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Angelopoulos N, Paparodis RD, Androulakis I, Anagnostis P, Boniakos A, Duntas L, Karras SN, Livadas S. The clinical significance of low dose biotin supplements (<300μg/day) in the treatment of patients with hypothyroidism: crucial or overestimated? Thyroid Res 2023; 16:18. [PMID: 37455308 DOI: 10.1186/s13044-023-00162-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/07/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND In the last decade, the combination of the widespread use of streptavidin-biotin technology and biotin-containing supplements (BCS) in the daily clinical practice, have led to numerous reports of erroneous hormone immunoassay results. However, there are no studies assessing the clinical and biochemical significance of that phenomenon, when treating patients with hypothyroidism. Therefore, a prospective study was designed to investigate the potential alterations in the measurement of thyroid hormone concentrations and clinical consequences in patients with hypothyroidism using low -dose BCS containing less than 300 μg/day. METHODS Fifty-seven patients on thyroxine supplementation, as a result of hypothyroidism and concurrent use of BCS at a dose <300μg/day for 10 to 60 days were prospectively evaluated. Namely, TSH and free T4 (FT4) concentration measurements were performed, during BC supplementation and 10 days post BCS discontinuation and compared to 31 age-matched patients with supplemented hypothyroidism and without BCS. RESULTS A statistically significant increase in TSH and decline in FT4 concentrations was observed after BCS discontinuation. However, on clinical grounds, these modifications were minor and led to medication dose adjustment in only 2/57 patients (3.51%) in whom TSH was notably decreased after supplement discontinuation. CONCLUSION Our study suggests that changes in thyroid hormones profiling, due to supplements containing low dose biotin, are of minimal clinical relevance and in most cases don't occult the need to adjust the thyroxine replacement dose in patients with hypothyroidism. Larger, well-designed trials are required to further evaluate this phenomenon.
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Affiliation(s)
- Nicholas Angelopoulos
- Endocrine Unit, Athens Medical Centre, Athens, Greece.
- Private Practice, 26G Venizelou St, 65302, Kavala, Greece.
| | - Rodis D Paparodis
- Center for Diabetes and Endocrine Research, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Private Practice, Patras, Greece
| | | | - Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1St Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Leonidas Duntas
- Unit of Endocrinology, Diabetes and Metabolism, Evgenideion Hospital, University of Athens, 11528, Athens, Greece
| | - Spyridon N Karras
- Laboratory of Biological Chemistry, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Abstract
Nail conditions are not only aesthetic concerns, and nail changes may be a clue to an underlying systemic diseases or infection. Without timely treatment, nail diseases can continue to worsen and significantly impair performance of daily activities and reduce quality of life. Examination of the nails is essential at every medical visit, and may uncover important findings. Brittle nail syndrome, onychomycosis, paronychia, nail psoriasis, longitudinal melanonychia, Beau's lines, onychomadesis and retronychia are common nail disorders seen in clinical practice. These conditions stem from infectious, inflammatory, neoplastic and traumatic aetiologies. Though each nail condition presents with its own distinct characteristics, the clinical findings may overlap between different conditions, resulting in misdiagnosis and treatment delays. Patients can present with nail plate changes (e.g. hyperkeratosis, onycholysis, pitting), discolouration, pain and inflammation. The diagnostic work-up of nail disease should include a detailed history and clinical examination of all 20 nail units. Dermoscopy, diagnostic imaging and histopathologic and mycological analyses may be necessary for diagnosis. Nail findings concerning for malignancy should be promptly referred to a dermatologist for evaluation and biopsy. Nail disease management requires a targeted treatment approach. Treatments include topical and/or systemic medications, discontinuation of offending drugs or surgical intervention, depending on the condition. Patient education on proper nail care and techniques to minimize further damage to the affected nails is also important. This article serves to enhance familiarity of the most common nail disorders seen in clinical practice. It will highlight the key clinical manifestations, systematic approaches to diagnosis and treatment options for each nail condition to improve diagnosis and management of nail diseases, as well as patient outcomes.Key messagesNail disease is not only a cosmetic issue, as nail changes can indicate the presence of a serious underlying systemic disease, infection or malignancy.Nail pain and changes associated with NP are physically and emotionally distressing and may contribute to functional impairment and diminished quality of life.LM is a hallmark sign of subungual melanoma and this finding warrants further investigation to rule out malignancy.
