thyroid hormone replacement is being reevaluated. The assessment of clinical health outcomes and patient-reported outcomes (PROs), often within the context of intensity of treatment as defined by thyroid function tests (i.e., undertreatment, appropriate treatment, or overtreatment), may play a role in evaluating the effectiveness of treatment. The purpose of this narrative review is to summarize the prominent health outcomes literature in patients with treated hypothyroidism. To date, overall mortality, cardiovascular morbidity and mortality, bone health and cognitive function have been evaluated as endpoints in clinical outcomes studies in patients with treated hypothyroidism. More recent investigations have sought to establish the relationships between these end results and thyroid function during the treatment course. In addition to clinical event outcomes, patient-reported quality of life (QoL) has also been considered in the assessment of adequacy of hypothyroidism treatment. From a health care quality perspective, treatment of hypothyroidism should be evaluated not just on its effectiveness for the individual patients but also to the extent to which patients of different sociodemographic groups are treated equally. Ultimately, more research is needed to explore differences in health outcomes between different sociodemographic groups with hypothyroidism. Future prospective studies of treated hypothyroidism that integrate biochemical testing, PROs, and end result clinical outcomes could provide a more complete picture into the effectiveness of treatment of hypothyroidism.
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Affiliation(s)
- Matthew D. Ettleson
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, United States
- *Correspondence: Matthew D. Ettleson,
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes and Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States
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Bornikowska K, Gietka-Czernel M, Raczkiewicz D, Glinicki P, Zgliczyński W. Improvements in Quality of Life and Thyroid Parameters in Hypothyroid Patients on Ethanol-Free Formula of Liquid Levothyroxine Therapy in Comparison to Tablet LT4 Form: An Observational Study. J Clin Med 2021; 10:jcm10225233. [PMID: 34830515 PMCID: PMC8624226 DOI: 10.3390/jcm10225233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 12/17/2022] Open
Abstract
Levothyroxine (LT4) is a standard therapy in hypothyroidism; however, its bioavailability and therapeutic effects might be affected by many factors. Data shows that therapy with liquid LT4 characterized by quicker pharmacokinetics provides better thyroid hormones control than tablet LT4. We addressed the quality of life (QoL) and efficacy of the new ethanol-free formula of liquid LT4 (Tirosint®SOL) treatment in 76 euthyroid patients with primary (PH, n = 46) and central hypothyroidism (CH, n = 30), and compared the results to retrospective data on equivalent doses of tablet L-T4 therapy. After 8 weeks of liquid LT4 therapy, we found a significant improvement in QoL in both PH and CH patients. TSH levels were unaltered in PH patients. Free hormone levels (fT4 and fT3) increased in all the patients, with the exception of fT3 in the CH group. SHBG and low-density lipoprotein (LDL) also improved. Liquid LT4 therapy provided a better thyroid hormone profile and improvement in patients' QoL than the tablet form, which was possibly due to the more favorable pharmacokinetics profile resulting in better absorption, as suggested by the increased free thyroid hormone levels. In summary, this is the first study addressing the QoL in hypothyroid patients, including primary and central hypothyroidism, treated with liquid LT4 formula in everyday practice.
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Affiliation(s)
- Katarzyna Bornikowska
- Department of Endocrinology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland; (M.G.-C.); (P.G.); (W.Z.)
- Correspondence: ; Tel.: +48-600-676-620
| | - Małgorzata Gietka-Czernel
- Department of Endocrinology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland; (M.G.-C.); (P.G.); (W.Z.)
| | - Dorota Raczkiewicz
- Department of Medical Statistics, School of Public Health, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland;
| | - Piotr Glinicki
- Department of Endocrinology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland; (M.G.-C.); (P.G.); (W.Z.)
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland; (M.G.-C.); (P.G.); (W.Z.)
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Juiz-Valiña P, Cordido M, Outeiriño-Blanco E, Pértega S, Urones P, García-Brao MJ, Mena E, Pena-Bello L, Sangiao-Alvarellos S, Cordido F. Evaluation of Thyroid Hormone Replacement Dosing in Morbidly Obese Hypothyroid Patients after Bariatric Surgery-Induced Weight Loss. J Clin Med 2021; 10:jcm10163685. [PMID: 34441981 PMCID: PMC8396870 DOI: 10.3390/jcm10163685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/05/2021] [Accepted: 08/15/2021] [Indexed: 12/12/2022] Open
Abstract
The most frequent endocrine disease in obese patients is hypothyroidism. To date, there are no clear data regarding what happens to the dose of levothyroxine (LT4) after bariatric surgery (BS). The objective of the present study was to evaluate thyroid hormone replacement dose in morbidly obese hypothyroid patients after BS-induced weight loss. We explore the best type of measured or estimated body weight for LT4 dosing. We performed an observational study evaluating patients with morbid obesity and hypothyroidism who underwent BS. We included 48 patients (three men). In morbidly obese hypothyroid patients 12 months after BS-induced weight loss, the total LT4 dose or the LT4 dose/kg ideal body weight did not change, while there was a significant increase in LT4 dose/body surface area, LT4 dose/kg weight, LT4 dose/kg adjusted body weight, LT4 dose/kg body fat, and LT4 dose/kg lean body weight. There were no differences in LT4 dose and its variation between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). The present study strongly suggests that LT4 dosing in obese hypothyroid patients can be individually adapted more precisely if it is based on ideal body weight.
