1
|
Fallahi P, Ragusa F, Patrizio A, Mazzi V, Botrini C, Elia G, Balestri E, Barozzi E, Rugani L, Palmisano E, Cosenza MC, Varricchi G, Ulisse S, Benvenga S, Ferrari SM, Antonelli A. Liquid L-T4 therapy in hypothyroid patients with gastric diseases, an observational study. Front Endocrinol (Lausanne) 2024; 15:1386629. [PMID: 39027476 PMCID: PMC11254624 DOI: 10.3389/fendo.2024.1386629] [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: 02/15/2024] [Accepted: 06/11/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction This is an observational and retrospective study, in which we have analyzed data from patients affected by gastric diseases (p) who have been treated with liquid L-T4 (L-LT4;84 p), or tablet L-T4 (T-LT4;120 p), for the replacement therapy of hypothyroidism. The aim of the study is to compare the stability of TSH [normal range, 0.3-3.5 μIU/ml] in these patients. Methods All p assumed L-T4 30 minutes before breakfast. The types of gastric disease were: a) T-LT4 group: 74 chronic gastritis (CG); 4 gastrectomy for gastric cancer (GTx); 42 gastro-plastics (GP); b) L-LT4 group: 60 CG; 3 GTx; 21 GP (p>0.05). 66% p in T-LT4 group were chronically treated with proton pump inhibitors (PPI), against 51% in L-LT4 group (p>0.05). The frequency of Helicobacter Pylori infection was 17% in both T-LT4 and L-LT4 groups. The gender distribution, mean age and body weight were similar in the 2 groups (p>0.05). The mean L-T4 dosage in T-LT4 group at the basal evaluation was 1.22+/-0.27 μg/kg/die, in the L-LT4 group 1.36+/-0.22 μg/kg/die (p>0.05). Results At the basal evaluation the prevalence of patients with a TSH>3.5 μIU/mL in T-LT4 group was 36%, in L-LT4 group 46% (p<0.05). After adjustment of the dosage of the LT-4 therapy, the p were re-evaluated in an interval range of 5-9 months, for 4 times, during an overall period ranging from 23 to 31 months. At the first re-evaluation, the prevalence of p with a TSH>3.5 μIU/mL was 13% in both groups. At the second re-evaluation, the prevalence of p with a TSH>3.5 μIU/mL in T-LT4 group was 26%, in L-LT4 group 13% (p>0.05). At the third re-evaluation, the prevalence of p with TSH<3.5 μIU/mL in T-LT4 group was 19%, in L-LT4 group 9% (p=0.05). At the fourth and last re-evaluation, the prevalence of patients with a TSH>3.5 μIU/mL in T-LT4 group was 18%, in L-LT4 group 5% (p<0.05). Mean FT4 and FT3 circulating levels were not significantly different in the two group at each visit. Discussion These data suggest that the liquid L-T4 formulation therapy can result in a more stable control of TSH levels in hypothyroid patients with gastric disorders in the long-term follow-up.
Collapse
Affiliation(s)
- Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Armando Patrizio
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Valeria Mazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Chiara Botrini
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Giusy Elia
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Eugenia Balestri
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Emilio Barozzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Licia Rugani
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Elena Palmisano
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Maria Carla Cosenza
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Salvatore Ulisse
- Department of Surgery, “Sapienza” University of Rome, Rome, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women’s Endocrine Health, Azienda Ospedaliera Universitaria Policlinico “G. Martino”, Messina, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| |
Collapse
|
2
|
Patrizio A, Ferrari SM, Elia G, Ragusa F, Balestri E, Botrini C, Rugani L, Mazzi V, Antonelli A, Fallahi P, Benvenga S. Hypothyroidism and metabolic cardiovascular disease. Front Endocrinol (Lausanne) 2024; 15:1408684. [PMID: 38887272 PMCID: PMC11180764 DOI: 10.3389/fendo.2024.1408684] [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: 03/28/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
Cardiovascular disease (CVD) remains the leading cause of death worldwide, representing a major health issue of social and economic relevance. Both hyperthyroidism and hypothyroidism are very common in the adult population, and both disorders may contribute to the onset and progression of CVD. After a brief description of the role of thyroid hormones (THs) on the physiology of the cardiovascular system and the potential mechanism that links THs alterations with changes in cardiac function, blood pressure, endothelial function, and lipid levels, we review updated data about the clinical impact of overt hypothyroidism (OH) and subclinical hypothyroidism (SCH) on CV risk, CVD, and mortality. Furthermore, we summarize the current evidence for treating SCH with levothyroxine (L-T4). Several guidelines of distinguished endocrine societies recommend treatment for SCH with TSH higher than 10 mIU/L, where the benefit of L-T4 therapy is more evident for younger people, but still controversial in those aged over 65 years. Based on current knowledge, more research efforts are needed to better address the clinical management of CV risk and CVD in the elderly affected by SCH.
Collapse
Affiliation(s)
- Armando Patrizio
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Giusy Elia
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Eugenia Balestri
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Chiara Botrini
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Licia Rugani
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Valeria Mazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, 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
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine-Endocrinology, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology and Women’s Endocrine Health, University Hospital Policlinico “G. Martino”, Messina, Italy
| |
Collapse
|
3
|
Mustafa M, Ali E, McGowan A, McCabe L, Hegedüs L, Attanasio R, Nagy EV, Papini E, Perros P, Moran C. Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients: A THESIS questionnaire survey of members of the Irish Endocrine Society. Ir J Med Sci 2023; 192:2179-2187. [PMID: 36482281 PMCID: PMC10522726 DOI: 10.1007/s11845-022-03235-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Replacement of thyroid hormones (TH) with Levothyroxine (LT4) is the treatment of choice for hypothyroidism, however, there are aspects of treatment where uncertainties exist and practice varies. Factors influencing initiation and choice of TH replacement may impact patient satisfaction, safety, and health care costs. METHODS The aim of the study was to examine the attitudes of Irish endocrinologists regarding the treatment of hypothyroid and euthyroid patients with TH. Members of the Irish Endocrine Society (IES) were invited to participate in an online survey. RESULTS Forty-eight invitations were sent, and 39 (81.3%) participants responded. All respondents favoured LT4 tablet therapy for treatment of hypothyroidism, but 20.5% prescribed combination therapy (LT4 and liothyronine), and 13% regularly used desiccated thyroid extract. A significant proportion (51%) might prescribe TH in euthyroid patients; 41% for thyroid auto-antibody positive women seeking pregnancy, 18% for goitre and 5% for unexplained fatigue. Many (38%) consider combination therapy in patients with persistent symptoms. Respondents reported seeing LT4 treated patients with persistent symptomatology more frequently and perceive psychosocial factors and comorbidities to be the most common reasons for such symptoms. CONCLUSION LT4 tablets are the treatment of choice for hypothyroidism in Ireland. Approximately a third of Irish endocrinologists either regularly use, or would consider, liothyronine for hypothyroid patients. A significant proportion would give TH to euthyroid individuals in specific circumstances. The prescription of TH amongst Irish endocrinologists was generally in keeping with recommended practice, and areas where practice deviated from guidance were typically where evidence was conflicting or insufficient.
