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Seng Yue C, Scarsi C, Bettazzi E, Mautone G, Celi FS, Ducharme M. Proton Pump Inhibitors Do Not Affect the Bioavailability of a Novel Liquid Formulation of Levothyroxine. Endocr Pract 2024; 30:513-520. [PMID: 38554774 DOI: 10.1016/j.eprac.2024.03.388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE This study evaluates the impact of a representative proton pump inhibitor (PPI) (omeprazole), administered simultaneously or staggered, on the pharmacokinetics of levothyroxine (LT4) solution (Tirosint-SOL). METHODS This was a randomized, 3-way crossover, comparative bioavailability study in 36 healthy adults under fasting conditions. Omeprazole 40 mg delayed-release capsule was administered once daily from Day 1 to 6 (mornings, Treatment-A; evenings, Treatment-B; none, Treatment-C) to increase and stabilize gastric pH. In the morning of Day 5, a single dose of LT4 solution 600 mcg was administered. Blood samples were collected 0 to 48 hours post-LT4 administration. Noncompartmental pharmacokinetic parameters were calculated for total serum thyroxine using baseline-corrected data. Maximum concentration (Cmax) and area under the concentration-time curve (AUC0-48) were included in an analysis of variance to obtain geometric mean ratios and 90% confidence intervals. RESULTS For both comparisons (A/C and B/C), geometric mean ratios and 90% confidence intervals for all parameters were within the equivalence boundaries (80%-125%), indicating bioequivalence: for A/C, AUC0-48 98.98% [94%-104%], and Cmax 91.68% [87%-97%]; for B/C, AUC0-48 98.94% [95%-103%], and Cmax 94.90% [90%-100%]. Median Tmax (time associated with Cmax) was similar across treatments. CONCLUSION This study demonstrated that Tirosint-SOL bioavailability is unaffected by coadministration of a representative PPI, given simultaneously or staggered by about 12 hours, compared to administration of LT4 solution alone. For hypothyroid patients on PPI therapy, administration of LT4 solution may reduce variations in thyroid stimulating hormone levels related to intermittent use of acid-reducing drugs and consequently the need for dose adjustments.
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Affiliation(s)
| | | | | | | | - Francesco S Celi
- Department of Medicine at University of Connecticut Health, Farmington, Connecticut
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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] [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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3
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Dvořáčková E, Pilková A, Matoulek M, Slanař O, Hartinger JM. Bioavailability of Orally Administered Drugs After Bariatric Surgery. Curr Obes Rep 2024; 13:141-153. [PMID: 38172482 DOI: 10.1007/s13679-023-00548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Oral drug absorption after bariatric surgery is likely to be altered, but the impact of different bariatric surgery procedures on individual drugs is not uniform. The aim of this article is to describe factors influencing the bioavailability of orally administered drugs after bariatric surgery and to provide readers with practical recommendations for drug dosing. We also discuss the medications that may be harmful after bariatric surgery. RECENT FINDINGS The fundamental factors for enteral drug absorption are the production of gastric acid; the preserved length of the intestine, i.e., the size of the absorption surface and/or the preserved enterohepatic circulation; and the length of common loop where food and drugs are mixed with digestive enzymes and bile acids. Bypassing of metabolizing enzymes or efflux pumps and changes in intestinal motility can also play an important role. Significant changes of drug absorption early after the anatomic alteration may also be gradually ameliorated due to gradual intestinal adaptation. The most affected drugs are those with low or variable bioavailability and those undergoing enterohepatic circulation. Attention should also be paid to oral drug formulations, especially in the early postoperative period, when immediate-release and liquid formulations are preferred. The changes in oral bioavailability are especially clinically meaningful in patients treated with drugs possessing narrow therapeutic index (e.g., oral anticoagulants, levothyroxine, and anticonvulsants) or in acute conditions (e.g., anti-infectives); nevertheless, it may also influence the therapeutic value of chronic therapy (e.g., antidepressants. antihypertensives, antiplatelets, statins, PPIs, contraceptives, and analgesics); therapeutic effect of chronic therapy is further influenced by pharmacokinetic alterations resulting from weight loss. Therapeutic drug monitoring, periodical clinical evaluation, and adequate dose adjustments are necessary. Due to safety reasons, patients should avoid oral bisphosphonates, regular use of non-steroidal anti-inflammatory drugs, and, if possible, corticosteroids after bariatric surgery.
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Affiliation(s)
- Eliška Dvořáčková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Clinical Pharmacy, Hospital Na Františku, Prague, Czech Republic
| | - Alena Pilková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Matoulek
- Third Internal Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Miroslav Hartinger
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
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Trimboli P, Piticchio T, Dadda Z, Stramazzo I, Gamarra E, Ruinelli L, Virili C. Analysis of dose-TSH response effect of levothyroxine soft-gel formulation. Front Endocrinol (Lausanne) 2024; 15:1340204. [PMID: 38449850 PMCID: PMC10915021 DOI: 10.3389/fendo.2024.1340204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/30/2024] [Indexed: 03/08/2024] Open
Abstract
Background Hypothyroidism is treated with daily levothyroxine (LT4). In recent years, soft gel caps of LT4 (LT4-C) have been commercialized, and their performance has been optimized. Since guidelines recommend dose LT4 according to the tablet preparation efficacy, the present study was undertaken to obtain data about the daily requirement, normalized per body weight, of LT4-C. Methods Patients undergoing LT4-C after total thyroidectomy and radioiodine treatment for differentiated thyroid carcinoma were selected. There was no specific indication of suppression of TSH (i.e., <0.5 or <0.1 mIU/L). Patients were required to maintain a stable LT4 dose during the study period. Patients with interfering factors were excluded from this study. Results Thirty patients were enrolled (18 females and 12 males; median age, 50 years; median body weight, 71 kg; median LT4-C dose, 1.71 µg/kg/day). The analysis of patient age did not reveal any differences. The LT4-C dose correlated with free-T4 p = 0.03), but not with TSH (p = 0.42) and free-T3 (p = 0.13). TSH was <1.0 mIU/L in 90% of the cases. The LT4-C dose-TSH response effect was analysed by probit regression model: the probability to achieve TSH <1.0 mIU/l was 99% with a dose of 1.84 (95%CI 1.57-2.12) µg/kg/day, 75% with a dose of 1.38 µg/kg/day (95%CI 1.17-1.59), and 50% with a dose of 1.20 (95%CI 0.96-1.43). At ROC curve analysis, the most accurate cut-off of LT4-C dose to achieve TSH <1.0 mIU/l was 1.53 ug/kg/day with 70% sensitivity and 100% specificity. Conclusions Athyreotic patients can be initially treated with an LT4-C dose lower than previously stated. Therefore, further prospective studies are warranted.
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Affiliation(s)
- Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Tommaso Piticchio
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Zeno Dadda
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Ilaria Stramazzo
- Endocrinology Section, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Elena Gamarra
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Lorenzo Ruinelli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Team Data Science and Research, Area ICT, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Camilla Virili
- Endocrinology Section, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
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Sachmechi I, Lucas KJ, Stonesifer LD, Ansley JF, Sack P, Celi FS, Scarsi C, Lanzi G, Wartofsky L, Burman KD. Efficacy of Levothyroxine Sodium Soft Gelatin Capsules in Thyroidectomized Patients Taking Proton Pump Inhibitors: An Open-Label Study. Thyroid 2023; 33:1414-1422. [PMID: 37885233 PMCID: PMC10754356 DOI: 10.1089/thy.2023.0382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background: Treatment with proton pump inhibitors (PPIs) and antacids affects the gastrointestinal absorption of levothyroxine sodium (LT4) tablets. Patients with hypothyroidism taking LT4 and PPIs or antacids, thus, require appropriate monitoring. The objective of this study was to determine whether a soft gelatin capsule of LT4 (Tirosint®) would obviate the effect of PPIs on LT4 absorption. The objective was achieved by assessing the effects of a switch from a conventional LT4 tablet form to the same dose as soft capsules in thyroidectomized patients on treatment with LT4 and PPIs. Methods: Patients with history of hypothyroidism due to total thyroidectomy on stable treatment with LT4 tablets, and with gastrointestinal disease treated with PPIs, were switched to a 12-week treatment with Tirosint at the same dose of the LT4 tablets, while maintaining treatment with PPIs. Serum thyrotropin (TSH) levels were the primary endpoint of the study. Secondary efficacy endpoints were: serum levels of free thyroxine (fT4), total thyroxine (TT4), free triiodothyronine (fT3), total triiodothyronine (TT3), creatine-phosphokinase (CPK), sex-hormone binding globulin, ferritin, angiotensin converting enzyme, and a lipid panel. Results: Forty-seven patients (36 females and 11 males, mean age 55.4 years) were enrolled and 45 of them completed the study (2 patients withdrew consent). During treatment with Tirosint, mean TSH levels demonstrated a statistically significant decrease (mean changes from baseline: -0.32 mIU/L at week 6 and -0.68 mIU/L at week 12) and concomitant increases in thyroid hormone (TH) levels from baseline to week 12, which were statistically significant for fT3 and TT3 (mean changes from baseline: 0.26 pmol/L and 0.10 nmol/L, respectively). Significant decreases of serum low-density lipoprotein, total cholesterol, and CPK levels were observed at week 12. No signs/symptoms arose during the study that could be specifically correlated to either hypo- or hyperthyroidism. Conclusions: In thyroidectomized patients taking PPIs and replacement LT4, a switch from conventional LT4 tablets to LT4 soft capsules at the same dose was associated with a significant decrease in TSH and increase in TH, indicating that LT4 absorption may be less affected by PPIs when given in the form of soft capsules. Clinical Trial Registration: NCT03094416.