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Affiliation(s)
- Paula Juiz-Valiña
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - María Cordido
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Elena Outeiriño-Blanco
- Servicio Endocrinología y Nutrición, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
| | - Sonia Pértega
- Unidad Epidemiologia Clínica y Bioestadística, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
| | - Paula Urones
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - María Jesús García-Brao
- Servicio Cirugía General y Digestiva, Hospital Universitario A Coruña, 15006 A Coruña, Spain; (M.J.G.-B.); (E.M.)
| | - Enrique Mena
- Servicio Cirugía General y Digestiva, Hospital Universitario A Coruña, 15006 A Coruña, Spain; (M.J.G.-B.); (E.M.)
| | - Lara Pena-Bello
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Susana Sangiao-Alvarellos
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981-178-127 (S.S.-A. & F.C.); Fax: +34-981-178-204 (S.S.-A. & F.C.)
| | - Fernando Cordido
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Servicio Endocrinología y Nutrición, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981-178-127 (S.S.-A. & F.C.); Fax: +34-981-178-204 (S.S.-A. & F.C.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wolf CPJG, Rachow T, Ernst T, Hochhaus A, Zomorodbakhsch B, Foller S, Rengsberger M, Hartmann M, Hübner J. Interactions in cancer treatment considering cancer therapy, concomitant medications, food, herbal medicine and other supplements. J Cancer Res Clin Oncol 2021. [PMID: 33864520 DOI: 10.1007/s00432-021-03625-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
Purpose The aim of our study was to analyse the frequency and severity of different types of potential interactions in oncological outpatients’ therapy. Therefore, medications, food and substances in terms of complementary and alternative medicine (CAM) like dietary supplements, herbs and other processed ingredients were considered. Methods We obtained data from questionnaires and from analysing the patient records of 115 cancer outpatients treated at a German university hospital. Drug–drug interactions were identified using a drug interaction checking software. Potential CAM-drug interactions and food–drug interactions were identified based on literature research. Results 92.2% of all patients were at risk of one or more interaction of any kind and 61.7% of at least one major drug–drug interaction. On average, physicians prescribed 10.4 drugs to each patient and 6.9 interactions were found, 2.5 of which were classified as major. The most prevalent types of drug–drug interactions were a combination of QT prolonging drugs (32.3%) and drugs with a potential for myelotoxicity (13.4%) or hepatotoxicity (10.1%). In 37.2% of all patients using CAM supplements the likelihood of interactions with medications was rated as likely. Food-drug interactions were likely in 28.7% of all patients. Conclusion The high amount of interactions could not be found in literature so far. We recommend running interaction checks when prescribing any new drug and capturing CAM supplements in medication lists too. If not advised explicitly in another way drugs should be taken separately from meals and by using nonmineralized water to minimize the risk for food–drug interactions.
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Lammert A, Nowak K, Weber R, Rotter N, Schölch S, Krämer BK, Lammert A. [Postoperative hypocalcemia - the most common complication of endocrine head and neck surgery: acute management]. Laryngorhinootologie 2021; 100:610-617. [PMID: 33652494 DOI: 10.1055/a-1381-8286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In Germany, 8000 patients are affected by postoperative hypoparathyroidism per year following surgery of the thyroid gland, parathyroidal glands and the larynx. Patients do not only suffer from paresthesia in the acute phase of this complication, but are also adversely affected by the fear of loss of control following episodes of tetany even years after the first episode. OBJECTIVES Discussion of a diagnostic pathway and presentation of a management pathway for postoperative hypocalcemia. METHODS Narrative review, analysis and discussion of current literature and expert recommendations. RESULTS Early determination of calcium and parathyroid hormone allows timely diagnosis and treatment of postoperative hypoparathyroidism. Active vitamin D is pivotal for the resorption of calcium. Only the combined treatment with active vitamin D and calcium can mitigate or prevent the postoperative drop of calcium levels. CONCLUSIONS A standard operating procedure (SOP) for postoperative hypoparathyroidism should be implemented in every surgical department. An SOP for diagnosis and treatment of postoperative hypoparathyroidism is proposed for institutional individualization and implementation.
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Affiliation(s)
- Anne Lammert
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Kai Nowak
- Klinik für Allgemein-, Gefäß- und Thoraxchirurgie, RoMed Klinikum, Rosenheim, Germany
| | - Roland Weber
- Medizinische Klinik II, RoMed Kliniken, Rosenheim, Germany
| | - Nicole Rotter
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Sebastian Schölch
- Chirurgische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Bernhard K Krämer
- V. Medizinische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Alexander Lammert
- V. Medizinische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany.,Apherese- und Dialysezentrum Grünstadt, Praxis für Diabetes, Stoffwechsel und Nierenerkrankungen, Grünstadt, Germany
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Markantes GK, Dimitropoulos K, Mamali I, Tseti I, Sakellaropoulos G, Markou KB, Michalaki MA. Therapeutic Equivalence of a New Preparation of Liquid Levothyroxine with Tablets in Patients with Overt Primary Hypothyroidism. Eur Thyroid J 2021; 10:59-64. [PMID: 33777820 PMCID: PMC7983587 DOI: 10.1159/000508216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/26/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A new liquid levothyroxine (LT4) dissolved in glycerol and water has recently been developed by a Greek pharmaceutical company (Uni-Pharma, Athens, Greece). OBJECTIVES To evaluate the therapeutic equivalence of this new liquid LT4 preparation versus the already existing tablet formulation of the same manufacturer, in order to obtain approval by the Greek National Organization for Medicines. METHODS This was a prospective, randomized, cross-over phase III study. The study included 50 patients (9 men and 41 non-pregnant women, with a mean age of 42.5 ± 12.5 years), with documented overt primary hypothyroidism. All subjects were well controlled on substitution therapy with various LT4 formulations. None of the patients had known LT4 malabsorption. The patients were randomized into 2 groups (A and B). The individuals of group A initially received T4® tablets for 10 ± 2 weeks and subsequently switched to T4® drops (100 μg/mL solution) at the same dose for another 10 ± 2 weeks. In group B, the reverse procedure was followed. Total T3 (T3), free T4 (fT4), and TSH were measured in all participants at enrollment and at the end of each 10 ± 2-week trial period. RESULTS Out of the 50 recruited patients, 6 were lost to follow-up and 5 were excluded due to non-compliance with the study protocol. In the 39 patients who completed the study, the serum TSH levels after 10 ± 2 weeks of treatment either with T4® tablets or with T4® drops did not differ (1.759 ± 1.104 vs. 2.076 ± 1.334 mIU/L, mean ± SD). CONCLUSIONS In hypothyroid patients, the new liquid LT4 preparation (T4® drops) is therapeutically equivalent to the tablet form (T4® tablets).