Collapse
Affiliation(s)
- Mohamad Mustafa
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Elsheikh Ali
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Laura McCabe
- Pharmacy Department, Tallaght University Hospital, Dublin, Ireland
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Roberto Attanasio
- Scientific Committee Associazione Medici Endocrinologi, Milan, Italy
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Opsedale Regina Apostolorum, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Sandyford, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| |
Collapse
|
4
|
Development of Ultra High-Performance Liquid Chromatography–Tandem Mass Spectrometry Method for Enantiomer Resolution of Thyroxine on a Chiral Crown Ether Derived Chiral Stationary Phase. Chromatographia 2022. [DOI: 10.1007/s10337-022-04219-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
5
|
Caron P, Grunenwald S, Persani L, Borson-Chazot F, Leroy R, Duntas L. Factors influencing the levothyroxine dose in the hormone replacement therapy of primary hypothyroidism in adults. Rev Endocr Metab Disord 2022; 23:463-483. [PMID: 34671932 PMCID: PMC8528480 DOI: 10.1007/s11154-021-09691-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/19/2022]
Abstract
Levothyroxine (LT4) is a safe, effective means of hormone replacement therapy for hypothyroidism. Here, we review the pharmaceutical, pathophysiological and behavioural factors influencing the absorption, distribution, metabolism and excretion of LT4. Any factor that alters the state of the epithelium in the stomach or small intestine will reduce and/or slow absorption of LT4; these include ulcerative colitis, coeliac disease, bariatric surgery, Helicobacter pylori infection, food intolerance, gastritis, mineral supplements, dietary fibre, resins, and various drugs. Once in the circulation, LT4 is almost fully bound to plasma proteins. Although free T4 (FT4) and liothyronine concentrations are extensively buffered, it is possible that drug- or disorder-induced changes in plasma proteins levels can modify free hormone levels. The data on the clinical significance of genetic variants in deiodinase genes are contradictory, and wide-scale genotyping of hypothyroid patients is not currently justified. We developed a decision tree for the physician faced with an abnormally high thyroid-stimulating hormone (TSH) level in a patient reporting adequate compliance with the recommended LT4 dose. The physician should review medications, the medical history and the serum FT4 level and check for acute adrenal insufficiency, heterophilic anti-TSH antibodies, antibodies against gastric and intestinal components (gastric parietal cells, endomysium, and tissue transglutaminase 2), and Helicobacter pylori infection. The next step is an LT4 pharmacodynamic absorption test; poor LT4 absorption should prompt a consultation with a gastroenterologist and (depending on the findings) an increase in the LT4 dose level. An in-depth etiological investigation can reveal visceral disorders and, especially, digestive tract disorders.
Collapse
Affiliation(s)
- Philippe Caron
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Hôpital Larrey, CHU de Toulouse, 24 chemin de Pouvourville, 31059, Toulouse Cedex, France.
| | - Solange Grunenwald
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Hôpital Larrey, CHU de Toulouse, 24 chemin de Pouvourville, 31059, Toulouse Cedex, France
| | - Luca Persani
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | | | - Leonidas Duntas
- Unit of Endocrinology, Diabetes and Metabolism Division, Evgenideion Hospital, University of Athens, Athens, Greece
| |
Collapse
|
6
|
Vardarli I, Brandenburg T, Hegedüs L, Attanasio R, Nagy E, Papini E, Perros P, Weidemann F, Herrmann K, Führer D. A Questionnaire Survey of German Thyroidologists on the Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients: The THESIS (Treatment of Hypothyroidism in Europe by Specialists: An International Survey) Collaborative. Exp Clin Endocrinol Diabetes 2022; 130:577-586. [PMID: 35640637 DOI: 10.1055/a-1832-0644] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To identify the attitudes of German thyroid specialists towards the clinical treatment of hypothyroidism using thyroid hormones (TH). METHODS All members of the thyroid section of the German Endocrine Society (DGE) were e-mailed an invitation to participate in a web-based survey about substitution with TH. RESULTS Out of 206 members of the DGE's thyroid section, 163 (79.1%) responses were received and included in the analysis. Of responding members, 98.6% used levothyroxine (LT4) as the treatment of choice, and 45.4% also prescribed combination therapy with liothyronine (LT4+LT3) in their clinical practice (p<0.001). LT4+LT3 combination was favored in patients with persistent hypothyroidism symptoms despite biochemical euthyroidism on LT4 treatment (p<0.001). Of all respondents, 26.4% never indicated TH therapy for euthyroid patients (p<0.001), while the remainder would consider THs for one or more indications (62.9% for euthyroid infertile women with high anti-thyroid antibody levels (p<0.001), 7.1% in patients with severe hypercholesterolemia, as complementary treatment (p=0.007), and 57.1% in patients with simple goiter (p<0.001)). In conditions that could interfere with LT4 absorption, most respondents still preferred tablets and did not expect a significant difference when switching from one LT4 formulation to another. CONCLUSION For German thyroid specialists, LT4 is the treatment of choice for hypothyroidism. Combination therapy with LT4+LT3 was considered for patients with persistent symptoms. Even in conditions that could affect bioavailability, German thyroid specialists prefer LT4 tablets rather than other LT4 formulations, such as liquid or soft-gel capsules. The widespread use of thyroid hormone for non-hypothyroid conditions is not consistent with current evidence and needs further study.