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Affiliation(s)
- Debra K Lee
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine New York, NY, USA
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Falotico JM, Lipner SR. Biotin Beware: Perils of Biotin Supplementation. J Am Acad Dermatol 2022; 86:e279-e280. [DOI: 10.1016/j.jaad.2022.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
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Ghazal K, Brabant S, Prie D, Piketty ML. Hormone Immunoassay Interference: A 2021 Update. Ann Lab Med 2022; 42:3-23. [PMID: 34374345 PMCID: PMC8368230 DOI: 10.3343/alm.2022.42.1.3] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/08/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022] Open
Abstract
Immunoassays are powerful qualitative and quantitative analytical techniques. Since the first description of an immunoassay method in 1959, advances have been made in assay designs and analytical characteristics, opening the door for their widespread implementation in clinical laboratories. Clinical endocrinology is closely linked to laboratory medicine because hormone quantification is important for the diagnosis, treatment, and prognosis of endocrine disorders. Several interferences in immunoassays have been identified through the years; although some are no longer encountered in daily practice, cross-reaction, heterophile antibodies, biotin, and anti-analyte antibodies still cause problems. Newer interferences are also emerging with the development of new therapies. The interfering substance may be exogenous (e.g., a drug or substance absorbed by the patient) or endogenous (e.g., antibodies produced by the patient), and the bias caused by interference can be positive or negative. The consequences of interference can be deleterious when clinicians consider erroneous results to establish a diagnosis, leading to unnecessary explorations or inappropriate treatments. Clinical laboratories and manufacturers continue to investigate methods for the detection, elimination, and prevention of interferences. However, no system is completely devoid of such incidents. In this review, we focus on the analytical interferences encountered in daily practice and possible solutions for their detection or elimination.
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Affiliation(s)
- Khaldoun Ghazal
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Severine Brabant
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Dominique Prie
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Marie-Liesse Piketty
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
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Abstract
The nail is a specialized keratinous skin appendage that is often overlooked, even though nail disorders comprise approximately 10% of all dermatologic conditions. We provide an overview on the basic anatomy of the nail and function of each structure. We examine the chemical profile, including the keratin and mineral composition, of the nail plate. Subsequently, nail manifestations are reviewed, as virtually every nutritional deficiency can affect nail growth in some manner. We focus on how each nutritional deficiency can affect the different anatomic structures of the nail unit. The terminology and the differential diagnoses of the many different nail plate and nail bed abnormalities are reviewed. Finally, we focus on the evidence behind nutrition-based treatments in the setting of several nail disorders.
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Affiliation(s)
- Suraj Muddasani
- University of Cininnati College of Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Gloria Lin
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jette Hooper
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Steven Brett Sloan
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA; VA Connecticut Healthcare System, Newington, Connecticut, USA.
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Abstract
Vitamin and mineral supplement consumption is widespread. They are taken for a variety of conditions, including dermatologic disorders. Although consumers often assume these supplements are safe, excessive consumption of supplements may have deleterious effects. Such vitamin supplements include vitamin A, niacin, biotin, vitamin D, and vitamin E, and specific mineral supplements include zinc, copper, and iron. These supplements may have a number of potential adverse effects.