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Affiliation(s)
- Georgios K. Markantes
- Division of Endocrinology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Konstantinos Dimitropoulos
- Division of Endocrinology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Irene Mamali
- Division of Endocrinology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | | | | | - Kostas B. Markou
- Division of Endocrinology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
- *Kostas B. Markou, Division of Endocrinology, Department of Internal Medicine, University of Patras Medical School, Rio-Patras, GR–26500 Patras (Greece),
| | - Marina A. Michalaki
- Division of Endocrinology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
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Spanakis M, Melissourgaki M, Lazopoulos G, Patelarou AE, Patelarou E. Prevalence and Clinical Significance of Drug-Drug and Drug-Dietary Supplement Interactions among Patients Admitted for Cardiothoracic Surgery in Greece. Pharmaceutics 2021; 13:239. [PMID: 33572247 DOI: 10.3390/pharmaceutics13020239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Drug interactions represent a major issue in clinical settings, especially for critically ill patients such as those with cardiovascular disease (CVD) who require cardiothoracic surgery (CTS) and receive a high number of different medications. Methods: A cross-sectional study aimed at evaluating the exposure and clinical significance of drug–drug (DDIs) and drug–dietary supplement interactions (DDSIs) in patients admitted for CTS in the University Hospital of Crete Greece. DDIs were evaluated regarding underlying pharmacological mechanisms upon admission, preoperation, postoperation, and discharge from CTS clinic. Additionally, upon admission, the use of dietary supplements (DSs) and if patients had informed their treating physician that they were using these were recorded with subsequent analysis of potential DDSIs with prescribed medications. Results: The study employed 76 patients who were admitted for CTS and accepted to participate. Overall, 166 unique DDIs were identified, with 32% of them being related to pharmacokinetic (PK) processes and the rest (68%) were related to possible alterations of pharmacodynamic (PD) action. CVD medications and drugs for central nervous system disorders were the most frequently interacting medications. In total, 12% of the identified DDIs were of serious clinical significance. The frequency of PK-DDIs was higher during admission and discharge, whereas PD-DDIs were mainly recorded during pre- and postoperation periods. Regarding DS usage, 60% of patients were using DSs and perceived them as safe, and the majority had not informed their treating physician of this or sought out medical advice. Analysis of medical records showed 30 potential combinations with prescribed medications that could lead in DDSIs due to modulation of PK or PD processes, and grapefruit juice consumption was involved in 38% of them. Conclusions: An increased burden of DDIs and DDSIs was identified mostly upon admission for patients in CTS clinics in Greece. Healthcare providers, especially prescribing physicians in Greece, should always take into consideration the possibility of DDIs and the likely use of DS products by patients to promote their well-being; this should only be undertaken after receiving medical advice and an evidenced-based evaluation.
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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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Abstract
Calcium is responsible for the effectiveness of various processes, and its supply in the diet is necessary for the normal function of the human body. Apart from being an important component of the skeleton, calcium also helps maintain the structure of cell organelles and regulates intracellular and extracellular fluid homeostasis. This review presents the nutritional and health factors that affect the bioavailability of calcium. Physiological conditions and factors such as pregnancy, infancy, menopause, old age, hormones, growth factors associated with calcium metabolism, diseases limiting its absorption, and intestinal microbiota are distinguished among endogenous factors. Although the calcium supply in the body is genetically conditioned and specific to each person, its qualitative and quantitative composition can be modified by external factors. The exogenous factors include dietary modifications with particular nutrients and pharmacological treatment. Adequate calcium levels increase bone protection and prevent osteoporosis, a disease involving low mineral bone mass.