Collapse
Affiliation(s)
- Irfan Vardarli
- Department of Medicine I, Klinikum Vest, Knappschaftskrankenhaus Recklinghausen, Academic Teaching Hospital, Ruhr-University Bochum, Recklinghausen, Germany
| | - Tim Brandenburg
- Department of Endocrinology, Diabetes, and Metabolism, Clinical Chemistry - Division of Laboratory Research; Endocrine Tumor Center at WTZ/Comprehensive Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Denmark
| | - Roberto Attanasio
- Scientific Committee Associazione Medici Endocrinologi, Milan, Italy
| | - EndreV Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Ospedale Regina Apostolorum, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Frank Weidemann
- Department of Medicine I, Klinikum Vest, Knappschaftskrankenhaus Recklinghausen, Academic Teaching Hospital, Ruhr-University Bochum, Recklinghausen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Dagmar Führer
- Department of Endocrinology, Diabetes, and Metabolism, Clinical Chemistry - Division of Laboratory Research; Endocrine Tumor Center at WTZ/Comprehensive Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
7
|
Paschou SA, Alevizaki M, Attanasio R, Hegedüs L, Nagy EV, Papini E, Perros P, Vryonidou A. Use of thyroid hormones in hypothyroid and euthyroid patients: a 2020 THESIS questionnaire survey of members of the Hellenic Endocrine Society. Hormones (Athens) 2022; 21:103-111. [PMID: 34755283 DOI: 10.1007/s42000-021-00335-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate current practices of specialists in the use of thyroid hormone preparations in Greece as part of an ongoing international survey, namely THESIS-Treatment of Hypothyroidism in Europe by Specialists: an International Survey. METHODS An electronic link leading to an anonymized questionnaire was sent to all (n = 837) members of the Hellenic Endocrine Society. RESULTS In total, 501 respondents participated in the survey, though only part of the questionnaire was filled in by some participants. A total of 88.2% were endocrinologists and 57.9% worked in private practice. Levothyroxine (LT4) was the first-line choice (98.6%) for the treatment of hypothyroid patients. In total, 70.2% preferred LT4 soft-gel capsules for patients reporting intolerance to various foods. Soft-gel capsules were the preferred LT4 formulation for patients on generic LT4 and with unexplained poor biochemical control of hypothyroidism (66.3%) or inability to take LT4 fasted and separate from food/drink (68.3%). It was found that 48.4% would never use combined LT4 + LT3. However, 25% would use combination therapy for a short period in patients recovering from protracted hypothyroidism or in patients with normal serum TSH but persistent symptoms. Concerning euthyroid individuals, 31.9% considered treatment with thyroid hormones in infertile females with positive thyroid antibodies and 24.4% in patients with growing goiter. Selenium or iodine supplementation was used occasionally, mostly in patients with coexisting autoimmune thyroiditis. CONCLUSIONS LT4 tablets are the treatment of choice for hypothyroidism in Greece. Several conditions may lead to various other practices, some of which deviate from current evidence-based guidelines and need more scrutiny.
Collapse
Affiliation(s)
- Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Alevizaki
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes Center, Hellenic Red Cross Hospital, Athens, Greece.
| |
Collapse
|
8
|
Lai YW, Huang SM. Tea consumption affects the absorption of levothyroxine. Front Endocrinol (Lausanne) 2022; 13:943775. [PMID: 36171905 PMCID: PMC9511168 DOI: 10.3389/fendo.2022.943775] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
Levothyroxine (LT4) is a convenient treatment for hypothyroidism. Coffee, however, prevents the body from efficaciously absorbing LT4. It is unknown whether the intake of tea interferes with LT4 absorption. Thirty-seven hypothyroidism patients with the following types of consumption were recruited: 1) only tea, 2) tea and coffee, and 3) only coffee. The concentrations of thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) were recorded before and 3 months after changing the consumption. The patients had reductions in the concentration of TSH to varying degrees after 3 months (p < 0.001 or p < 0.05). The natural logarithms of the differences between the concentrations of TSH before and after the change in the consumption (Δln-TSH) of tea and coffee, only coffee, and only tea were 1.94, 2.00, and 2.18, respectively. Long-term consumption of tea, like coffee, interfered with the absorption of LT4. We believe that avoiding tea when taking LT4 will reduce malabsorption.
Collapse
|
9
|
Шепелькевич АП, Дыдышко ЮВ, Юреня ЕB, Лобашова ВЛ, Аттанасио Р, Хегедюс Л, Надь Э, Негро Р, Папини Э, Перрос П. [Features of the use of synthetic analogues of thyroid hormones: а 2020 THESIS* questionnaire survey of members of the Belarusian Public Medical Association of Endocrinology and Metabolism]. PROBLEMY ENDOKRINOLOGII 2021; 68:18-26. [PMID: 35262294 PMCID: PMC9112860 DOI: 10.14341/probl12828] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The standard treatment for hypothyroidism is levothyroxine (LT4), which in the Republic of Belarus is available in tablet form whereas liothyronine (LT3) is not registered, but patients can purchase them on their own abroad. AIM This study aimed to investigate Belarusian endocrinologists' attitude of thyroid hormones in hypothyroid and euthyroid patients. MATERIALS AND METHODS An online survey was conducted, for which members of the Belarusian Medical Association of Endocrinology and Metabolism were invited by posting information in the group chat and by e-mail. The research period was from October 1 to December 26, 2020. 210 questionnaires were received, 146 of which were used. RESULTS The majority of participants, 145 (99.3%), indicated that they were using LT4 as the first-choice drug for the treatment hypothyroidism. Sixty-one (41.8%) doctors answered that LT3 + LT4 combination likely can be used in patients with long-term untreated hypothyroidism and 15 (10.3%) - in patients with persistent symptoms of hypothyroidism, despite biochemical euthyroidism on therapy LT4. Over half of the respondents 84 (57.5%) answered that thyroid hormone therapy was never indicated for euthyroid patients, but 50 (34.2%) would consider it for female infertility with high level of thyroid antibodies and 36 (24.7%) for simple goiter growing over time. In various conditions that could interfere with absorption of LT4, most responding Belarusian endocrinologists do not expect a significant difference with different formulations (tablets+"I do not expect major changes in different forms" vs. "soft gel capsules"+"liquid solution"; p <0.001). Persistent symptoms of hypothyroidism on the background of LT4 replacement therapy with the achievement of the target TSH can mainly be caused by psychosocial factors, concomitant diseases, unrealistic patient expectations, chronic fatigue syndrome, and the burden of chronic disease. CONCLUSION The method of choice of Belarusian endocrinologists in the treatment of hypothyroidism is LT4 replacement therapy, but the appointment of LT4 + LT3 combination therapy can be considered in certain clinical situations. As a rule, endocrinologists do not prescribe LT4 in patients with euthyroidism and do not expect a significant difference when using other forms of levothyroxine.