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Affiliation(s)
- Freidrich Anselmo
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marcia S Driscoll
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Ylli D, Soldin SJ, Stolze B, Wei B, Nigussie G, Nguyen H, Mendu DR, Mete M, Wu D, Gomes-Lima CJ, Klubo-Gwiezdzinska J, Burman KD, Wartofsky L. Biotin Interference in Assays for Thyroid Hormones, Thyrotropin and Thyroglobulin. Thyroid 2021; 31:1160-1170. [PMID: 34042535 PMCID: PMC8420951 DOI: 10.1089/thy.2020.0866] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Biotin has been reported to interfere with several commonly used laboratory assays resulting in misleading values and possible erroneous diagnosis and treatment. This report describes a prospective study of possible biotin interference in thyroid-related laboratory assays, with a comparison of different commonly used assay platforms. Materials and Methods: Thirteen adult subjects (mean age 45 ± 13 years old) were administered biotin 10 mg/day for eight days. Blood specimens were collected at three time points on day 1 and on day 8 (baseline, two, and five hours after biotin ingestion). Thyrotropin (TSH), free triiodothyronine (fT3), free thyroxine (fT4), total triiodothyronine (TT3), total thyroxine (TT4), thyroxine binding globulin (TBG), and thyroglobulin (Tg) levels were analyzed with four different platforms: Abbott Architect, Roche Cobas 6000, Siemens IMMULITE 2000, and liquid chromatography with tandem mass spectrometry (LC-MS/MS). TSH, fT3, fT4, TT3, and TT4 were measured with Abbott Architect and Roche Cobas 6000. fT3, fT4, TT3, and TT4 were also measured by LC-MS/MS. Tg was measured by Siemens IMMULITE 2000. TBG was assessed with Siemens IMMULITE 2000. Results: Significant changes in TSH, fT4, and TT3 measurements were observed after biotin exposure when the Roche Cobas 6000 platform was used. Biotin intake resulted in a falsely lower Tg level when measurements were performed with Siemens IMMULITE 2000. At the time points examined, maximal biotin interference was observed two hours after biotin exposure both on day 1 and day 8. Conclusions: A daily dose of 10 mg was shown to interfere with specific assays for TSH, fT4, TT3, and Tg. Physicians must be aware of the potential risk of erroneous test results in subjects taking biotin supplements. Altered test results for TSH and Tg can be particularly problematic in patients requiring careful titration of levothyroxine therapy such as those with thyroid cancer.
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Affiliation(s)
- Dorina Ylli
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, District of Columbia, USA
- Faculty of Medicine, University of Medicine, Tirana, Albania
| | - Steven J. Soldin
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, Maryland, USA
| | - Brian Stolze
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, Maryland, USA
| | - Bin Wei
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, Maryland, USA
| | - Girum Nigussie
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, Maryland, USA
| | - Hung Nguyen
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, Maryland, USA
| | - Damodara Rao Mendu
- Department of Laboratory Medicine, Mount Sinai Hospital NY, New York, New York, USA
| | - Mihriye Mete
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Di Wu
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Cristiane J. Gomes-Lima
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Joanna Klubo-Gwiezdzinska
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kenneth D. Burman
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Leonard Wartofsky
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, District of Columbia, USA
- Address correspondence to: Leonard Wartofsky, MD, Endocrinology Division, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
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Waqas B, Wu A, Yim E, Lipner SR. A survey-based study of physician practices regarding biotin supplementation. J DERMATOL TREAT 2020; 33:573-574. [PMID: 32419559 DOI: 10.1080/09546634.2020.1770178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Biotin is an important cofactor in several metabolic pathways in humans. Biotin deficiencies are quite uncommon and there is limited data to support recommending it to treat hair, skin, and nail conditions. A 2017 FDA safety alert warned that biotin can interfere with laboratory testing resulting in incorrect diagnoses and even death. Therefore, our study objectives were to assess biotin recommendation practices and survey physician knowledge of biotin interference in routine laboratory tests. In a national survey of 149 physicians, we found that 43.9% of physicians prescribe biotin, primarily for hair and nail disorders, and 39.5% recommended other biotin-containing supplements. Most physicians answered correctly that there are no randomized studies that biotin improves dermatological conditions, and that biotin interferes with thyroid and troponin testing. Few knew of interference with b-HCG, Hepatitis serology, HIV serology and Vitamin D levels, and 19.5% were unaware of any interference. Almost half of physicians did not ask patients to discontinue biotin prior to laboratory testing. Our study shows that physicians continue to prescribe biotin despite knowledge gaps about laboratory interference, and highlights the need for increasing physician awareness of risks and benefits of recommending biotin to treat skin, hair, and nail conditions.