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Affiliation(s)
- Natalia Wawrzyniak
- N. Wawrzyniak and J. Suliburska are with the Department of Human Nutrition and Dietetics, Faculty of Food and Nutrition Science, Poznań University of Life Sciences, Poznań, Poland
| | - Joanna Suliburska
- N. Wawrzyniak and J. Suliburska are with the Department of Human Nutrition and Dietetics, Faculty of Food and Nutrition Science, Poznań University of Life Sciences, Poznań, Poland
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Abstract
Levothyroxine (L-T4) absorption can be impaired by various causes: a) L-T4 ingestion during breakfast, or with food; b) conditions of reduced gastric acidity; c) intestinal procedures and diseases such as bariatric surgery, lactose intolerance (LI), celiac disease (CD), inflammatory bowel disease; d) drugs that alter L-T4 absorption, increasing the gastric pH, or preventing the dissolution of tablets. The development of new oral formulations, i.e. the liquid preparation and the soft gel capsule, represents the most recent advance regarding L-T4 therapy. Treating hypothyroidism with L-T4 tablets can lead to an improper control of thyroid-stimulating hormone (TSH) in ~10%-15% of patients. The improperly elevated TSH is usually managed by increasing the L-T4 daily dose, and revaluating TSH upon 2-6 months. The increase of the L-T4 dosage may cause iatrogenic hyperthyroidism, especially when the underlying disorders are cured. Liquid L-T4 can be administered in patients unable to swallow capsules or tablets, and this is one of its major benefits. Liquid L-T4 can: 1- overcome food and beverages interference; 2- bypass the malabsorption associated with an increased gastric pH; 3- circumvent the issue of malabsorption in patients who underwent bariatric surgery; 4-maintain TSH values under control better than L-T4 tablets in hypothyroid patients with typical or atypical CD, or in patients with LI. Few clinical studies evaluated soft gel L-T4 with encouraging findings in patients with gastric- or coffee-related malabsorption, or hypothyroid patients without malabsorption. Additional research is necessary to investigate liquid L-T4, or soft gel capsule, in other conditions of altered L-T4 absorption.
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Affiliation(s)
- Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- *Correspondence: Poupak Fallahi,
| | | | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
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Saiz Ladera GM, Pejenaute Labari ME, García Pascual JN. [Updating in prescription of proton pump inhibitors. What to do and what not to do]. Semergen 2020; 47:267-279. [PMID: 33223372 DOI: 10.1016/j.semerg.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/22/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) are the most prescribed pharmacological subgroup of the National Health System and their use has been related to possible potentially serious adverse effects. OBJECTIVE To review the current indications for treatment with PPIs as well as the data related to their safety, in order to promote their adecuate use. MATERIAL AND METHODS A review of the literature focused on the following topics has been carried out: a) molecules and mechanism of action; b) current indications for treatment and adherence to them; c) adverse effects related to its use; d) drug interactions; e) alternatives in deprescription. RESULTS The current indications have not changed substantially in recent years and are well established, however, there is a high percentage of inappropriate prescription, mainly in individuals with low or no risk. CONCLUSIONS PPIs are safe drugs and generally well tolerated and their benefits are higher than possible adverse effects. Adhering to evidence-based recommendations represents the only rational approach to safe and effective therapy.
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Affiliation(s)
- G M Saiz Ladera
- Medicina de Familia, Centro de Salud Panaderas, Fuenlabrada (Madrid), España.
| | | | - J N García Pascual
- Medicina de Familia, Centro de Salud Arganda del Rey, Arganda del Rey (Madrid), España
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Abstract
PURPOSE OF REVIEW The aim of the article is to present the basics of oral levothyroxine (LT4) absorption, reasons why patients may have persistently elevated serum thyroid stimulation hormone (TSH) levels, and alternative strategies for LT4 dosing. RECENT FINDINGS Although oral LT4 tablets are most commonly used for thyroid hormone replacement in patients with hypothyroidism, case studies report that liquid oral LT4, intravenous, intramuscular, and rectal administration of LT4 can successfully treat refractory hypothyroidism. SUMMARY Hypothyroidism is one of the most common endocrine disorders encountered by primary care physicians and endocrinologists. LT4 is one of the most widely prescribed medications in the world and it is the standard of care treatment for hypothyroidism. Generally, hypothyroid patients will be treated with LT4 tablets to be taken orally, and monitoring will occur with routine serum thyroid tests, including TSH concentrations. However, many patients fail to maintain serum TSH levels in the target range while managed on oral LT4 tablets. A subset of these patients would be considered to have poorly controlled hypothyroidism, sometimes termed refractory hypothyroidism. For these patients, optimization of ingestion routines and alternative formulations and routes of administration of LT4 can be considered, including oral liquid, intravenous, intramuscular, and even rectal formulations.
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Affiliation(s)
| | - Suruchi Gupta
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Hassanpour S, Behnam B, Baradaran B, Hashemzaei M, Oroojalian F, Mokhtarzadeh A, de la Guardia M. Carbon based nanomaterials for the detection of narrow therapeutic index pharmaceuticals. Talanta 2020; 221:121610. [PMID: 33076140 DOI: 10.1016/j.talanta.2020.121610] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022]
Abstract
Precise detection of important pharmaceuticals with narrow therapeutic index (NTI) is very critical as there is a small window between their effective dose and the doses at which the adverse reactions are very likely to appear. Regarding the fact that various pharmacokinetics will be plausible while considering pharmacogenetic factors and also differences between generic and brand name drugs, accurate detection of NTI will be more important. Current routine analytical techniques suffer from many drawbacks while using novel biosensors can bring up many advantages including fast detection, accuracy, low cost with simple and repeatable measurements. Recently the well-known carbon Nano-allotropes including carbon nanotubes and graphenes have been widely used for development of different Nano-biosensors for a diverse list of analytes because of their great physiochemical features such as high tensile strength, ultra-light weight, unique electronic construction, high thermo-chemical stability, and an appropriate capacity for electron transfer. Because of these exceptional properties, scientists have developed an immense interest in these nanomaterials. In this case, there are important reports to show the effective Nano-carbon based biosensors in the detection of NTI drugs and the present review will critically summarize the available data in this field.