Collapse
Affiliation(s)
| | - Ю. В. Дыдышко
- Белорусский государственный медицинский университет;
Республиканский центр медицинской реабилитации и бальнеолечения
| | - Е. B. Юреня
- Минский городской клинический эндокринологический центр
| | - В. Л. Лобашова
- Республиканский центр медицинской реабилитации и бальнеолечения
| | | | | | | | | | | | | |
Collapse
|
10
|
Buffet C, Belin L, Attanasio R, Hegedüs L, Nagy EV, Papini E, Perros P, Leenhardt L. Real-life practice of thyroid hormone use in hypothyroid and euthyroid patients: a detailed view from the THESIS* questionnaire survey in France. ANNALES D'ENDOCRINOLOGIE 2021; 83:27-34. [PMID: 34861221 DOI: 10.1016/j.ando.2021.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
AIM To describe practices of French physicians regarding thyroid hormone therapy, focusing on available LT4 formulations. MATERIAL AND METHODS Members of the French Endocrine Society (FES) and affiliated societies (the Endocrine Tumor Group, French College of Teachers of Endocrinology, Diabetes and Metabolic Diseases and the Union of Endocrinology, Diabetology, Metabolic Diseases and Nutrition Specialists) were invited to participate in an online survey. RESULTS 534 of the 2,094 persons contacted (25.5%) completed the survey and were included in the analysis. The vast majority (99.4%) reported that levothyroxine (LT4) is the treatment of choice for hypothyroidism. 7.1% and 14.2% of respondents respectively considered liothyronine (LT3) or a combination of LT4 and LT3 for the treatment of hypothyroidism, mainly when symptoms persisted despite achieving normal TSH concentrations with LT4 therapy. For 44% of respondents, thyroid hormone treatment is never indicated in euthyroid patients, while the remainder would consider treating euthyroid patients with a goiter growing over time (40.2%) and/or euthyroid women with positive anti-TPO antibodies and infertility (31.7%). LT4 tablets were the preferred LT4 formulation. A significant proportion of FES members expected no major clinical differences upon changing to formulations such as soft-gel capsules or liquid solutions, even in specific scenarios such as poor biochemical control or suspicion of malabsorption. CONCLUSION The treatment of choice for hypothyroidism in France is LT4. LT3-based therapy is considered by some physicians in case of persistent symptoms of hypothyroidism despite normal TSH level. A significant proportion of respondents (66.0%) would consider treating euthyroid patients, contrary to the present state of knowledge. These outdated practices should be addressed by professional bodies such as the FES.
Collapse
Affiliation(s)
- C Buffet
- Sorbonne Université, GRC n°16, GRC Thyroid Tumors, Thyroid Pathology and Endocrine Tumor Department, AP-HP, Hôpital Pitié-Salpêtrière, 75013 Paris, France.
| | - L Belin
- Sorbonne Université, Biostatistics Department, AP-HP, Hôpital Pitié-Salpêtrière, 75013 Paris, France
| | - R Attanasio
- Scientific Committee, Associazione Medici Endocrinologi, International Chapter of Clinical Endocrinology, Italy
| | - L Hegedüs
- Department of Endocrinology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - E V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - E Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - P Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - L Leenhardt
- Sorbonne Université, GRC n°16, GRC Thyroid Tumors, Thyroid Pathology and Endocrine Tumor Department, AP-HP, Hôpital Pitié-Salpêtrière, 75013 Paris, France
| |
Collapse
|
11
|
Ferrari SM, Ragusa F, Elia G, Paparo SR, Mazzi V, Baldini E, Benvenga S, Antonelli A, Fallahi P. Precision Medicine in Autoimmune Thyroiditis and Hypothyroidism. Front Pharmacol 2021; 12:750380. [PMID: 34867359 PMCID: PMC8635786 DOI: 10.3389/fphar.2021.750380] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
Autoimmune thyroid diseases (AITD) are T-cell-mediated organ specific autoimmune disorders, deriving from an altered response of the immune system that leads to the immune attack to the thyroid. Hashimoto’s thyroiditis (HT) and Graves’ disease (GD) are the two principal AITD clinical presentations. Hypothyroidism and thyrotoxicosis are, respectively, the clinical hallmarks of HT and GD. Patients with autoimmune thyroiditis are treated daily with synthetic L-thyroxine (L-T4) at the dose of 1.5–1.7 μg/kg. Various L-T4 formulations are commercially available (tablet, liquid solution, or soft gel capsule). L-T4 in tablets is generally prescribed to treat hypothyroidism, whereas the liquid formulation, or soft gel capsules, can be administered in hypothyroid patients in case of malabsorption or in patients in therapy with drugs interfering with L-T4 absorption. Furthermore, myoinositol has a crucial role in thyroid autoimmunity and function. Clinical studies reported a significant decline in TSH and antithyroid autoantibodies levels after treatment with myoinositol + selenium in patients with subclinical hypothyroidism and autoimmune thyroiditis. Moreover, thyroidectomy can be rarely recommended in patients with autoimmune thyroiditis, with cosmetic reasons for a goiter, or with important signs or symptoms of local compression, or nodular disease with a “suspicious” cytology for malignancy. Furthermore, a recent randomized trial suggested that total thyroidectomy can improve quality of life and fatigue, while medical therapy did not. In this review, we overview currently available evidence in personalized medicine in patients with autoimmune thyroiditis and hypothyroidism. Further research is needed in larger population to investigate the effect of these new treatments on quality of life.