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Affiliation(s)
| | - Alan Wu
- Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - Elizabeth Yim
- Department of Medicine, Division of Dermatology, University of California, Los Angeles, CA, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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Altmetric analysis of biotin in scholarly outputs after the biotin Food and Drug Administration warning. J Am Acad Dermatol 2020; 82:1017-1018. [DOI: 10.1016/j.jaad.2019.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 11/19/2022]
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Chessa MA, Iorizzo M, Richert B, López-Estebaranz JL, Rigopoulos D, Tosti A, Gupta AK, Di Chiacchio N, Di Chiacchio NG, Rubin AI, Baran R, Lipner SR, Daniel R, Chiheb S, Grover C, Starace M, Piraccini BM. Pathogenesis, Clinical Signs and Treatment Recommendations in Brittle Nails: A Review. Dermatol Ther (Heidelb) 2020; 10:15-27. [PMID: 31749091 PMCID: PMC6994568 DOI: 10.1007/s13555-019-00338-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Indexed: 02/06/2023] Open
Abstract
Nail plate brittleness (or fragility) is a common complaint affecting up to 20% of the population, especially women over 50 years of age, with fingernail fragility being more prevalent than toenail fragility. Nail brittleness is characterized by nails that split, flake and crumble, become soft and lose elasticity. The main clinical presentations are: onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nails. According to causative factors, we can distinguish 2 forms of nail fragility (NF): a primary "idiopathic or brittle nail syndrome" form and NF secondary to different causes such as inflammatory nail disorders, infections, systemic diseases and general conditions, traumas and alteration of the nail hydration. Optimal management requires treatment of the primary cause of brittle nails, when possible. In idiopathic NF oral supplementation, vitamins (especially biotin, also known as vitamin B7), trace elements and amino acids (especially cysteine) have been reported to be useful. In addition, several products, such as topical moisturizers and lacquers could be considered to restructure the affected nail plate and to reduce psychological impacts of this common problem.
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Affiliation(s)
- Marco A Chessa
- Dermatology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
| | - Matilde Iorizzo
- Private Dermatology Practice, Bellinzona/Lugano, Switzerland
| | - Bertrand Richert
- Saint Pierre - Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Dimitrios Rigopoulos
- Department of Dermatology, National and Kapodistrian University of Athens, "A. Sygros" Hospital, Athens, Greece
| | - Antonella Tosti
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Aditya K Gupta
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Canada and Mediprobe Research Inc., London, ON, Canada
| | - Nilton Di Chiacchio
- Dermatology Clinic - Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil
| | - Nilton G Di Chiacchio
- Dermatology Clinic - Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil
- Dermatology Discipline - Faculade de Medicina do ABC, Santo André, Brazil
| | - Adam I Rubin
- Department of Dermatology, Hospital of the University of Pennsylvania, and Section of Dermatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
| | - Ralph Daniel
- University of Mississippi, Medical Center, University of Alabama, Birmingham, AL, USA
| | - Soumya Chiheb
- Faculty of Medicine and Pharmacy, University Hassan II, Casablanca, Morocco
| | - Chander Grover
- University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Michela Starace
- Dermatology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Bianca M Piraccini
- Dermatology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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Abstract
Background Biotin is an essential cofactor for metabolic pathways in humans. It is frequently self-prescribed by consumers and often recommended by dermatologists and primary care physicians, despite limited evidence of its effect on skin, hair, and nail disorders. A recent Food and Drug Administration (FDA) warning stated that biotin can interfere with laboratory tests. Objectives Our objectives were to determine the perception of biotin by Amazon consumers, including perception of improvement in hair, skin, or nails with biotin supplementation and consumers’ awareness of the FDA warning on biotin. Methods The keyword biotin was searched on Amazon.com, and the top 1 percentile of biotin products according to average consumer review were analyzed for dosage, indications, price, quantity, warnings, number, and average score of reviews. Results From 16 biotin products analyzed, the mean review score was 4.38. The mean percentage of reviews stating that biotin helped hair, nails, and skin was 27.2%, 15.03%, and 2.8%, respectively. No biotin products mentioned the FDA warning, and only 1 reviewer referenced the warning. Conclusions These findings suggest that biotin supplementation is prevalent and perceived as helpful despite limited evidence of improvement. The majority of biotin users were unaware that biotin interacted with laboratory testing demonstrating the need for biotin manufacturers to include a warning label about the FDA warning and for physicians to warn their patients on the risks and benefits of biotin supplementation.
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Affiliation(s)
- Jason J. John
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Shari R. Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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