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Affiliation(s)
- Soodabeh Hassanpour
- Department of Analytical Chemistry, Faculty of Science, Palacky University Olomouc, 17. Listopadu 12, 77146, Olomouc, Czech Republic
| | - Behzad Behnam
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahmoud Hashemzaei
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Zabol University of Medical Sciences, Zabol, Iran
| | - Fatemeh Oroojalian
- Department of Advanced Sciences and Technologies, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Ahad Mokhtarzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Miguel de la Guardia
- Department of Analytical Chemistry, University of Valencia, Dr. Moliner 50, 46100, Burjassot, Valencia, Spain.
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Brito JP, Ross JS, Sangaralingham L, Dutcher SK, Graham DJ, Wang Z, Wu Y, Yao X, Smallridge RC, Bernet V, Shah ND, Lipska KJ. Comparative Effectiveness of Generic vs Brand-Name Levothyroxine in Achieving Normal Thyrotropin Levels. JAMA Netw Open 2020; 3:e2017645. [PMID: 32997127 PMCID: PMC7527873 DOI: 10.1001/jamanetworkopen.2020.17645] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Whether the use of generic vs brand levothyroxine affects thyrotropin levels remains unclear. OBJECTIVE To compare the effectiveness of generic vs brand levothyroxine in achieving and maintaining normal thyrotropin levels among new users. DESIGN, SETTING, AND PARTICIPANTS This retrospective, 1:1 propensity score-matched longitudinal cohort study used the OptumLabs Data Warehouse administrative claims database linked to laboratory results from commercially insured and Medicare Advantage enrollees throughout the United States. Eligible patients were adults (aged ≥18 years) with thyrotropin levels ranging from 4.5 to 19.9 mIU/L who initiated use of generic or brand-name levothyroxine from January 1, 2008, to October 1, 2017. Data were analyzed from August 13, 2018, to October 25, 2019. EXPOSURE Patients received generic or brand-name levothyroxine. MAIN OUTCOMES AND MEASURES Proportion of patients with normal vs markedly abnormal thyrotropin levels (<0.1 or >10 mIU/L) within 3 months and with stable thyrotropin levels within 3 months after the thyrotropin value fell into the normal range. RESULTS A total of 17 598 patients were included (69.0% female; 74.0% White; mean [SD] age, 55.1 [16.0] years), of whom 15 299 filled generic and 2299 filled brand-name levothyroxine prescriptions during the study period. Among 4570 propensity score-matched patients (mean [SD] age, 50.3 [13.8] years; 3457 [75.6%] female; 3510 [76.8%] White), the proportion with normal thyrotropin levels within 3 months of filling levothyroxine prescriptions was similar for patients who received generic vs brand-name levothyroxine (1722 [75.4%; 95% CI, 71.9%-79.0%] vs 1757 [76.9%; 95% CI, 73.4%-80.6%]; P = .23), as was the proportion with markedly abnormal levels (94 [4.1%; 95% CI, 3.4%-5.0%] vs 88 [3.9%; 95% CI, 3.1%-4.7%]; P = .65). Among 1034 propensity score-matched patients who achieved a normal thyrotropin value within 3 months of initiation of levothyroxine, the proportion maintaining subsequent normal thyrotropin levels during the next 3 months was similar for patients receiving generic vs brand-name levothyroxine (427 [82.6%] vs 433 [83.8%]; P = .62). CONCLUSIONS AND RELEVANCE Initiation of generic vs brand-name levothyroxine formulations was associated with similar rates of normal and stable thyrotropin levels. These results suggest that generic levothyroxine as initial therapy for mild thyroid dysfunction is as effective as brand-name levothyroxine.
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Affiliation(s)
- Juan P. Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph S. Ross
- Section of General Internal Medicine and the National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Lindsey Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Sarah K. Dutcher
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration (FDA), Silver Spring, Maryland
| | - David J. Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration (FDA), Silver Spring, Maryland
| | - Zhong Wang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Yute Wu
- Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota
| | | | - Victor Bernet
- Division of Endocrinology, Mayo Clinic, Jacksonville, Florida
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota
- Optum Labs, Cambridge, Massachusetts
| | - Kasia J. Lipska
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Kazma JM, van den Anker J, Allegaert K, Dallmann A, Ahmadzia HK. Anatomical and physiological alterations of pregnancy. J Pharmacokinet Pharmacodyn 2020; 47:271-285. [PMID: 32026239 PMCID: PMC7416543 DOI: 10.1007/s10928-020-09677-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/28/2020] [Indexed: 02/07/2023]
Abstract
The extensive metabolic demands of pregnancy require specific physiological and anatomical changes. These changes affect almost all organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and hematologic system. The placenta adds another layer of complexity. These changes make it challenging for clinicians to understand presenting signs and symptoms, or to interpret laboratory and radiological tests. Furthermore, these physiological alterations can affect the pharmacokinetics and pharmacodynamics of drugs. Drug safety in lactation is only supported by limited evidence. In addition, the teratogenic effects of medications are often extrapolated from animals, which further adds uncertainties. Unfortunately, pregnant women are only rarely included in clinical drug trials, while doses, regimens, and side effects are often extrapolated from studies conducted in non-pregnant populations. In this comprehensive review, we present the changes occurring in each system with its effects on the pharmacokinetic variables. Understanding these physiological changes throughout normal pregnancy helps clinicians to optimize the health of pregnant women and their fetuses. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable 'orphan' population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia.