Collapse
Affiliation(s)
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giusy Elia
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | | | - Valeria Mazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Enke Baldini
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women’s Endocrine Health, Azienda Ospedaliera Universitaria Policlinico “G. Martino”, I-98125, Messina, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| |
Collapse
|
12
|
Riis KR, Frølich JS, Hegedüs L, Negro R, Attanasio R, Nagy EV, Papini E, Perros P, Bonnema SJ. Use of thyroid hormones in hypothyroid and euthyroid patients: A 2020 THESIS questionnaire survey of members of the Danish Endocrine Society. J Endocrinol Invest 2021; 44:2435-2444. [PMID: 33774809 PMCID: PMC8004561 DOI: 10.1007/s40618-021-01555-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/10/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE The standard treatment of hypothyroidism is levothyroxine (LT4), which is available as tablets or soft-gel capsules in Denmark. This study aimed to investigate Danish endocrinologists' use of thyroid hormones in hypothyroid and euthyroid patients. METHODS An e-mail with an invitation to participate in an online survey investigating practices about substitution with thyroid hormones was sent to all members of the Danish Endocrine Society (DES). RESULTS Out of 488 eligible DES members, a total of 152 (31.2%) respondents were included in the analysis. The majority (94.1%) of responding DES members use LT4 as the treatment of choice. Other treatment options for hypothyroidism are also used, as 58.6% prescribe combination therapy with liothyronine (LT3) + LT4 in their clinical practice. LT4 + LT3 combination is preferred in patients with persistent symptoms of hypothyroidism despite biochemical euthyroidism on LT4 treatment. Over half of the respondents answered that thyroid hormone therapy is never indicated for euthyroid patients, but 42.1% will consider it for euthyroid infertile women with high antibody levels. In various conditions that could interfere with the absorption of LT4, most responding Danish endocrinologists prefer tablets and do not expect a significant difference when switching from one type of tablet formulation to another. CONCLUSION The treatment of choice for hypothyroidism is LT4. Combination therapy with LT4 + LT3 is considered for patients with persistent symptoms. Even in the presence of conditions affecting bioavailability, responding Danish endocrinologists prefer LT4 tablets rather than newer LT4 formulations, such as soft-gel capsules.
Collapse
Affiliation(s)
- K R Riis
- Department of Endocrinology, Odense University Hospital, Odense, Denmark.
| | - J S Frølich
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - L Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - R Negro
- Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy
| | - R Attanasio
- IRCCS Orthopedic Institute Galeazzi, Endocrinology Service, Milan, Italy
| | - E V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - E Papini
- Department of Endocrinology and Metabolism, Opsedale Regina Apostolorum, Rome, Italy
| | - P Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S J Bonnema
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
13
|
Dinicola S, Unfer V, Facchinetti F, Soulage CO, Greene ND, Bizzarri M, Laganà AS, Chan SY, Bevilacqua A, Pkhaladze L, Benvenga S, Stringaro A, Barbaro D, Appetecchia M, Aragona C, Bezerra Espinola MS, Cantelmi T, Cavalli P, Chiu TT, Copp AJ, D’Anna R, Dewailly D, Di Lorenzo C, Diamanti-Kandarakis E, Hernández Marín I, Hod M, Kamenov Z, Kandaraki E, Monastra G, Montanino Oliva M, Nestler JE, Nordio M, Ozay AC, Papalou O, Porcaro G, Prapas N, Roseff S, Vazquez-Levin M, Vucenik I, Wdowiak A. Inositols: From Established Knowledge to Novel Approaches. Int J Mol Sci 2021; 22:10575. [PMID: 34638926 PMCID: PMC8508595 DOI: 10.3390/ijms221910575] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 12/24/2022] Open
Abstract
Myo-inositol (myo-Ins) and D-chiro-inositol (D-chiro-Ins) are natural compounds involved in many biological pathways. Since the discovery of their involvement in endocrine signal transduction, myo-Ins and D-chiro-Ins supplementation has contributed to clinical approaches in ameliorating many gynecological and endocrinological diseases. Currently both myo-Ins and D-chiro-Ins are well-tolerated, effective alternative candidates to the classical insulin sensitizers, and are useful treatments in preventing and treating metabolic and reproductive disorders such as polycystic ovary syndrome (PCOS), gestational diabetes mellitus (GDM), and male fertility disturbances, like sperm abnormalities. Moreover, besides metabolic activity, myo-Ins and D-chiro-Ins deeply influence steroidogenesis, regulating the pools of androgens and estrogens, likely in opposite ways. Given the complexity of inositol-related mechanisms of action, many of their beneficial effects are still under scrutiny. Therefore, continuing research aims to discover new emerging roles and mechanisms that can allow clinicians to tailor inositol therapy and to use it in other medical areas, hitherto unexplored. The present paper outlines the established evidence on inositols and updates on recent research, namely concerning D-chiro-Ins involvement into steroidogenesis. In particular, D-chiro-Ins mediates insulin-induced testosterone biosynthesis from ovarian thecal cells and directly affects synthesis of estrogens by modulating the expression of the aromatase enzyme. Ovaries, as well as other organs and tissues, are characterized by a specific ratio of myo-Ins to D-chiro-Ins, which ensures their healthy state and proper functionality. Altered inositol ratios may account for pathological conditions, causing an imbalance in sex hormones. Such situations usually occur in association with medical conditions, such as PCOS, or as a consequence of some pharmacological treatments. Based on the physiological role of inositols and the pathological implications of altered myo-Ins to D-chiro-Ins ratios, inositol therapy may be designed with two different aims: (1) restoring the inositol physiological ratio; (2) altering the ratio in a controlled way to achieve specific effects.