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Affiliation(s)
- Issac Sachmechi
- Mount Sinai Services—NYC Health+Hospitals/Queens, Jamaica, New York, USA
| | - Kathryn Jean Lucas
- LucasResearch, Inc., Diabetes & Endocrinology Consultants, Morehead City, North Carolina, USA
| | | | | | - Paul Sack
- MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Francesco S. Celi
- Division of Endocrinology and Metabolism, Department of Medicine, UConn Health, Farmington, Connecticut, USA
| | | | | | - Leonard Wartofsky
- MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Kenneth D. Burman
- Endocrine Section, MedStar Washington Hospital Center, Washington, District of Columbia, USA
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6
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Liu H, Lu M, Hu J, Fu G, Feng Q, Sun S, Chen C. Medications and Food Interfering with the Bioavailability of Levothyroxine: A Systematic Review. Ther Clin Risk Manag 2023; 19:503-523. [PMID: 37384019 PMCID: PMC10295503 DOI: 10.2147/tcrm.s414460] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
Purpose Levothyroxine is a common prescribed drug. Many medications and food, however, can interfere with its bioavailability. The aim of this review was to summarize the medications, food and beverages that interact with levothyroxine and to assess their effects, mechanisms and treatments. Methods A systematic review on interfering substances that interact with levothyroxine was performed. Web of Science, Embase, PubMed, the Cochrane library, grey literature from other sources and the lists of references were searched for human studies comparing the levothyroxine efficacy with and without interfering substances. The patient characteristics, drug classes, effects and mechanism were extracted. The NHLBI study quality assessment tools and the JBI critical appraisal checklist were used to assess the quality of included studies. Results A total of 107 articles with 128 studies were included. Drugs interactions were revealed in calcium and iron supplements, proton pump inhibitors, bile acid sequestrants, phosphate binders, sex hormones, anticonvulsants and other drugs. Some food and beverage could also induce malabsorption. Proposed mechanisms included direct complexing, alkalization, alteration of serum thyroxine-binding globulin levels and acceleration of levothyroxine catabolism via deiodination. Dose adjustment, administration separation and discontinuation of interfering substances can eliminate the interactions. Liquid solutions and soft-gel capsules could eliminate the malabsorption due to chelation and alkalization. The qualities of most included studies were moderate. Conclusion Lots of medications and food can impair the bioavailability of levothyroxine. Clinicians, patients and pharmaceutical companies should be aware of the possible interactions. Further well-designed studies are needed to provide more solid evidence on treatment and mechanisms.
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Affiliation(s)
- Hanqing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Man Lu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Jiawei Hu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Guangzhao Fu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Qinyu Feng
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
| | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
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Stramazzo I, Capriello S, Antonelli A, Fallahi P, Centanni M, Virili C. Seeking optimization of LT4 treatment in patients with differentiated thyroid cancer. Hormones (Athens) 2022; 21:537-543. [PMID: 35655116 PMCID: PMC9712340 DOI: 10.1007/s42000-022-00376-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/19/2022] [Indexed: 12/25/2022]
Abstract
Levothyroxine sodium (LT4) is the mainstay treatment to replace thyroid hormonal production in thyroidectomized patients, but, depending on the aggressiveness of the cancer and on the risk of recurrence, patients with differentiated thyroid cancer may also be treated in a TSH-suppressive or semi-suppressive mode. The pathophysiological rationale for this LT4 treatment stems from the role of TSH, considered to be a growth factor for follicular cells, potentially inducing initiation or progression of follicular cell-derived thyroid cancer. Therefore, accurate tailoring of treatment, taking into account both patient characteristics (age and comorbidities) and risk of persistent/recurrent disease, is highly recommended. Furthermore, adjustments to traditional LT4 treatment should be made in thyroidectomized patients due to the lack of thyroidal contribution to whole body triiodothyronine (T3) concentration. Since LT4 exhibits a narrow therapeutic index and the side effects of over- and under-treatment could be deleterious, particularly in this category of patients, caution is required in dose individualization, in the mode of ingestion, and in potential pharmacological and other types of interference as well. Our aim was to analyze the current knowledge concerning LT4 dose requirements in patients with thyroid cancer according to different therapeutic approaches, taking into account a number of factors causing interference with LT4 efficacy. Specific mention is also made about the use of the novel LT4 formulations.
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Affiliation(s)
- Ilaria Stramazzo
- Department of Medico-Surgical Sciences and Biotechnologies, ''Sapienza'' University of Rome, Latina, Italy
- Endocrine Unit, AUSL Latina, Latina, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, ''Sapienza'' University of Rome, Latina, Italy.
- Endocrine Unit, AUSL Latina, Latina, Italy.
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, ''Sapienza'' University of Rome, Latina, Italy
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Liu H, Li W, Zhang W, Sun S, Chen C. Levothyroxine: Conventional and novel drug delivery formulations. Endocr Rev 2022; 44:393-416. [PMID: 36412275 PMCID: PMC10166268 DOI: 10.1210/endrev/bnac030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/18/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
Despite the fact that levothyroxine is one of the most prescribed medications in the world, its bioavailability has been reported to be impaired by many factors, including interfering drugs or foods and concomitant diseases, and persistent hypothyroidism with a high dose of levothyroxine is thus elicited. Persistent hypothyroidism can also be induced by noninterchangeability between formulations and poor compliance. To address these issues, some strategies have been developed. Novel formulations (liquid solutions and soft-gel capsules) have been designed to eliminate malabsorption. Some other delivery routes (injections, suppositories, sprays, and sublingual and transdermal administrations) are aimed at circumventing different difficulties in dosing, such as thyroid emergencies and dysphagia. Moreover, nanomaterials have been used to develop delivery systems for the sustained release of levothyroxine to improve patient compliance and reduce costs. Some delivery systems encapsulating nanoparticles show promising release profiles. In this review, we first summarize the medical conditions that interfere with the bioavailability of oral levothyroxine and discuss the underlying mechanisms and treatments. The efficacy of liquid solutions and soft-gel capsules are systematically evaluated. We further summarize the novel delivery routes for levothyroxine and their possible applications. Nanomaterials in the levothyroxine field are then discussed and compared based on their load and release profile. We hope the article provides novel insights into the drug delivery of levothyroxine.
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Affiliation(s)
- Hanqing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wei Li
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wen Zhang
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
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9
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Rodriguez L, Dinauer C, Francis G. Treatment of hypothyroidism in infants, children and adolescents. Trends Endocrinol Metab 2022; 33:522-532. [PMID: 35537910 DOI: 10.1016/j.tem.2022.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/11/2022] [Indexed: 11/22/2022]
Abstract
In 2014, treatment guidelines from the American Thyroid Association reflected the general consensus that levothyroxine (LT4), adjusted to maintain a normal thyrotropin (TSH) level, is the preferred method for treatment of hypothyroidism. Although this is generally applicable to children, there are subsets of children for whom the diagnosis and treatment of hypothyroidism are problematic. These include children with congenital hypothyroidism (CH), low birth weight (LBW) and very low birth weight (VLBW), Down syndrome (DS), subclinical hypothyroidism, and obesity. In this Review, we focus on the progress and remaining pitfalls in diagnosis and treatment of hypothyroidism in these and other groups.
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Affiliation(s)
- Luisa Rodriguez
- Assistant Professor of Pediatrics, Division of Endocrinology and Diabetes, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Catherine Dinauer
- Associate Professor of Pediatrics, Division of Endocrinology, Yale University, New Haven, CT, USA
| | - Gary Francis
- Professor of Pediatrics, Division of Endocrinology and Diabetes, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.
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10
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Trimboli P, Mouly S. Pharmacokinetics and Clinical Implications of Two Non-Tablet Oral Formulations of L-Thyroxine in Patients with Hypothyroidism. J Clin Med 2022; 11:jcm11123479. [PMID: 35743549 PMCID: PMC9224574 DOI: 10.3390/jcm11123479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Increased knowledge of the pharmacokinetic characteristics of orally administered levothyroxine (L-T4) has improved individualization of dosing regimens. However, up to 40-45% of patients, depending on the leading cause of hypothyroidism, are still over- or, more often, undertreated. Unintentional non-adherence to L-T4 replacement therapy includes all situations of unintended drug-drug and drug-food interactions as well as fasting conditions that are not necessarily respected by patients. RESULTS In this specific context, the overall information concerning those factors with the potential to affect L-T4 absorption refers only to tablet formulation. Indeed, this is the reason why new non-tablet formulations of L-T4 were introduced some years ago. In this regard, the current literature review was designed to summarize pharmacokinetic, drug and food interactions and clinical data focusing on two new oral L-T4 formulations, i.e., liquid and soft-gel capsule in healthy volunteers and patients with primary hypothyroidism. The non-tablet L-T4 soft-gel capsules and solution have proven bioequivalence with the usual L-T4 tablet Princeps and generic formulations. Clinical studies have suggested higher performance of non-tablet formulations than tablet in those patients with suboptimal adherence. The impact of gastrointestinal conditions and variation of gastric pH was lower with either soft gel/solution than with tablets. In addition, the extent of drug-drug and drug-food interactions remains low and of uncertain clinical relevance. CONCLUSIONS Pending further studies allowing one to extend the use of soft-gel/solution preparations in unselected patients, non-tablet L-T4 formulations should be considered as a first-line choice, especially in those patients with moderate-to-high potential of suboptimal tablet performance.