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Affiliation(s)
- Jamil M Kazma
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - André Dallmann
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Leverkusen, Germany
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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Elbasan O, Gogas Yavuz D. REFRACTORY HYPOTHYROIDISM TO LEVOTHYROXINE TREATMENT: FIVE CASES OF PSEUDOMALABSORPTION. Acta Endocrinol (Buchar) 2020; 16:339-345. [PMID: 33363657 PMCID: PMC7748222 DOI: 10.4183/aeb.2020.339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CONTEXT A persistently elevated thyroid stimulating hormone (TSH) level is a common clinical problem in primary hypothyroidism patients treated with levothyroxine (LT4). "Pseudomalabsorption", which is characterized by poor adherence,should be considered in cases of refractory hypothyroidism after excluding other causes, such as malabsorption. OBJECTIVE We reviewed the features of the patients with persistently elevated TSH despite high-dose LT4 therapy. DESIGN Symptom evaluation, medications, comorbid diseases and physical examination features of five patients who applied to our outpatient clinic between 2016-2019 and diagnosed with LT4 pseudomalabsorption were retrospectively analyzed. SUBJECTS AND METHODS The LT4 loading test was performed with an oral dose of 1,000 µg LT4. Demographic parameters, BMI, thyroid function tests, laboratory parameters for malabsorption were recorded. RESULTS We observed at least two-fold increase of free thyroxine levels during the test, which was considered pseudomalabsorption. Euthyroidism was achieved in two patients by increasing the LT4 dosage and in one patient with a change in the preparation. TSH decreased significantly after being informed about compliance in one patient. Another one was given LT4 twice weekly, but TSH remained elevated because of nonadherence. CONCLUSION The LT4 loading/absorption test is a valuable tool to confirm the diagnosis of pseudomalabsorption. Informing patients, changing the preparation, increasing the dose, supervised intake of daily/weekly LT4 forms are treatment options for managing these cases.
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Affiliation(s)
- O. Elbasan
- Marmara University School of Medicine, Department of Endocrinology and Metabolism, Istanbul, Turkey
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Guzman-Prado Y, Vita R, Samson O. The impact of proton pump inhibitors on levothyroxine absorption: The good, the bad and the ugly. Eur J Intern Med 2020; 76:118-119. [PMID: 32094018 DOI: 10.1016/j.ejim.2020.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/16/2020] [Indexed: 12/18/2022]
Affiliation(s)
| | - Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Italy
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Pang X, Pu T, Xu L, Sun R. Effect of l-thyroxine administration before breakfast vs at bedtime on hypothyroidism: A meta-analysis. Clin Endocrinol (Oxf) 2020; 92:475-481. [PMID: 32022947 DOI: 10.1111/cen.14172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/01/2020] [Accepted: 02/04/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE To compare the effects of l-thyroxine (L-T4) administration before breakfast and administration at bedtime on hypothyroidism. METHODS The PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) and Wanfang databases were searched to identify relevant articles. All prospective or randomized controlled studies (RCTs) comparing L-T4 administration before breakfast to the administration at bedtime in patients with hypothyroidism were included in the analysis. RESULTS Initially, 2884 articles were retrieved from the databases, and 10 articles were included in the quantitative analysis. The effect of L-T4 administration before breakfast compared with administration at bedtime had no statistically significant association with hormone thyrotropin (TSH) (Standardized mean differences [SMD] = 0.09, 95% confidence intervals (CI): -0.12, 0.30; P = .39), or free triiodothyronine (FT3) (SMD=-0.19, 95% CI: -0.53, 0.15; P = .28) in patients with hypothyroidism. However, the result of FT4 level was favourable for L-T4 bedtime administration group (SMD=-0.27, 95% CI: -0.52, -0.02; P = .03). CONCLUSION Our meta-analysis revealed that L-T4 administration at bedtime is as effective as administration before breakfast for patients with hypothyroidism. Taking L-T4 at bedtime may be an attractive option for patients with hypothyroidism.
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Affiliation(s)
- Xiao Pang
- Department of Nuclear Medicine, Nanchong Central Hospital, The Second Clinical College of North Sichuan Medical College, Nanchong, China
| | - Tao Pu
- Department of Nuclear Medicine, Nanchong Central Hospital, The Second Clinical College of North Sichuan Medical College, Nanchong, China
| | - Li Xu
- Department of Nuclear Medicine, Nanchong Central Hospital, The Second Clinical College of North Sichuan Medical College, Nanchong, China
| | - Ru Sun
- Department of Blood Transfusion, Affiliated Hospital of North Sichuan Medical College, North Sichuan Medical College, Nanchong, China
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Tribulova N, Kurahara LH, Hlivak P, Hirano K, Szeiffova Bacova B. Pro-Arrhythmic Signaling of Thyroid Hormones and Its Relevance in Subclinical Hyperthyroidism. Int J Mol Sci 2020; 21:ijms21082844. [PMID: 32325836 PMCID: PMC7215427 DOI: 10.3390/ijms21082844] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
A perennial task is to prevent the occurrence and/or recurrence of most frequent or life-threatening cardiac arrhythmias such as atrial fibrillation (AF) and ventricular fibrillation (VF). VF may be lethal in cases without an implantable cardioverter defibrillator or with failure of this device. Incidences of AF, even the asymptomatic ones, jeopardize the patient's life due to its complication, notably the high risk of embolic stroke. Therefore, there has been a growing interest in subclinical AF screening and searching for novel electrophysiological and molecular markers. Considering the worldwide increase in cases of thyroid dysfunction and diseases, including thyroid carcinoma, we aimed to explore the implication of thyroid hormones in pro-arrhythmic signaling in the pathophysiological setting. The present review provides updated information about the impact of altered thyroid status on both the occurrence and recurrence of cardiac arrhythmias, predominantly AF. Moreover, it emphasizes the importance of both thyroid status monitoring and AF screening in the general population, as well as in patients with thyroid dysfunction and malignancies. Real-world data on early AF identification in relation to thyroid function are scarce. Even though symptomatic AF is rare in patients with thyroid malignancies, who are under thyroid suppressive therapy, clinicians should be aware of potential interaction with asymptomatic AF. It may prevent adverse consequences and improve the quality of life. This issue may be challenging for an updated registry of AF in clinical practice. Thyroid hormones should be considered a biomarker for cardiac arrhythmias screening and their tailored management because of their multifaceted cellular actions.