Collapse
Affiliation(s)
- Simona Dinicola
- Systems Biology Group Lab, 00161 Rome, Italy; (S.D.); (V.U.); (M.B.); (C.A.); (M.S.B.E.); (G.M.)
| | - Vittorio Unfer
- Systems Biology Group Lab, 00161 Rome, Italy; (S.D.); (V.U.); (M.B.); (C.A.); (M.S.B.E.); (G.M.)
| | - Fabio Facchinetti
- Obstetrics and Gynecology Unit, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Christophe O. Soulage
- CarMeN Lab, INSA-Lyon, INSERM U1060, INRA, University Claude Bernard Lyon 1, 69100 Villeurbanne, France;
| | - Nicholas D. Greene
- Newlife Birth Defects Research Centre and Developmental Biology and Cancer Programme, Institute of Child Health, University College London, London WC1E 6BT, UK; (N.D.G.); (A.J.C.)
| | - Mariano Bizzarri
- Systems Biology Group Lab, 00161 Rome, Italy; (S.D.); (V.U.); (M.B.); (C.A.); (M.S.B.E.); (G.M.)
- Department of Experimental Medicine, University La Sapienza, 00161 Rome, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, Hospital “Filippo Del Ponte”, University of Insubria, 21100 Varese, Italy;
| | - Shiao-Yng Chan
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore;
| | - Arturo Bevilacqua
- Department of Dynamic, Clinical Psychology and Health Studies, Sapienza University, 00161 Rome, Italy;
| | - Lali Pkhaladze
- Zhordania and Khomasuridze Institute of Reproductology, Tbilisi 0112, Georgia;
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Annarita Stringaro
- National Center for Drug Research and Evaluation, Italian National Institute of Health, 00161 Rome, Italy;
| | - Daniele Barbaro
- U.O. Endocrinology in Livorno Hospital, USL Nordovest Toscana, 57100 Livorno, Italy;
| | - Marialuisa Appetecchia
- Oncological Endocrinology Unit, Regina Elena National Cancer Institute, IRCCS, 00161 Rome, Italy;
| | - Cesare Aragona
- Systems Biology Group Lab, 00161 Rome, Italy; (S.D.); (V.U.); (M.B.); (C.A.); (M.S.B.E.); (G.M.)
| | | | - Tonino Cantelmi
- Institute for Interpersonal Cognitive Therapy, 00100 Rome, Italy;
| | - Pietro Cavalli
- Humanitas Research Hospital, Rozzano, 20089 Milan, Italy;
| | | | - Andrew J. Copp
- Newlife Birth Defects Research Centre and Developmental Biology and Cancer Programme, Institute of Child Health, University College London, London WC1E 6BT, UK; (N.D.G.); (A.J.C.)
| | - Rosario D’Anna
- Department of Human Pathology, University of Messina, 98122 Messina, Italy;
| | - Didier Dewailly
- Faculty of Medicine, University of Lille, 59000 Lille, France;
| | - Cherubino Di Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, 04100 Latina, Italy;
| | - Evanthia Diamanti-Kandarakis
- Department of Endocrinology and Diabetes, HYGEIA Hospital, Marousi, 15123 Athens, Greece; (E.D.-K.); (E.K.); (O.P.)
| | - Imelda Hernández Marín
- Human Reproduction Department, Hospital Juárez de México, Universidad Nacional Autónoma de México (UNAM), Mexico City 07760, Mexico;
| | - Moshe Hod
- Department of Obstetrics and Gynecology Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel;
| | - Zdravko Kamenov
- Department of Internal Medicine, Medical University of Sofia, 1431 Sofia, Bulgaria;
| | - Eleni Kandaraki
- Department of Endocrinology and Diabetes, HYGEIA Hospital, Marousi, 15123 Athens, Greece; (E.D.-K.); (E.K.); (O.P.)
| | - Giovanni Monastra
- Systems Biology Group Lab, 00161 Rome, Italy; (S.D.); (V.U.); (M.B.); (C.A.); (M.S.B.E.); (G.M.)
| | | | - John E. Nestler
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA;
| | | | - Ali C. Ozay
- Department of Obstetrics and Gynecology, Near East University Hospital, Nicosia 99138, Cyprus;
| | - Olga Papalou
- Department of Endocrinology and Diabetes, HYGEIA Hospital, Marousi, 15123 Athens, Greece; (E.D.-K.); (E.K.); (O.P.)
| | | | - Nikos Prapas
- IAKENTRO, Infertility Treatment Center, 54250 Thessaloniki, Greece;
| | - Scott Roseff
- Reproductive Endocrinology and Infertility, South Florida Institute for Reproductive Medicine (IVFMD), Boca Raton, FL 33458, USA;
| | - Monica Vazquez-Levin
- Instituto de Biología y Medicina Experimental (IBYME, CONICET-FIBYME), Consejo Nacional de Investigaciones Científicas y Técnicas de Argentina (CONICET), Buenos Aires 2490, Argentina;
| | - Ivana Vucenik
- Department of Medical & Research Technology and Pathology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Artur Wdowiak
- Diagnostic Techniques Unit, Medical University of Lublin, 20-081 Lublin, Poland;
| |
Collapse
|
14
|
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] [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.
Collapse
|
15
|
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.
Collapse
Affiliation(s)
- Ernest Asamoah
- Diabetes & Endocrinology CareCommunity Physicians NetworkIndianapolisINUSA
| |
Collapse
|
16
|
Planck T, Lantz M, Perros P, Papini E, Attanasio R, Nagy EV, Hegedüs L. Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients: A 2020 THESIS Questionnaire Survey of Members of the Swedish Endocrine Society. Front Endocrinol (Lausanne) 2021; 12:795111. [PMID: 34938274 PMCID: PMC8687360 DOI: 10.3389/fendo.2021.795111] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/15/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The standard treatment of hypothyroidism is levothyroxine (LT-4). However, there are several controversies regarding treatment of hypothyroid patients. AIM To investigate the Swedish endocrinologists' use of thyroid hormones in hypothyroid and euthyroid individuals. METHODS Physician members of the Swedish Endocrine Society (SEF) were invited by e-mail to participate in an online survey investigating this topic. RESULTS Out of the eligible 411 members, 116 (28.2%) responded. The majority (98.9%) stated that L-T4 is the treatment of choice. However, around 50% also prescribed liothyronine (L-T3) or a combination of L-T4+L-T3 in their practice. Combination therapy was mostly (78.5%) used in patients with persistent hypothyroid symptoms despite biochemical euthyroidism on L-T4 treatment. Most respondents prescribed L-T4 tablets and did not expect any major changes with alternative formulations such as soft-gel capsules or liquid formulations in situations influencing the bioavailability of L-T4. In euthyroid patients, 49.5% replied that treatment with thyroid hormones was never indicated, while 47.3% would consider L-T4 for euthyroid infertile women with high thyroid peroxidase (TPO) antibody levels. CONCLUSION The treatment of choice for hypothyroidism in Sweden is L-T4 tablets. Combination therapy with L-T4+L-T3 tablets was considered for patients with persistent symptoms despite biochemical euthyroidism. Soft-gel capsules and liquid solutions of L-T4 were infrequently prescribed. Swedish endocrinologists' deviation from endocrine society guidelines merits further study.