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Affiliation(s)
- Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ente Ospedaliero Cantonale (EOC), 6500 Bellinzona, Switzerland;
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Stéphane Mouly
- Assistance Publique-Hôpitaux de Paris Nord, Département Médico-Universitaire (DMU) INVICTUS, Département de Médecine Interne, Hôpital Lariboisière, INSERM UMRS-1144, Université de Paris Cité, 75010 Paris, France
- Correspondence: ; Tel.: +33-1-49-95-81-26; Fax: +33-1-49-95-84-46
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11
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Virili C, Bruno G, Santaguida MG, Gargano L, Stramazzo I, De Vito C, Cicenia A, Scalese G, Porowska B, Severi C, Centanni M. Levothyroxine treatment and gastric juice pH in humans: the proof of concept. Endocrine 2022; 77:102-111. [PMID: 35477833 PMCID: PMC9242941 DOI: 10.1007/s12020-022-03056-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/04/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE Despite the absorption of oral thyroxine (T4) occurs in the small bowel, several patients with gastric disorders show an increased need for T4. In vitro evidence suggested that medium pH variations interfere with T4 dissolution. This study was aimed at finding the proof of concept of a direct relationship between the minimal effective dose of T4 and the actual gastric juice pH. PATIENTS AND METHODS Among 311 consecutively thyroxine-treated patients, 61 bearing Hashimoto's thyroiditis (52 F/9 M; median age = 51 years) who complained persistent dyspepsia and/or upper abdominal symptoms following a noninvasive workup for gastrointestinal disorders, underwent EGDS with multiple biopsies and gastric juice pH measurement. All patients accepted to take thyroxine in fasting conditions, abstaining from eating or drinking for one hour. RESULTS Thyroxine requirement increased along with the rising gastric pH (ρ = 0.4229; p = 0.0007). A multivariate analysis revealed that gastric pH was, beside body mass index, the far more important independent variable in determining the effective dose of T4 (p = 0.001). The ROC curve revealed that the pH threshold for an increased thyroxine requirement was at 2.28, being the AUC by 78%. Subdividing patients by the histologic findings, it appeared a significant increase (p = 0.0025) along with the progressive damage of gastric mucosa. CONCLUSION The in vivo measurement of gastric pH highlighted its key role in determining the minimal effective dose of oral T4 and may explain the interference of food, of some drugs and gut disorders on levothyroxine treatment.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Giovanni Bruno
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | | | | | - Ilaria Stramazzo
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, University of Rome, Rome, Italy
| | - Alessia Cicenia
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Giulia Scalese
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Barbara Porowska
- General and Specialistic Surgery 'Paride Stefanini', University of Rome, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.
- Endocrine Unit, AUSL Latina, Latina, Italy.
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12
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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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13
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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] [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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14
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Virili C, Capriello S, Stramazzo I, Brusca N, Santaguida MG, Gargano L, Bagaglini MF, Bruno G, Severi C, Centanni M. Daily requirement of softgel thyroxine is independent from gastric juice pH. Front Endocrinol (Lausanne) 2022; 13:1002583. [PMID: 36225208 PMCID: PMC9549358 DOI: 10.3389/fendo.2022.1002583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Softgel levothyroxine (LT4) preparation showed a better in vitro dissolution profile at increasing pH as compared to tablet LT4 preparation. Clinical studies suggested a better performance of softgel LT4 preparation in patients with gastric disorders but whether this finding is related to gastric juice pH variation in vivo is not known. METHODS Twenty-eight hypothyroid patients (24F/4M; median age=50 treated with tablet LT4 (median dose= 1.65 µg/kg/day) and with stable thyroid stimulating hormone (TSH) values on target (<0.8-2.5> mU/l) have been shifted to softgel LT4 preparation. The dose of softgel LT4 has been titrated to obtain a similar individual serum TSH value. All subjects followed a specific treatment schedule, taking LT4 in fasting condition and then abstaining from eating or drinking for at least 1 hour. Owing to the presence of long-lasting dyspepsia or of already known gastric disorders, all patients underwent endoscopy, upon informed consent. Gastric juice has been collected during endoscopy to measure gastric pH. Then we plotted the dose of LT4 with the gastric pH obtained in vivo, before and after the switch tablet/softgel preparation in all patients. RESULTS Upon the switch tablet/softgel preparation, the therapeutic LT4 dose was very slightly reduced (-6%) in the whole sample. However, the individual variations revealed the existence of two populations, one without any dose reduction (A) and the other showing a dose reduction >20% (B). Upon matching with the actual gastric pH, patients with normal pH (A: n=17; 14F/3M, median 1.52) no showed a lower softgel LT4 requirement. Instead, among patients with reduced gastric acid production (B: n=11; 10F/1M, median pH 5.02) the vast majority (10/11; 91%, p<0.0001) benefited from a lower dose of softgel LT4 (median = -23%, p<0.0001). Interestingly, the dose of LT4 in tablet correlated with pH value (Spearman's ρ =0.6409; p = 0.0002) while softgel dose was independent from gastric juice pH (Spearman's ρ =1.952; p = 0.3194). CONCLUSIONS These findings provide evidence that softgel LT4 preparation is independent from the actual gastric pH in humans and may represent a significant therapeutic option in patients with increased LT4 requirement, owed to disorders impairing the gastric acidic output.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Silvia Capriello
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Ilaria Stramazzo
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Nunzia Brusca
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
| | | | - Lucilla Gargano
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
| | - Maria Flavia Bagaglini
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
| | - Giovanni Bruno
- Department of Translational and Precision Medicine, Gastroenterology Unit, ‘‘Sapienza’’ University of Rome, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Gastroenterology Unit, ‘‘Sapienza’’ University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina, Italy
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, Latina, Italy
- *Correspondence: Marco Centanni,
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15
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Gatta E, Bambini F, Buoso C, Gava M, Maltese V, Anelli V, Delbarba A, Pirola I, Cappelli C. Liquid levothyroxine formulations in patients taking drugs interfering with L-T4 absorption. Front Endocrinol (Lausanne) 2022; 13:1080108. [PMID: 36561558 PMCID: PMC9764388 DOI: 10.3389/fendo.2022.1080108] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To describe the current knowledge on thyroid hormonal profile in patients on liquid L-T4 therapy and drugs known to interfere with L-T4 absorption. METHODS A PubMed/MEDLINE, Web of Science, and Scopus research was performed. Case reports, case series, original studies and reviews written in English and published online up to 31 August 2022 were selected and reviewed. The final reference list was defined based on the relevance of each paper to the scope of this review. RESULTS The available data showed that novel levothyroxine formulations circumvent gastric pH impairment due to multiple interfering drugs such as proton pump inhibitors, calcium or iron supplements, sevelamer, aluminum/magnesium hydroxide and sodium alginate. CONCLUSION New formulations can be taken simultaneously with drugs interfering with L-T4 absorption, in particular liquid formulations. Softgel capsules need more studies to support these data.
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16
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Bohinc Henderson B. Levothyroxine Sodium Oral Solution Normalizes Thyroid Function in a Patient with Hashimoto's Disease, Gastritis, Diabetic Gastroparesis, and Small Intestinal Bacterial Overgrowth (SIBO). Int Med Case Rep J 2021; 14:627-632. [PMID: 34557042 PMCID: PMC8453642 DOI: 10.2147/imcrj.s326481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/27/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Levothyroxine (L-T4) is used as a standard-of-care treatment in patients with hypothyroidism. L-T4 is absorbed throughout the small intestine, and consistent drug absorption is required for successful treatment. Patients with Hashimoto's disease (autoimmune thyroiditis) often have food and medication sensitivities, as well as comorbid gastrointestinal (GI) disorders detrimental to L-T4 absorption. CASE PRESENTATION This case report describes a 51-year-old female patient with long-standing Hashimoto's disease and multiple sensitivities to food chemicals and medications. The patient suffered from GI symptoms and poor thyroid-stimulating hormone (TSH) control. She was switched to compounded thyroxine/triiodothyronine medication due to her multiple allergies, with only mild improvement in thyroid function and no symptom resolution. She was subsequently diagnosed with gastroparesis and small intestinal bacterial overgrowth (SIBO). Because of further worsening of her GI symptoms and weight loss, she was switched to levothyroxine sodium oral solution (Tirosint®-SOL), which contains only three ingredients-levothyroxine, water, and glycerol-which was well tolerated and led to normalization of TSH levels. CONCLUSION Malabsorption of L-T4 is often seen in patients with Hashimoto's disease-related hypothyroidism and comorbid GI conditions, such as gastroparesis and SIBO. L-T4 tablets and a compounded oral suspension were inefficiently absorbed, leading to suboptimal TSH control. Switching to levothyroxine sodium oral solution resulted in sustained TSH control with subsequent resolution of symptoms. No side effects or reactions to the medication were observed, despite the patient's multiple allergies and sensitivities to food chemicals and medications.
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17
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Kaur N, Suryanarayanan R. Investigating the Influence of Excipients on the Stability of Levothyroxine Sodium Pentahydrate. Mol Pharm 2021; 18:2683-2693. [PMID: 34061524 DOI: 10.1021/acs.molpharmaceut.1c00217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A range of tablet excipients were evaluated for their influence on the physical form and chemical stability of levothyroxine sodium pentahydrate (LSP; C15H10I4NNaO4·5H2O). LSP-excipient binary powder blends were stored under two conditions: (a) in hermetically sealed containers at 40 °C and (b) at 40 °C/75% RH. By use of synchrotron X-ray diffractometry, the disappearance of LSP could be quantified and the appearance of crystalline levothyroxine (free acid) could be identified. Under hermetically sealed conditions (40 °C) hygroscopic excipients such as povidone induced partial dehydration of LSP to form levothyroxine sodium monohydrate. When stored at 40 °C/75% RH, acidic excipients induced measurable disproportionation of LSP resulting in the formation of levothyroxine (free acid). HPLC analyses of drug-excipient mixtures revealed that lactose monohydrate, microcrystalline cellulose, and croscarmellose sodium caused pronounced chemical decomposition of LSP. On the other hand, magnesium stearate, sodium stearyl fumarate, and alkaline pH modifiers did not affect the physical and chemical stability of the API following storage at 40 °C/75% RH. HPLC, being a solution based technique, revealed chemical decomposition of the API, but the technique was insensitive to physical transformations. Excipient properties such as hygroscopicity and microenvironmental acidity were identified to be critical determinants of both physical and chemical stability of LSP in a drug product. For drugs exhibiting both physical and chemical transformations, simultaneous solid-state and solution based analyses will enable comprehensive stability evaluation.