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Affiliation(s)
- Narcis Tribulova
- Centre of Experimental Medicine, Slovak Academy of Sciences, Institute for Heart Research, 84104 Bratislava, Slovakia
- Correspondence: (N.T.); (B.S.B.); Tel.: +421-2-32295-423 (B.S.B.)
| | - Lin Hai Kurahara
- Department of Cardiovascular Physiology, Faculty of Medicine, Kagawa University, Kagawa 76 0793, Japan; (L.H.K.); (K.H.)
| | - Peter Hlivak
- Department of Arrhythmias and Pacing, National Institute of Cardiovascular Diseases, Pod Krásnou Hôrkou 1, 83348 Bratislava, Slovakia;
| | - Katsuya Hirano
- Department of Cardiovascular Physiology, Faculty of Medicine, Kagawa University, Kagawa 76 0793, Japan; (L.H.K.); (K.H.)
| | - Barbara Szeiffova Bacova
- Centre of Experimental Medicine, Slovak Academy of Sciences, Institute for Heart Research, 84104 Bratislava, Slovakia
- Correspondence: (N.T.); (B.S.B.); Tel.: +421-2-32295-423 (B.S.B.)
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Castellana M, Castellana C, Giovanella L, Trimboli P. Prevalence of gastrointestinal disorders having an impact on tablet levothyroxine absorption: should this formulation still be considered as the first-line therapy? Endocrine 2020; 67:281-290. [PMID: 31953721 DOI: 10.1007/s12020-019-02185-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 12/31/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE In patients with hypothyroidism, levothyroxine (LT4) is the treatment of choice, and tablets are the most commonly prescribed formulation. Despite multiple scenarios being reported in the literature with impaired tablet absorption and likely missed TSH targets, it is yet unclear what the implications are for clinical practice and the role of liquid solution (LS) and soft gel (SG) formulations. We have thus conducted a narrative review evaluating the prevalence within the general population of gastrointestinal disorders impacting tablet LT4 absorption. METHODS PubMed and Google Scholar were searched until December 2019 for systematic reviews and meta-analyses on the topic. If they could not be retrieved, other types of manuscripts were searched. RESULTS Lactose malabsorption and Helicobacter pylori infection represented the most common disorders, with a global prevalence of 68% and 48%, respectively. The prevalence of other conditions, including autoimmune gastritis, bariatric surgery, celiac disease, gastroparesis, giardiasis, liver cirrhosis, or ulcerative colitis, was lower than 20%. Data at regional and country levels were found to be heterogeneous, but at least one in five patients was diagnosed with one disorder. CONCLUSIONS The worldwide prevalence of gastrointestinal disorders associated with tablet LT4 malabsorption, including lactose malabsorption and Helicobacter pylori infection, is high. Interactions with drugs or food can further increase this risk. Considering that all studies investigating the impact of switching patients from tablet to LS or SG found an improved thyroid balance, the latter formulations should be considered as first-line therapy for managing hypothyroidism.
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Affiliation(s)
- Marco Castellana
- National Institute of Gastroenterology "S. De Bellis", Castellana Grotte, Bari, Italy
| | | | - Luca Giovanella
- Clinic for Nuclear Medicine and Competence Center for Thyroid Diseases, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Pierpaolo Trimboli
- Clinic for Nuclear Medicine and Competence Center for Thyroid Diseases, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
- Scienze Biomediche, Università della Svizzera Italiana (USI), Lugano, Switzerland.
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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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Garayalde Gamboa MDLÁ, Saban M, Curriá MI. Treatment with Intramuscular Levothyroxine in Refractory Hypothyroidism. Eur Thyroid J 2019; 8:319-323. [PMID: 31934558 PMCID: PMC6944946 DOI: 10.1159/000503324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/11/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Orally and daily levothyroxine (LT4) is the treatment of choice for hypothyroidism. In the majority of cases, the lack of effectiveness by this way may be due to poor adherence; however, gastrointestinal malabsorption may explain more cases of thyroxine refractoriness than previously reputed, due to the number of occult forms of these disorders. CASE PRESENTATION A 55-year-old white man with a diagnosis of low risk of recurrence of follicular variant of papillary thyroid carcinoma was treated with total thyroidectomy, 30 mCi iodine 131, and oral LT4. A year before he presented a gastric adenocarcinoma that required a partial gastrectomy. He evolved with multiple episodes of intestinal subocclusion that had to be treated with enterectomy in the first instance, then digestive rest and total parenteral nutrition. In spite of having made increases in oral LT4 dose (3 µg/kg), the patient persisted with a thyroid-stimulating hormone level >100 mIU/L. For this reason, we decided to administer intramuscular LT4. CONCLUSION Since there are no guidelines or consensus of intramuscular LT4 use, our experience and how we decided the dose and way of administration are presented in this article to contribute to future cases.