Collapse
Affiliation(s)
- Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
- *Correspondence: Tereza Planck,
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Roberto Attanasio
- Endocrine Unit, Institutes for Care and Scientific Research (IRCCS) Orthopedic Institute Galeazzi, Milan, Italy
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| |
Collapse
|
17
|
Antonelli A, Elia G, Ragusa F, Paparo SR, Cavallini G, Benvenga S, Ferrari SM, Fallahi P. The Stability of TSH, and Thyroid Hormones, in Patients Treated With Tablet, or Liquid Levo-Thyroxine. Front Endocrinol (Lausanne) 2021; 12:633587. [PMID: 33790863 PMCID: PMC8006411 DOI: 10.3389/fendo.2021.633587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/29/2021] [Indexed: 01/01/2023] Open
Abstract
Approximately, 5% of the population is affected by hypothyroidism, mainly women and persons aged more than 60 years. After the diagnosis of hypothyroidism the usual therapy is tablet levothyroxine (L-T4), with a monitoring of the thyroid-stimulating hormone (TSH) level in primary hypothyroidism every 6-8 weeks and L-T4 is adjusted as necessary to reach an euthyroid state. Once TSH is stabilized in the normal range, it is recommended to conduct annual testing in the treated subjects to warrant suitable replacement. More recently advances regarding L-T4 treatment are the introduction of new oral formulations: the liquid solution, and soft gel capsule. The soft gel capsule permits a quick dissolution in the acid gastric pH. The liquid preparation does not require an acid gastric environment. Many pharmacokinetic studies demonstrated a more rapid absorption for the liquid L-T4, or capsule, than with tablet. Many studies have shown that the liquid, or capsule, formulations can overcome the interaction with foods, drugs or malabsorptive conditions, that are able to impair the tablet L-T4 absorption. Lately studies have suggested that liquid L-T4 can permit to maintain more efficiently normal TSH levels in hypothyroid patients in the long-term follow-up, than tablet L-T4, both in patients with malabsorptive states, and in those without malabsorption. Further large, prospective, longitudinal studies are needed to evaluate the stability of TSH, in hypothyroid patients treated with different L-T4 formulations.
Collapse
Affiliation(s)
- Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - 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
| | | | - Gabriella Cavallini
- Interdepartmental Research Centre on Biology and Pathology of Aging, University of Pisa, Pisa, Italy
| | - Salvatore Benvenga
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program on Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, A.O.U. Policlinico Gaetano Martino, Messina, Italy
| | | | - Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Antonelli A, Wartofsky L, Miccoli P. Editorial: Levothyroxine Therapy in Patients With Hypothyroidism. Front Endocrinol (Lausanne) 2021; 12:734895. [PMID: 34354674 PMCID: PMC8329437 DOI: 10.3389/fendo.2021.734895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - Leonard Wartofsky
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, DC, United States
| | - Paolo Miccoli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| |
Collapse
|
20
|
Yoshida T, Nakayama A, Tamura A, Higuchi S, Sakuma I, Nagano H, Felizola SJ, Hashimoto N, Takemoto M, Tatsuno I, Koide H, Yokote K, Tanaka T. A Case of Hashimoto's Thyroiditis with Multiple Drug Resistance and High Expression of Efflux Transporters. J Clin Endocrinol Metab 2020; 105:5588081. [PMID: 31614366 DOI: 10.1210/clinem/dgz073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/27/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Hashimoto's thyroiditis is the most common cause of hypothyroidism. Patients usually respond well to oral synthetic thyroxine (levothyroxine); however, for unknown reasons some individuals present with treatment-resistant Hashimoto thyroiditis. In cases of cancer and certain infectious diseases, the ATP binding cassette (ABC) transporters have been implicated in multidrug resistance, and we hypothesized and investigated a role of ABC transporters in drug-resistant Hashimoto's thyroiditis. CASE DESCRIPTION The patient whose case we report had a history of Hashimoto's thyroiditis, immune thrombocytopenia, and refractory hypertension, with varying treatment resistance to the oral medications prescribed for each condition. In order to establish or exclude a genetic basis for her illness, we examined the patient's gene expression profiles using peripheral blood leukocytes, and found that ABCG2/BCRPexpression was significantly high compared with healthy volunteers. Also, the increased daunomycin efflux capacity of our patient's lymphocytes was successfully inhibited by fumitremorgin C, a specific ABCG2/BCRP inhibitor, and the patient's level of thyroid-stimulating hormone increased by 248.6% after administration of intact levothyroxine tablets but decreased by 45.1% when tablets were crushed. Her average blood pressure decreased from 166.3/108.5 mmHg to 125.9/78.8 mmHg when switching from intact to crushed losartan tablets. CONCLUSIONS High expression and accelerated efflux transporter activity of ABCG2/BCRP in the small intestine are expected to contribute to the ineffectiveness of orally administered intact tablets in cases with treatment-resistant Hashimoto's thyroiditis, and crushed tablets can be more effective for some of these patients.