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Affiliation(s)
- Navpreet Kaur
- Department of Pharmaceutics, College of Pharmacy, University of Minnesota-Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Raj Suryanarayanan
- Department of Pharmaceutics, College of Pharmacy, University of Minnesota-Twin Cities, Minneapolis, Minnesota 55455, United States
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18
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Asamoah E. Levothyroxine sodium oral solution to control thyroid function in a patient with hypothyroidism and celiac disease. Clin Case Rep 2021; 9:e04170. [PMID: 34094556 PMCID: PMC8163109 DOI: 10.1002/ccr3.4170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/29/2021] [Accepted: 02/11/2021] [Indexed: 11/24/2022] Open
Abstract
Implementing a gluten-free diet and switching to the levothyroxine oral solution significantly improved malabsorptive and hypothyroid symptoms in a patient with hypothyroidism, Addison's disease, and celiac disease without the need to increase levothyroxine dosage.
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Affiliation(s)
- Ernest Asamoah
- Diabetes & Endocrinology CareCommunity Physicians NetworkIndianapolisINUSA
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19
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Levothyroxine Interactions with Food and Dietary Supplements-A Systematic Review. Pharmaceuticals (Basel) 2021; 14:ph14030206. [PMID: 33801406 PMCID: PMC8002057 DOI: 10.3390/ph14030206] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/07/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022] Open
Abstract
Levothyroxine (l-thyroxine, l-T4) is a drug of choice for treating congenital and primary hypothyroidism. Although clinically significant interactions between l-T4 and food can alter the safety and efficacy of the treatment, they still seem to be generally underestimated by patients, physicians and pharmacists. This review aimed to investigate the effects of meals, beverages, and dietary supplements consumption on l-T4 pharmacokinetics and pharmacodynamics, to identify the most evident interactions, and to perform the recommendations for safe co-administering of l-T4 and food. A total of 121 studies were identified following a systematic literature search adhering to PRISMA guidelines. After full-text evaluation, 63 studies were included. The results proved that l-T4 ingestion in the morning and at bedtime are equally effective, and also that the co-administration of l-T4 with food depends on the drug formulation. We found limited evidence for l-T4 interactions with coffee, soy products, fiber, calcium or iron supplements, and enteral nutrition but interestingly they all resulted in decreased l-T4 absorption. The altered l-T4 efficacy when ingested with milk, juices, papaya, aluminium-containing preparations, and chromium supplements, as well as observed enhancement effect of vitamin C on l-T4 absorption, shall be further investigated in larger, well-designed studies. Novel formulations are likely to solve the problem of coffee, calcium and iron induced malabsorption of l-T4. Maintaining a proper time interval between l-T4 and food intake, especially for coffee and calcium, or iron supplements, provides another effective method of eliminating such interactions.
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20
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Nagy EV, Perros P, Papini E, Katko M, Hegedüs L. New Formulations of Levothyroxine in the Treatment of Hypothyroidism: Trick or Treat? Thyroid 2021; 31:193-201. [PMID: 33003978 DOI: 10.1089/thy.2020.0515] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Levothyroxine (LT4) as a medication is used by up to 5.3% of the adult population. For optimal efficacy, the traditional tablet formulation (LT4tab) requires that patients avoid concomitant ingestion with food, drinks, and certain medications, as well as excellent patient compliance. Some comorbidities influence bioavailability of LT4 and may mandate repeated dose adjustments. Summary: New LT4 formulations (soft gel [LT4soft] and liquid [LT4liq]) containing predissolved LT4 are claimed to improve bioavailability, presumably by facilitating absorption. Thus, these formulations may well be more suitable than LT4tab for patients whose daily requirements are subjected to variations in bioavailability. Here, we review the evidence and indications for use of new LT4 formulations and highlight areas of uncertainty that are worthy of further investigation. While bioequivalence is established for LT4soft and LT4liq administered to healthy volunteers compared with LT4tab in pharmacokinetic (PK) studies, therapeutic equivalence of the new formulations seems to be different in several clinical settings. Some evidence suggests that new formulations of LT4 may mitigate against the strict requirements relating to concomitant ingestion with food, drinks, and certain medications, which apply to traditional LT4 tablets. The principal indication is in selected patients with disease fluctuations and intermittent therapies with interfering medications, where the need for frequent dose adjustments and office visits may be diminished. Whether the use of LT4soft or LT4liq in patients with impaired gastric acid secretion results in better control of hypothyroidism than LT4tab remains unclear. Conclusions: The evidence in favor of using LT4soft and LT4liq in clinical practice over LT4tab is weak, and the underlying putative PK mechanisms unclear. Additional studies to investigate these potential benefits, define the cost-effectiveness, and understand the PK mechanisms involved with new LT4 formulations are needed.
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Affiliation(s)
- Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - Monika Katko
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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21
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Fallahi P, Ferrari SM, Elia G, Ragusa F, Paparo SR, Antonelli A. L-T4 Therapy in Enteric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2021; 12:626371. [PMID: 33708175 PMCID: PMC7940821 DOI: 10.3389/fendo.2021.626371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
Levothyroxine (L-T4) absorption can be impaired by various causes: a) L-T4 ingestion during breakfast, or with food; b) conditions of reduced gastric acidity; c) intestinal procedures and diseases such as bariatric surgery, lactose intolerance (LI), celiac disease (CD), inflammatory bowel disease; d) drugs that alter L-T4 absorption, increasing the gastric pH, or preventing the dissolution of tablets. The development of new oral formulations, i.e. the liquid preparation and the soft gel capsule, represents the most recent advance regarding L-T4 therapy. Treating hypothyroidism with L-T4 tablets can lead to an improper control of thyroid-stimulating hormone (TSH) in ~10%-15% of patients. The improperly elevated TSH is usually managed by increasing the L-T4 daily dose, and revaluating TSH upon 2-6 months. The increase of the L-T4 dosage may cause iatrogenic hyperthyroidism, especially when the underlying disorders are cured. Liquid L-T4 can be administered in patients unable to swallow capsules or tablets, and this is one of its major benefits. Liquid L-T4 can: 1- overcome food and beverages interference; 2- bypass the malabsorption associated with an increased gastric pH; 3- circumvent the issue of malabsorption in patients who underwent bariatric surgery; 4-maintain TSH values under control better than L-T4 tablets in hypothyroid patients with typical or atypical CD, or in patients with LI. Few clinical studies evaluated soft gel L-T4 with encouraging findings in patients with gastric- or coffee-related malabsorption, or hypothyroid patients without malabsorption. Additional research is necessary to investigate liquid L-T4, or soft gel capsule, in other conditions of altered L-T4 absorption.
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Affiliation(s)
- Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- *Correspondence: Poupak Fallahi,
| | | | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
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22
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Richou M, Gilly O, Taillard V, Paul De Brauwere D, Donici I, Guedj AM. Levothyroxine dose adjustment in hypothyroid patients following gastric sleeve surgery. ANNALES D'ENDOCRINOLOGIE 2020; 81:500-506. [PMID: 32445637 DOI: 10.1016/j.ando.2020.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 04/10/2020] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
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23
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Liquid Levothyroxine Formulation Taken during Lunch in Italy: A Case Report and Review of the Literature. Case Rep Endocrinol 2020; 2020:8858887. [PMID: 32963845 PMCID: PMC7492953 DOI: 10.1155/2020/8858887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 12/27/2022] Open
Abstract
Levothyroxine (L-T4) is among the most widely prescribed medications in the world, and it is considered by the World Health Organization an essential medicine for basic health care. Replacement therapy has always been considered straightforward although different factors may interfere with intestinal absorption of L-T4, including food, dietary fibre, coffee, drugs, and gastrointestinal diseases. For these reasons, current guidelines recommend that L-T4 should be taken in a fasting state because its absorption is maximised when it is taken on an empty stomach, reflecting the importance of gastric acidity in the absorption process. In addition to sodium L-T4 in tablet form, various formulations (soft-gel capsules and liquid solutions) have become available for clinical use in the last years promising improved absorption. We described a 31-year-old Italian man who took liquid levothyroxine formulation during lunch. He was under replacement therapy with liquid levothyroxine 75 mcg daily for hypothyroidism due to Hashimoto thyroiditis for three years. During confirmation of the L-T4 replacement therapy, the patient stated that he was going to continue to “take liquid levothyroxine during (his) lunch every day.” We recommended taking the medication correctly in the morning at least thirty minutes before breakfast and repeating TSH, fT4, and fT3 after three months. The thyroid hormonal profiles taken after 3 and 6 months were comparable to those when the patient was taking the medication during lunch. In conclusion, liquid levothyroxine formulation should be preferred in case of malabsorption or potential malabsorption. Liquid formulation should be preferred due to the possibility of taking it during breakfast, which significantly improves the compliance of patients. Further studies are needed to evaluate the possibility of taking liquid L-T4 during lunch.
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24
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Perry IE, Sonu I, Scarpignato C, Akiyama J, Hongo M, Vega KJ. Potential proton pump inhibitor-related adverse effects. Ann N Y Acad Sci 2020; 1481:43-58. [PMID: 32761834 DOI: 10.1111/nyas.14428] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/31/2020] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
Abstract
Proton pump inhibitors (PPIs) are one of the most common medications taken by patients worldwide. PPIs are used to treat acid-related disorders, including gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori infection, and nonsteroidal anti-inflammatory drug/stress ulceration. For some of these diseases, long-term treatment is necessary. With such prolonged use, concern and investigation into potential adverse effects has increased. In addition, data are available regarding potential anticancer effects of PPIs, especially regarding solid tumors. The aim of this review is to assess the literature on PPIs with regard to common concerns, such as drug-drug interactions, the intestinal microbiome, dementia and central nervous system disease, and osteoporosis, as well as to highlight potential negative and positive impacts of the drug in cancer.