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Affiliation(s)
| | - Melina Saban
- Service of Endocrinology, Metabolism, Nutrition, and Diabetes, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Marina Ines Curriá
- Service of Endocrinology, Metabolism, Nutrition, and Diabetes, Buenos Aires British Hospital, Buenos Aires, Argentina
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Abstract
Background: Levothyroxine (LT4) is the mainstay of therapy for hypothyroidism. Yet, despite physician efforts at dose titration, some patients remain hypothyroid on LT4 doses in excess of weight-based calculations, a condition known as refractory hypothyroidism. The LT4 absorption test (LT4AT) has been proposed to have utility in these patients by enabling distinction of LT4 malabsorption from pseudomalabsorption, a condition of intentional nonadherence. Given its rare use in clinical practice, we reviewed our institution's experience with the LT4AT to assess its impact on management of refractory hypothyroidism. Methods: We reviewed the charts of 16 patients diagnosed with refractory hypothyroidism and who had completed the LT4AT between January 2015 to January 2019. The primary aim was to determine the utility of this test in distinguishing LT4 malabsorption from pseudomalabsorption. Secondary aims were to determine whether the results of this test impacted physicians' management decisions, as well as to report on clinical outcomes at follow-up. Our LT4AT is a six-hour test wherein patients receive a weight-based dose of LT4 followed by serial measurements of total thyroxine (TT4) and thyrotropin (TSH). Percentage absorption is calculated using the following formula, with normal absorption being ≥60%: [Formula: see text] Results: Percentage absorption was calculated in 13 of 16 patients due to lack of TT4 data for 3 patients. Absorption was impaired in one patient (% absorbed = 0), who had known causes of malabsorption. The remaining 12 patients had normal absorption by hour 4 of the test (% absorption 60-158) in conjunction with upward TT4 trends. Clinical follow-up ranged from 1 to 32 months (median 6.5 months), with 11 patients having follow-up data. Six of these had normal or suppressed TSH values at most recent follow-up, and four had improved but persistent TSH elevations. The one said patient with malabsorption improved with intravenous LT4. Conclusions: The LT4AT can provide valuable information for distinguishing malabsorption from pseudomalabsorption. Our findings support the combined use of calculated percentage absorptions with TT4 trends for at least a four-hour time frame when making determinations regarding absorption.
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Pedro J, Cunha F, Souteiro P, Neves JS, Guerreiro V, Magalhães D, Bettencourt-Silva R, Oliveira SC, Costa MM, Queirós J, Freitas P, Varela A, Carvalho D. The Effect of the Bariatric Surgery Type on the Levothyroxine Dose of Morbidly Obese Hypothyroid Patients. Obes Surg 2019; 28:3538-3543. [PMID: 30008061 DOI: 10.1007/s11695-018-3388-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Doubts exist about the effect of different bariatric surgery (BS) types on levothyroxine (Lt4) absorption. We compared Lt4 doses and their variation (ΔLt4) in patients with hypothyroidism that underwent malabsorptive (MS) or restrictive (RS) surgery and studied predictors of Lt4 dose change. METHODS Retrospective study of morbidly obese hypothyroid patients submitted to BS. We compared RS ("sleeve" gastrectomy or adjustable gastric banding) with MS (Roux-en-Y gastric bypass) patients. We built a multivariable logistic regression and a linear regression model to study predictors of Lt4 dose changes and ΔLt4, respectively. RESULTS Fifty-seven patients: 35 MS and 22 RS. Mean age 47 years; 7% men. Patients submitted to MS had lower BMI at 1 year than those submitted to RS. Lt4 dose remained unchanged in 61.4%, increased in 12.3%, and decreased in 26.3% of patients. Initial and 1-year Lt4 dose were not different between surgical groups. Relative Lt4 dose, but not absolute (p = 0.07), increased at 1 year (p < 0.001). Neither BS nor BMI variation were predictors of Lt4 dose variation. BMI variation was associated with relative Lt4 dose change independently of initial BMI and BS type: β (95%CI) - 0.03 (- 0.05; 0.00); p = 0.03. CONCLUSIONS There were no differences in Lt4 dose and its variation between restrictive and malabsorptive techniques 1 year after surgery. Malabsorptive procedures may not affect Lt4 absorption differently from restrictive ones. Bariatric surgery type was not predictive of Lt4 dose changes. BMI variation is associated with relative Lt4 dose (dose per weight) variation and its association was independent of bariatric surgery type.
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Affiliation(s)
- Jorge Pedro
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal.
| | - Filipe Cunha
- Department of Endocrinology of Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Pedro Souteiro
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - João Sérgio Neves
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Vanessa Guerreiro
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Daniela Magalhães
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Rita Bettencourt-Silva
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Sofia Castro Oliveira
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Maria Manuel Costa
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Joana Queirós
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Paula Freitas
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Ana Varela
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
| | - Davide Carvalho
- Service of Endocrinology, Diabetes and Metabolism of Centro Hospitalar de São João, EPE, Porto, Portugal
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Abstract
The purpose of this article will be to review the basics of thyroid hormone therapy, including various thyroid hormone formulations, the institution and monitoring of thyroid hormone therapy, adverse effects of overtreatment, the management of patients with persistent symptoms despite normal thyroid function tests, and potential new innovations in thyroid hormone therapy. The conclusions support the necessity to personalize thyroid hormone replacement therapy in hypothyroid patients.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy.
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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