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Affiliation(s)
- Issac E Perry
- Division of Gastroenterology and Hepatology, Augusta University-Medical College of Georgia, Augusta, Georgia
| | - Irene Sonu
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City, California
| | - Carmelo Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta.,Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - Junichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Michio Hongo
- Department of Comprehensive Medicine, Tohoku University School of Medicine, Sendai, Miyagi, Japan.,Department of Medicine, Kurokawa General Hospital, Kurokawa, Miyagi, Japan
| | - Kenneth J Vega
- Division of Gastroenterology and Hepatology, Augusta University-Medical College of Georgia, Augusta, Georgia
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25
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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] [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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26
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Virili C, Brusca N, Capriello S, Centanni M. Levothyroxine Therapy in Gastric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2020; 11:621616. [PMID: 33584549 PMCID: PMC7876372 DOI: 10.3389/fendo.2020.621616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/11/2020] [Indexed: 12/19/2022] Open
Abstract
Oral levothyroxine sodium is absorbed in the small intestine, mainly in the jejunum and the ileum being lower the absorption rate at duodenal level. The time interval between the ingestion of oral thyroxine and its appearance in the plasma renders unlike a gastric absorption of the hormone. However, several evidence confirm the key role of the stomach as a prerequisite for an efficient absorption of oral levothyroxine. In the stomach, in fact, occur key steps leading to the dissolution of thyroxine from the solid form, the process bringing the active ingredient from the pharmaceutical preparation to the aqueous solution. In particular, gastric juice pH, volume, viscosity, as well as gastric emptying time seem to be the most important limiting factors. These hypotheses are confirmed by the detection of an increased need for levothyroxine in patients with Helicobacter pylori infection, chronic atrophic gastritis, gastroparesis, or in simultaneous treatment with drugs interfering with gastric acidic output. The aim of the present article is to focus on the knowledge of pathophysiologic events that determine the absorptive fate of traditional (tablet) and alternative thyroxine preparations (softgel capsule and liquid solution) in patients bearing gastric disorders.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Nunzia Brusca
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Capriello
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
- *Correspondence: Marco Centanni,
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27
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Lahner E, Conti L, Cicone F, Capriello S, Cazzato M, Centanni M, Annibale B, Virili C. Thyro-entero-gastric autoimmunity: Pathophysiology and implications for patient management. Best Pract Res Clin Endocrinol Metab 2020; 34:101373. [PMID: 31864909 DOI: 10.1016/j.beem.2019.101373] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The association between autoimmune atrophic gastritis and thyroid disorders has been observed since the early 1960s and the expression "thyrogastric syndrome" was coined to indicate the presence of thyroid autoantibodies or autoimmune thyroid disease in patients with pernicious anemia, a late clinical stage of autoimmune atrophic gastritis. More recently, it was confirmed that autoimmune thyroid disorders, in particular Hashimoto's thyroiditis, may be frequently associated with other organ-specific, immune-mediated disorders, such as autoimmune atrophic gastritis or celiac disease. The association of Hashimoto's thyroiditis with autoimmune atrophic gastritis or celiac disease in adult patients is currently considered part of the polyglandular autoimmune syndromes which include several autoimmune disorders associated with an autoaggressive impairment of endocrine glands. From a clinical point of view, the thyro-entero-gastric autoimmunity may lead to potentially serious consequences like anemia, micronutrients deficiencies, and drugs malabsorption, as well as to an increased risk for malignancies. These alterations may frequently present in an underhand manner, with consequent diagnostic and treatment delays. Many aspects of the association between thyroid, gastric and intestinal autoimmune diseases still await clarification. The present review focuses on the embryological, genetic and pathophysiological aspects of thyro-entero-gastric autoimmunity. In particular, the current diagnostic criteria of autoimmune thyroid disease, autoimmune atrophic gastritis, and celiac disease are reviewed, along with the evidences for their association in poly-autoimmunity syndromes. The benefits of proactive screening of autoimmune thyroid disorders in patients with autoimmune gastritis or enteropathy and viceversa are also discussed.
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Affiliation(s)
- Edith Lahner
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Laura Conti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Francesco Cicone
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Silvia Capriello
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
| | - Maria Cazzato
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
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28
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Giassi K, Piccoli V, da Costa Rodrigues T, Gorga Bandeira de Mello R. Evaluation of evening versus morning levothyroxine intake in elderly (MONIALE). Trials 2019; 20:742. [PMID: 31847914 PMCID: PMC6918562 DOI: 10.1186/s13063-019-3816-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/22/2019] [Indexed: 12/30/2022] Open
Abstract
Background The aging population is associated with increased multimorbidity and polypharmacy. Older adults are at a higher risk of adverse events and reduced therapeutic response. This phenomenon is partially explained by drug interactions and treatment adherence. Most randomized clinical trials have found no significant differences between morning and evening levothyroxine (LT4) administration in young adults, but there is little evidence regarding alternative LT4 regimens in older populations. Thus, the MONIALE trial aims to test an alternative schedule for LT4 administration in older adults. Methods/design This randomized crossover clinical trial will include participants aged 60 years or older with primary hypothyroidism. The trial groups will consist of morning LT4 intake (60 min before breakfast) or evening LT4 intake (60 min after supper). The primary outcome will be variation in serum thyrotropin (TSH) levels after 24 weeks of the LT4 protocol. The secondary outcomes will be the prevalence of drugs that potentially interact with LT4 and hypothyroidism control according to interaction status. The sample size was calculated to detect a minimum mean difference of 1 mUI/L in serum TSH level between the groups with 80% power and a 5% probability of type I error, resulting in 91 patients per group. The project was approved by the Hospital de Clínicas de Porto Alegre Ethics Committee. Discussion Considering the aging population, the increased prevalence of multimorbidity and polypharmacy, as well as potential drug interactions and treatment adherence difficulties, an alternative LT4 protocol could be useful for hypothyroidism treatment in the elderly. Prior studies comparing alternative LT4 administration protocols have mainly included young adult populations and have not addressed potential drug interactions. Trial registration ClinicalTrials.gov, NCT03614988. Registered 30 July 2018.
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Affiliation(s)
- Karina Giassi
- Endocrinology Program, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Vanessa Piccoli
- Internal Medicine and Geriatric Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Ticiana da Costa Rodrigues
- Endocrinology Program, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, 4° andar, Porto Alegre, RS, CEP 90035-903, Brazil
| | - Renato Gorga Bandeira de Mello
- Endocrinology Program, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. .,Internal Medicine and Geriatric Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
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29
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Virili C, Trimboli P, Centanni M. Novel thyroxine formulations: a further step toward precision medicine. Endocrine 2019; 66:87-94. [PMID: 31617168 DOI: 10.1007/s12020-019-02049-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/05/2019] [Indexed: 02/06/2023]
Abstract
Levothyroxine (T4) is a critical-dose drug, because little variations in the blood concentration may cause treatment failure as well as iatrogenic thyrotoxicosis. Despite the dose response of this drug being more carefully titrated nowadays, several papers still report that a significant fraction of patients treated with levothyroxine demonstrate a TSH which is not on target. Moreover, some widespread gastrointestinal disorders as well as interfering drugs and foods may cause the "refractoriness" of a significant number of patients to an expected dose of thyroxine. The increasing awareness of the mechanisms interfering with the oral thyroid hormone bioavailability and the body of evidence regarding the complexity of treatment in certain classes of patients prompted pharmaceutical research to identify new hormonal formulations to optimize the performance of this drug. In this brief review, the progression of the scientific knowledge of novel T4 formulations use has been analyzed.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Thyroid Center and Nuclear Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.
- Endocrinology Unit, AUSL Latina, Latina, Italy.
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30
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Khosro Adibkia, Barzegar-Jalali M, Balaei N, Osouli-Bostanabad K, Ghajar S, Emami S, Zakhireh S. Formulation of Pioglitazone-Eudragit® RS100 Nanobeads and Nanofibers Using Electrospraying Technique. POLYMER SCIENCE SERIES A 2019. [DOI: 10.1134/s0965545x19030015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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31
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Virili C, Antonelli A, Santaguida MG, Benvenga S, Centanni M. Gastrointestinal Malabsorption of Thyroxine. Endocr Rev 2019; 40:118-136. [PMID: 30476027 DOI: 10.1210/er.2018-00168] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/12/2018] [Indexed: 02/07/2023]
Abstract
Levothyroxine, a largely prescribed drug with a narrow therapeutic index, is often a lifelong treatment. The therapeutic efficacy of T4 may be marred by behavioral, pharmacologic, and pathologic issues acting as interfering factors. Despite a continuous search for an optimal T4 treatment, a significant number of patients fail to show a complete chemical and/or clinical response to this reference dose of T4. Gastrointestinal malabsorption of oral T4 represents an emerging cause of refractory hypothyroidism and may be more frequent than previously reputed. In this review, we examine the pharmacologic features of T4 preparations and their linkage with the intestinal absorption of the hormone. We have stressed the major biochemical and pharmacologic characteristics of T4 and its interaction with the putative transporter at the intestinal level. We have examined the interfering role of nutrients, foods, and drugs on T4 absorption at the gastric and intestinal levels. The impact of gastrointestinal disorders on T4 treatment efficacy has been also analyzed, in keeping with the site of action and the interfering mechanisms. Based on the evidence obtained from the literature, we also propose a schematic diagnostic workup for the most frequent and often hidden gastrointestinal diseases impairing T4 absorption.
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Affiliation(s)
- Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Interdepartmental Program of Molecular and Clinical Endocrinology, and Women's Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
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32
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Janeva E, Anastasova L, Slaveska Spirevska I, Rusevska T, Bakovska Stoimenova T, Ibrahimi T, Petkovska R. A comparative in vitro dissolution study of generic moxifloxacin immediate-release film coated tablets and referent pharmaceutical product. MAKEDONSKO FARMACEVTSKI BILTEN 2019. [DOI: 10.33320/maced.pharm.bull.2018.64.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Dissolution testing of generic immediate release solid dosage forms represents a valuable tool to obtain dissolution profiles and to establish the similarity/dissimilarity between tested dosage forms.
In this study, the in vitro dissolution profiles of generic immediate-release moxifloxacin (MOX) film coated tablets and a referent pharmaceutical product were compared and evaluated. The dissolution behavior of the generic product was investigated in three different dissolution media (pH=1.2, 4.5 and 6.8). The amount of dissolved MOX was determined using validated UV spectrophotometric method. For comparison of the dissolution behavior, the similarity factor, f2, was used.
The dissolution profile of the generic product showed a release of >85 % MOX in the time frame of 30 min, in all the tested dissolution media. The similarity factor, f2, calculated from the comparison of the dissolution profiles of the generic and the referent pharmaceutical product in pH=1.2 dissolution medium was 50, 58, thus the products were established as similar. Based on the results of our study, the dissolution similarity between the generic MOX immediate-release film coated tablet and the referent product could be successfully used as a part of the approach to ensure their in vivo bioequivalence.
Keywords: moxifloxacin, immediate-release solid dosage forms, dissolution, in vitro similarity
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Affiliation(s)
- Emilija Janeva
- Quality Control Department, Replek Farm Ltd., Kozle 188, 1000 Skopje, Republic of North Macedonia
| | - Liljana Anastasova
- Institute of Applied Chemistry and Pharmaceutical Analysis, Faculty of Pharmacy, Ss. Cyril and Methodius University, Mother Theresa 47, 1000 Skopje, Republic of North Macedonia
| | - Irena Slaveska Spirevska
- Quality Control Department, Replek Farm Ltd., Kozle 188, 1000 Skopje, Republic of North Macedonia
| | - Tatjana Rusevska
- Quality Control Department, Replek Farm Ltd., Kozle 188, 1000 Skopje, Republic of North Macedonia
| | | | - Teuta Ibrahimi
- Institute of Pharmaceutical Technology, Faculty of Pharmacy, Ss. Cyril and Methodius University, Mother Theresa 47, 1000 Skopje, Republic of North Macedonia
| | - Rumenka Petkovska
- Institute of Applied Chemistry and Pharmaceutical Analysis, Faculty of Pharmacy, Ss. Cyril and Methodius University, Mother Theresa 47, 1000 Skopje, Republic of North Macedonia
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34
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Abou-Taleb BA, Nounou MI, Khalafallah N, Khalil S. Effect of batch age on potency and dissolution of levothyroxine sodium tablets: impact of BP and USP monograph differences on dissolution results. Drug Dev Ind Pharm 2018; 44:1762-1769. [DOI: 10.1080/03639045.2018.1496446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Basant A. Abou-Taleb
- Department of Pharmaceutics, Faculty of Pharmacy and Drug Manufacturing, Pharos University in Alexandria (PUA), Alexandria, Egypt
| | - Mohamed Ismail Nounou
- Department of Pharmaceutical Sciences, School of Pharmacy (SOP), University of Saint Joseph (USJ), Hartford, USA
| | - Nawal Khalafallah
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Saleh Khalil
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
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35
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Tanguay M, Girard J, Scarsi C, Mautone G, Larouche R. Pharmacokinetics and Comparative Bioavailability of a Levothyroxine Sodium Oral Solution and Soft Capsule. Clin Pharmacol Drug Dev 2018; 8:521-528. [PMID: 30153382 PMCID: PMC6585626 DOI: 10.1002/cpdd.608] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/05/2018] [Indexed: 12/11/2022]
Abstract
A new formulation of levothyroxine sodium has been developed in the form of an oral solution contained in unit‐dose ampules. A study has been conducted to compare the bioavailability of levothyroxine sodium oral solution and levothyroxine sodium soft capsule in healthy volunteers under fasting conditions. The rate and extent of absorption of the new levothyroxine solution were also evaluated when administered on dilution in water or directly into the mouth without water. In each period, according to the randomization scheme, subjects were administered single oral doses of either test, as 4 × 150‐μg unit‐dose ampules, with or without water, or reference, as 4 × 150‐μg capsules in a crossover design. Thirty‐six subjects were randomized and dosed in this study; of these, 31 completed all study periods. When comparing the solution with the capsule (both products administered with water), the 90% confidence intervals for the ratio of log‐transformed values of AUC0‐48 and Cmax were within 90.00% and 111.11%, respectively, for baseline‐corrected levothyroxine. Moreover, the administration of levothyroxine oral solution without water did not affect the rate and extent of its absorption. In conclusion, levothyroxine oral solution unit‐dose ampules were bioequivalent to the levothyroxine capsule when administered with or without water. All formulations were well tolerated, with no major side effects.
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Affiliation(s)
- Mario Tanguay
- Syneos Health, Quebec City, Quebec, Canada.,Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, Canada
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36
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Saito Y, Adachi N, Kato M, Nadai M. [Evaluation of Dissolution Profiles of Famotidine from OTC Drugs]. YAKUGAKU ZASSHI 2018; 138:843-851. [PMID: 29593173 DOI: 10.1248/yakushi.17-00205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In recent years, self-medication has started to receive more attention in Japan owing to increasing medical costs and health awareness among people. One of the main roles of pharmacists in self-medication is to provide appropriate information regarding OTC drugs. However, pharmacists promoting the proper use of OTC drugs have little information on their formulation properties. In this study, we performed dissolution tests on both OTC drugs and ethical drug (ED) containing famotidine, and evaluated the differences in their dissolution profiles. Marked differences in dissolution profiles of OTC drugs were observed in test solutions at pH 1.2, 4.0, and 6.8 and in water. To evaluate the differences quantitatively, we calculated the lag time and dissolution rate constant from the dissolution profiles. Significant differences in lag times and dissolution rate constants between some OTC drugs and ED were observed. We also used similarity factor (f2), to quantify the similarity between dissolution profiles of OTC drugs and ED. f2 values less than 42 were observed in some OTC drugs, suggesting that these differences might influence absorption in vivo resulting in differences in their onset time and efficacy. The findings of this study will provide useful information for the promotion of proper use of OTC drugs.
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Affiliation(s)
- Yuji Saito
- Department of Pharmaceutics, Faculty of Pharmacy, Meijo University
| | - Naoki Adachi
- Department of Pharmaceutics, Faculty of Pharmacy, Meijo University
| | - Miki Kato
- Department of Pharmaceutics, Faculty of Pharmacy, Meijo University
| | - Masayuki Nadai
- Department of Pharmaceutics, Faculty of Pharmacy, Meijo University
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Abstract
BACKGROUND Levothyroxine is the most commonly prescribed medication in the United States. Many foods and medications, including calcium supplements, can interfere with levothyroxine absorption. No studies have investigated the effect of cow's milk, a common breakfast staple, on the absorption of oral levothyroxine. Cow's milk contains approximately 450 mg of elemental calcium per 12 oz (355 mL) serving. METHODS A pharmacokinetic study was conducted in healthy euthyroid subjects to assess levothyroxine absorption with and without concurrent cow's milk consumption. Following an overnight fast, serum total thyroxine (TT4) concentrations were measured at baseline and at one, two, four, and six hours after ingestion of 1000 μg of oral levothyroxine alone or when co-administered with 12 oz (355 mL) of 2% milk. There was a four-week washout period between the two assessments in each subject. RESULTS Ten subjects (Mage ± SD = 33.7 ± 10.2 years; 60% male) completed the study. The area under the curve (AUC) of TT4 concentrations was significantly lower when levothyroxine was ingested along with 12 oz (355 mL) of 2% cow's milk (M ± SD = 67.3 ± 12.1) compared to that with levothyroxine alone (73.5 ± 17.0; p = 0.02). Also, peak serum TT4 concentrations were significantly lower when cow's milk was co-administered with levothyroxine (M ± SD = 14.1 ± 0.8 μg/dL) than with levothyroxine alone (13.0 ± 0.9 μg/dL; p = 0.04). CONCLUSIONS This is the first study to demonstrate that concurrent cow's milk ingestion reduces oral levothyroxine absorption. The findings support previous literature showing the interference of elemental calcium and food with thyroid hormone absorption. Patients managed with thyroid hormone should be advised to avoid taking their levothyroxine simultaneously with cow's milk.
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Affiliation(s)
- Deborah A. Chon
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Tamar Reisman
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jane E. Weinreb
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jerome M. Hershman
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
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38
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Trimboli P, Virili C, Centanni M, Giovanella L. Thyroxine Treatment With Softgel Capsule Formulation: Usefulness in Hypothyroid Patients Without Malabsorption. Front Endocrinol (Lausanne) 2018; 9:118. [PMID: 29619010 PMCID: PMC5871661 DOI: 10.3389/fendo.2018.00118] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 03/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Levothyroxine sodium (LT4) is the therapy of choice for hypothyroidism. In the last decade, new LT4 formulations, such as liquid and softgel capsules, became available. Even if some evidence has been reached in the efficacy of liquid LT4 in patients with suboptimal TSH on tablet LT4, the usefulness of softgel LT4 has been rarely studied. This study aimed at evaluating the effect of switching from tablet to softgel LT4 patients without increased need for LT4. TSH was used as proxy of LT4 bioavailability and effectiveness. METHODS During the period from April to August 2017, 19 patients on tablet LT4 treatment for hypothyroidism, mostly due to autoimmune thyroiditis, were enrolled. Subjects with causes of malabsorption or increased requirement of LT4 were previously excluded. Patients finally included were asked to switch from tablet to softgel LT4 formulation at unchanged dose and ingestion fashion (30 min before breakfast). TSH was measured with chemiluminescence immunoassays. RESULTS According to exclusion and inclusion criteria, 19 patients were finally selected. One of these had headache 4 days later and come back to tablet LT4, and 18 of them (16W/2M; mean age = 55 years; BMI 22.7 kg/m2) completed the study. They were treated with a median LT4 dose of 88 μg/day and showed a median TSH value of 3.33 mIU/L. The rate of cases with TSH ≤ 4.0 mIU/L was 61.1% (11/18 cases). When patients were re-evaluated after 3 months of softgel LT4, we observed that TSH reached levels under 4.0 mIU/L in 16/18 (88.9%) patients, TSH was lower in 11 cases, and in 6 out of 7 patients with pre-switch TSH values over the normal range. Overall, TSH values on softgel LT4 (median 1.90 mIU/L) was significantly lower from that observed during tablet LT4 (p = 0.0039). CONCLUSION These data show that hypothyroid patients with no proven malabsorption may have an improved TSH following 3 months from the switch from tablet to softgel LT4 preparation at unchanged dose.
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Affiliation(s)
- Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- *Correspondence: Pierpaolo Trimboli,
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Luca Giovanella
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Centanni M, Benvenga S, Sachmechi I. Diagnosis and management of treatment-refractory hypothyroidism: an expert consensus report. J Endocrinol Invest 2017; 40:1289-1301. [PMID: 28695483 PMCID: PMC5680379 DOI: 10.1007/s40618-017-0706-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/01/2017] [Indexed: 12/17/2022]
Abstract
There is a frequently encountered subset of hypothyroid patients who are refractory to standard thyroid hormone replacement treatment and require unexpectedly high doses of levothyroxine. In addition to clinical situations where hypothyroid patients are non-compliant, or where there is the possibility of excipient-induced disease exacerbation (gluten/celiac disease), therapeutic failure may be due to impaired absorption of the administered drug. The common approach to managing patients with unusual thyroxine needs is to escalate the dose of levothyroxine until targeted TSH levels are achieved. This approach can increase the risk for prolonged exposure to supratherapeutic doses of levothyroxine, which increase the chances of adverse outcomes. Repeated adjustments of levothyroxine can also escalate the costs of treatment, as frequent office visits and laboratory tests are required to determine and maintain the desired dose. Clinicians should take a systematic approach to managing patients whom they suspect of having treatment-refractory hypothyroidism. This may include searching for, and adjusting, occult medical conditions and/or other factors that may affect the absorption of levothyroxine, before up-titrating the dose of traditional levothyroxine therapy. Depending on the underlying pathology, another approach that may be considered is to try alternative formulations of levothyroxine that are less susceptible to intolerance issues related to excipients, or, in some cases, to malabsorption. The early discovery of these factors via a thoughtful patient work-up may avoid unnecessary thyroid medication adjustments and their consequences for both patients and clinicians.
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Affiliation(s)
- M. Centanni
- Section of Endocrinology, Department of Medico-surgical Services and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - S. Benvenga
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women’s Endocrine Health, A.O.U. Policlinico G Martino, Messina, Italy
| | - I. Sachmechi
- Division of Endocrinology, Queens Hospital Center, Icahn School of Medicine, Jamaica, NY USA
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Virtual bioequivalence for achlorhydric subjects: The use of PBPK modelling to assess the formulation-dependent effect of achlorhydria. Eur J Pharm Sci 2017; 109:111-120. [DOI: 10.1016/j.ejps.2017.07.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/31/2017] [Accepted: 07/30/2017] [Indexed: 01/27/2023]
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41
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Grimm M, Scholz E, Koziolek M, Kühn JP, Weitschies W. Gastric Water Emptying under Fed State Clinical Trial Conditions Is as Fast as under Fasted Conditions. Mol Pharm 2017; 14:4262-4271. [DOI: 10.1021/acs.molpharmaceut.7b00623] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Michael Grimm
- Institute
of Pharmacy, Center of Drug Absorption and Transport, University of Greifswald, D-17487 Greifswald, Germany
| | - Elisabeth Scholz
- Institute
of Pharmacy, Center of Drug Absorption and Transport, University of Greifswald, D-17487 Greifswald, Germany
| | - Mirko Koziolek
- Institute
of Pharmacy, Center of Drug Absorption and Transport, University of Greifswald, D-17487 Greifswald, Germany
| | - Jens-Peter Kühn
- Institute
of Radiology and Neuroradiology, University Medicine Greifswald, D-17475 Greifswald, Germany
- Department
of Radiology, University Medicine Dresden, D-01304 Dresden, Germany
| | - Werner Weitschies
- Institute
of Pharmacy, Center of Drug Absorption and Transport, University of Greifswald, D-17487 Greifswald, Germany
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Ferrara R, Ientile V, Arcoraci V, Ferrajolo C, Piccinni C, Fontana A, Benvenga S, Trifirò G. Treatment pattern and frequency of serum TSH measurement in users of different levothyroxine formulations: a population-based study during the years 2009-2015. Endocrine 2017; 58:143-152. [PMID: 28155170 DOI: 10.1007/s12020-017-1242-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/17/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several conditions can modify the intestinal absorption of levothyroxine tablets, with potential consequences on their therapeutic effect. Pre-dosed ampoules and oral drops have been recently made available to overcome this limitation. AIMS To describe the pattern of use of different formulations of levothyroxine in a general population of Southern Italy and to perform an exploratory analysis investigating the effect of switching from levothyroxine tablets to oral liquid formulations. METHODS Data were extracted from the Caserta Local Health Unit database. All patients receiving at least one levothyroxine prescription during the years 2009-2015 were identified. 1-year incidence of use of formulation-specific levothyroxine was calculated. Switchers between levothyroxine tablets and oral liquid formulations were identified and the frequency of thyroid-stimulating hormone measurement within 2 years prior and after the switch date was explored. RESULTS Overall, 56,354 levothyroxine users were included in the study. Of these, 55,147 patients received at least one prescription for tablets (97.9%), 1867 pre-dosed ampoules (3.3%) and 1550 oral drops (2.8%). The proportion of levothyroxine users receiving oral liquid formulations slightly increased over time. Patients switching from tablets to oral liquid formulations showed a statistically significant reduction in the number of thyroid-stimulating hormone measurements after switching from tablets, especially in presence of drugs interacting with levothyroxine potentially altering its absorption. CONCLUSIONS Use of levothyroxine oral liquid formulations is increasing over time even though their use is still limited in a general population of Southern Italy. Our exploratory analysis showed that the frequency of thyroid-stimulating hormone measurement was reduced in patients switching from levothyroxine tablet to new formulations.
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Affiliation(s)
- Rosarita Ferrara
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
| | - Valentina Ientile
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
| | - Vincenzo Arcoraci
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmen Ferrajolo
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Carlo Piccinni
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gianluca Trifirò
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy.
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy.
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TSH Normalization in Bariatric Surgery Patients After the Switch from L-Thyroxine in Tablet to an Oral Liquid Formulation. Obes Surg 2017; 27:78-82. [PMID: 27272506 DOI: 10.1007/s11695-016-2247-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Drug malabsorption is one of the potential troubles after bariatric surgery. Evidence for diminished levothyroxine (L-T4) absorption has been reported in patients after bariatric surgery. METHODS This study reports 17 cases of hypothyroid patients [who were well replaced with thyroxine tablets (for >1 year) to euthyroid thyrotropin (TSH) levels before surgery (13 Roux-en-Y gastric bypasses (RYGB); 4 biliary pancreatic diversions (BPD))]. From 3 to 8 months after surgery, these patients had elevated TSH levels. Patients were then switched from oral tablets to a liquid L-T4 formulation (with the same dosage, 30 min before breakfast). RESULTS Two-three months after the switch, TSH was significantly reduced both in patients treated with RYGB, as in those treated with BPD, while FT4 and FT3 levels were not significantly changed (RYGB group, TSH μIU/mL: 7.58 ± 3.07 vs 3.808 ± 1.83, P < 0.001; BPD group, TSH μIU/mL: 8.82 ± 2.76 vs 3.12 ± 1.33, P < 0.01). CONCLUSIONS These results first show that liquid L-T4 could prevent the problem of malabsorption in patients with BPD and confirm those of previous studies in patients submitted to RYGB, suggesting that the L-T4 oral liquid formulation could circumvent malabsorption after bariatric surgery.
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Ernst FR, Sandulli W, Elmor R, Welstead J, Sterman AB, Lavan M. Retrospective Study of Patients Switched from Tablet Formulations to a Gel Cap Formulation of Levothyroxine: Results of the CONTROL Switch Study. Drugs R D 2017; 17:103-115. [PMID: 27943146 PMCID: PMC5318319 DOI: 10.1007/s40268-016-0150-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Medication changes involving levothyroxine-either dose titrations or switching formulations-occur frequently in patients with erratic thyroid-stimulating hormone (TSH) levels and persistent hypothyroid symptoms. We investigated whether switching patients from levothyroxine tablets to a gel cap formulation of levothyroxine might reduce dose adjustments and improve tolerability and efficacy outcomes. OBJECTIVES Primary study objectives included quantifying the percentage of patients achieving TSH levels within a pre-specified range, median dose changes experienced, and the percentage of patients with improved hypothyroid symptom control after switching from levothyroxine tablets to levothyroxine gel caps. METHODS A retrospective medical chart review was conducted among 99 randomly selected hypothyroid patients who were switched from a tablet to a gel cap formulation of levothyroxine. Patients were required to have been on levothyroxine monotherapy for ≥1 year prior to the medication switch. Data was collected for 6 months pre-switch and up to 6 months post-switch. RESULTS Of the 99 patients studied, the majority (51.5%) experienced no documented change in TSH status after the switch (P < 0.0001). However, there was a decrease in the mean number of dose changes experienced (1.61 ± 0.96 vs. 0.73 ± 0.96; P < 0.0001). Improved hypothyroid symptom control was reported among 61.6% of patients (61 of 99; P < 0.0001). CONCLUSION The results of CONTROL Switch support a strategy of switching patients who may experience tolerability or efficacy problems with standard levothyroxine tablets to the levothyroxine gel cap formulation.
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Affiliation(s)
- Frank R Ernst
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA.
| | | | - Riad Elmor
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA
| | - Jennifer Welstead
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA
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A feasible method for indirect quantification of L-T 4 in drugs by iodine determination. Talanta 2017; 166:223-227. [PMID: 28213226 DOI: 10.1016/j.talanta.2017.01.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/20/2022]
Abstract
In this work, a method combining microwave-induced combustion (MIC) for sample preparation of commercial levothyroxine sodium (L-T4) drugs (L-T4: 25-200µg/tablet), and potentiometry with ion selective electrode (ISE) for iodine determination and subsequent indirect quantification of L-T4 was proposed. The type and concentration of the absorbing solution were evaluated to select the most suitable conditions for this study. Using the MIC method, it was possible to use solutions as diluted as 150mmolL-1 (NH4)2CO3 (for samples containing 25-200µg of L-T4/tablet) for I absorption. In these conditions, recoveries for L-T4 were between 99% and 101%, and relative standard deviations were lower than 10%. The limit of detection for L-T4 was 11.2µg/tablet, which is almost two times lower than the minimum concentration of L-T4 in commercially available drugs. Thus, the MIC was suitable for the digestion of several L-T4 drugs for subsequent I determination by ISE and indirect quantification of L-T4. Furthermore, the proposed method presents high throughput with low reagent consumption and consequently lower waste generation, making it suitable for routine determination of L-T4 in drugs. From the obtained results, it was possible to observe that one of the analyzed samples is not in agreement with the limits established by the United States Pharmacopeia, indicating the importance of the drug quality control. The United States Pharmacopeia establishes that each tablet must contain between 90% and 110% of the amount of active substance declared by the manufacturer.
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Skelin M, Lucijanić T, Amidžić Klarić D, Rešić A, Bakula M, Liberati-Čizmek AM, Gharib H, Rahelić D. Factors Affecting Gastrointestinal Absorption of Levothyroxine: A Review. Clin Ther 2017; 39:378-403. [PMID: 28153426 DOI: 10.1016/j.clinthera.2017.01.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/23/2016] [Accepted: 01/03/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Levothyroxine (LT4) is a drug with a narrow therapeutic index, applied in small amounts (micrograms), which makes interactions in the absorption phase clinically significant. The main aim of this article was to review and present the latest information on factors that affect the gastrointestinal absorption of this drug. METHODS Relevant data were collected by using the MEDLINE, PubMed, EMBASE, Web of Science, Science Direct, and Scopus databases with the key words levothyroxine and absorption. Searches were not limited to specific publication types, study designs, dates, or languages. The reports were highly variable in the amount of information provided regarding study design and methods. Because of the heterogeneity of studies, no statistical analysis was performed. FINDINGS Many gastrointestinal disorders, such as celiac disease, atrophic gastritis, lactose intolerance, and Helicobacter pylori infection, may impede the absorption of levothyroxine. During treatment of these disorders, it is necessary to monitor serum thyroid-stimulating hormone and free T4 values to reduce the risk of developing iatrogenic hyperthyroidism. Soybeans and coffee have the greatest impact on the reduction of absorption, whereas vitamin C has the ability to increase it. Conversely, the effect of dietary fiber on the absorption of LT4 is not yet fully understood; further research is needed on this topic. A decrease in the absorption of LT4 is established and clinically significant when administered concomitantly with cholestyramine, colesevelam, lanthanum, calcium carbonate, calcium citrate, calcium acetate, iron sulfate, ciprofloxacin, aluminum hydroxide, sevelamer, or proton pump inhibitors. This effect should be taken into consideration when prescribing these drugs concomitantly with LT4. The effects of Giardia lamblia infection and the influence of orlistat, polystyrene sulfonate, raloxifene, and simethicone on absorption of LT4 have been poorly documented. For bariatric surgery, sucralfate and H2-antagonist interactions are not well founded or contradictory evidence is available regarding their existence; additional research should be conducted. IMPLICATIONS The majority of the interactions are clinically significant. They are based on the LT4 adsorption on interfering substances in the digestive tract, as well as a consequently reduced amount of the drug available for absorption. These interactions can be avoided by separating the administration of LT4 and the interfering substance.
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Affiliation(s)
- Marko Skelin
- Pharmacy Department, General Hospital Šibenik, Šibenik, Croatia
| | - Tomo Lucijanić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Clinical Hospital Dubrava, Zagreb, Croatia
| | | | - Arnes Rešić
- Department of Paediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Miro Bakula
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh," Zagreb, Croatia
| | - Ana-Marija Liberati-Čizmek
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh," Zagreb, Croatia
| | - Hossein Gharib
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Dario Rahelić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Clinical Hospital Dubrava, Zagreb, Croatia
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Van Den Abeele J, Rubbens J, Brouwers J, Augustijns P. The dynamic gastric environment and its impact on drug and formulation behaviour. Eur J Pharm Sci 2017; 96:207-231. [DOI: 10.1016/j.ejps.2016.08.060] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 02/08/2023]
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Cellini M, Santaguida MG, Virili C, Capriello S, Brusca N, Gargano L, Centanni M. Hashimoto's Thyroiditis and Autoimmune Gastritis. Front Endocrinol (Lausanne) 2017; 8:92. [PMID: 28491051 PMCID: PMC5405068 DOI: 10.3389/fendo.2017.00092] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/07/2017] [Indexed: 12/16/2022] Open
Abstract
The term "thyrogastric syndrome" defines the association between autoimmune thyroid disease and chronic autoimmune gastritis (CAG), and it was first described in the early 1960s. More recently, this association has been included in polyglandular autoimmune syndrome type IIIb, in which autoimmune thyroiditis represents the pivotal disorder. Hashimoto's thyroiditis (HT) is the most frequent autoimmune disease, and it has been reported to be associated with gastric disorders in 10-40% of patients while about 40% of patients with autoimmune gastritis also present HT. Some intriguing similarities have been described about the pathogenic mechanism of these two disorders, involving a complex interaction among genetic, embryological, immunologic, and environmental factors. CAG is characterized by a partial or total disappearance of parietal cells implying the impairment of both hydrochloric acid and intrinsic factor production. The clinical outcome of this gastric damage is the occurrence of a hypochlorhydric-dependent iron-deficient anemia, followed by pernicious anemia concomitant with the progression to a severe gastric atrophy. Malabsorption of levothyroxine may occur as well. We have briefly summarized in this minireview the most recent achievements on this peculiar association of diseases that, in the last years, have been increasingly diagnosed.
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Affiliation(s)
- Miriam Cellini
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Silvia Capriello
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Nunzia Brusca
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Lucilla Gargano
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- *Correspondence: Marco Centanni,
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Hennessey JV. The emergence of levothyroxine as a treatment for hypothyroidism. Endocrine 2017; 55:6-18. [PMID: 27981511 DOI: 10.1007/s12020-016-1199-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/02/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe the historical refinements, understanding of physiology and clinical outcomes observed with thyroid hormone replacement strategies. METHODS A Medline search was initiated using the search terms, levothyroxine, thyroid hormone history, levothyroxine mono therapy, thyroid hormone replacement, combination LT4 therapy, levothyroxine Bioequivalence. Pertinent articles of interest were identified by title and where available abstract for further review. Additional references were identified in the course of review of the literature identified. RESULTS Physicians have intervened in cases of thyroid dysfunction for more than two millennia. Ingestion of animal thyroid derived preparations has been long described but only scientifically documented for the last 130 years. Refinements in hormone preparation, pharmaceutical production and regulation continue to this day. The literature provides documentation of physiologic, pathologic and clinical outcomes which have been reported and continuously updated. Recommendations for effective and safe use of these hormones for reversal of patho-physiology associated with hypothyroidism and the relief of symptoms of hypothyroidism has documented a progressive refinement in our understanding of thyroid hormone use. Studies of thyroid hormone metabolism, action and pharmacokinetics have allowed evermore focused recommendations for use in clinical practice. Levothyroxine mono-therapy has emerged as the therapy of choice of all recent major guidelines. CONCLUSIONS The evolution of thyroid hormone therapies has been significant over an extended period of time. Thyroid hormone replacement is very useful in the treatment of those with hypothyroidism. All of the most recent guidelines of major endocrine societies recommend levothyroxine mono-therapy for first line use in hypothyroidism.
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Affiliation(s)
- James V Hennessey
- Harvard Medical School, Division of Endocrinology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Gryzmish 619, Boston, 02215, MA, USA.
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50
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Fiorini G, Ribichini D, Pasquali R, Vaira D. In vivo dissolution of levothyroxine soft gel capsules. Intern Emerg Med 2016; 11:1151-1152. [PMID: 27562380 DOI: 10.1007/s11739-016-1526-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/13/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Giulia Fiorini
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Danilo Ribichini
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Renato Pasquali
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Dino Vaira
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy.
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