Collapse
Affiliation(s)
- Tomohiko Yoshida
- Department of Diabetes, Metabolism and Endocrinology, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Akitoshi Nakayama
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ai Tamura
- Department of Endocrinology, Hematology, and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiichiro Higuchi
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ikki Sakuma
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hidekazu Nagano
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Saulo Ja Felizola
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoko Hashimoto
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minoru Takemoto
- Department of Diabetes, Metabolism and Endocrinology, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Ichiro Tatsuno
- Center for Diabetes, Metabolism and Endocrinology, Toho University Sakura Medical Center, Chiba, Japan
| | - Hisashi Koide
- Department of Endocrinology, Hematology, and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology, and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| |
Collapse
|
21
|
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.
Collapse
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.
| |
Collapse
|
22
|
Negro R, Attanasio R, Nagy EV, Papini E, Perros P, Hegedüs L. Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients; the 2019 Italian Survey. Eur Thyroid J 2020; 9:25-31. [PMID: 32071899 PMCID: PMC7024857 DOI: 10.1159/000502057] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/09/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The incidence and prevalence of hypothyroidism are increasing and the threshold for the treatment of hypothyroid as well as individuals without evident thyroid disease with thyroid hormone is declining. OBJECTIVE To investigate endocrinologists' use of thyroid hormones in hypothyroid and euthyroid patients in Italy, a country where different formulations of levothyroxine (LT4; tablet, liquid solution and soft-gel capsule) are available on the market. METHODS Members of the Associazione Medici Endocrinologi (Italian Association of Clinical Endocrinologists) were invited to participate in a web-based survey investigating the topic. RESULTS A total of 797 of 2,028 (39.3%) members completed all the sections of the survey; 98.7% declared that the treatment of choice for hypothyroidism is LT4. A significant minority (37.3%) indicated that LT4 may be considered in infertile euthyroid women seeking pregnancy and harbouring positive thyroperoxidase antibodies (TPOAb) and in goitre increasing in size (18.1%). LT4 + LT3 was considered by 43.2% for LT4-replaced patients and normal TSH, if they reported persistent symptoms. High percentages of respondents chose LT4 in a liquid solution or soft-gel capsules when taken together with other drugs interfering with LT4 absorption (81.8%), in patients with a history of celiac disease, malabsorption, lactose intolerance, intolerance to common excipients (96.6%), or unexplained poor biochemical control of hypothyroidism (74.4%), or in patients not able to adhere to ingesting LT4 fasted and/or separated from food/drink (98.9%). In total, 43.6% of responders would use LT4 in a liquid solution or soft-gel capsules for hypothyroid patients with biochemical euthyroidism on LT4, who had persistent symptoms. CONCLUSIONS The preferred treatment for hypothyroidism is LT4; LT3 + LT4 combination treatment is mainly considered in patients with persistent symptoms. A significant minority would offer LT4 to euthyroid women with positive TPOAb and infertility and to euthyroid patients with progressive simple goitre. Alternative LT4 formulations like liquid solution or soft-gel capsules are largely reserved for specific conditions (interfering drugs, actual or suspected malabsorption, inability to take LT4 in the fasting state, unexplained poor biochemical control of hypothyroidism).
Collapse
Affiliation(s)
- Roberto Negro
- Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy
- *Roberto Negro, Division of Endocrinology, V. Fazzi Hospital, Piazza Muratore, IT–73100 Lecce (Italy), E-Mail
| | | | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Ospedale Regina Apostolorum, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| |
Collapse
|
23
|
Ragusa F, Fallahi P, Elia G, Gonnella D, Paparo SR, Giusti C, Churilov LP, Ferrari SM, Antonelli A. Hashimotos' thyroiditis: Epidemiology, pathogenesis, clinic and therapy. Best Pract Res Clin Endocrinol Metab 2019; 33:101367. [PMID: 31812326 DOI: 10.1016/j.beem.2019.101367] [Citation(s) in RCA: 226] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Hashimoto's thyroiditis (HT), the most frequent autoimmune thyroid disorders (AITDs), is the leading cause of hypothyroidism in the iodine-sufficient areas of the world. About 20-30% of patients suffers from HT, whose cause is thought to be a combination of genetic susceptibility and environmental factors that causes the loss of immunological tolerance, with a consequent autoimmune attack to the thyroid tissue and appearance of the disease. The pathologic features of lymphocytic infiltration, especially of T cells, and follicular destruction are the histological hallmark of autoimmune thyroiditis (AIT), that lead to gradual atrophy and fibrosis. An important role in the immune-pathogenesis of AITDs is due to chemokines and cytokines. In about 20% of patients, AITDs are associated with other organ specific/systemic autoimmune disorders. Many studies have demonstrated the relationship between papillary thyroid cancer and AITD. The treatment of hypothyroidism, as result of AIT, consists in daily assumption of synthetic levothyroxine.
Collapse
Affiliation(s)
- Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
| | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Debora Gonnella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | | | - Claudia Giusti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Leonid P Churilov
- Laboratory of the Mosaic of Autoimmunity, Saint Petersburg State University, Russia.
| | | | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| |
Collapse
|
24
|
Benvenga S, Carlé A. Levothyroxine Formulations: Pharmacological and Clinical Implications of Generic Substitution. Adv Ther 2019; 36:59-71. [PMID: 31485974 PMCID: PMC6822816 DOI: 10.1007/s12325-019-01079-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Indexed: 12/20/2022]
Abstract
Oral levothyroxine (LT4) is the standard therapy for patients with hypothyroidism. Oral LT4 is available in several formulations, including tablets, soft gel capsules and oral solution. Multiple brand-name and generic LT4 tablets are available. In the US, the Food and Drug Administration (FDA) has developed a protocol for establishing bioequivalence of LT4 formulations based on serum thyroxine (T4) levels after a single oral dose administered to healthy volunteers. This protocol has been criticized by professional endocrinology associations for using healthy individuals and ignoring serum thyroid-stimulating hormone (TSH) levels. In addition, the protocol did not initially correct for baseline T4 levels, although this was changed in a later version. There are concerns that the FDA's protocol could allow products with clinically significant differences in bioavailability to be declared therapeutically equivalent and interchangeable. Once a generic LT4 has been shown to be bioequivalent to a brand-name LT4, it may be substituted for that brand-name LT4 with no need for dose adjustment or follow-up therapeutic monitoring. Often, the substitution is made by the pharmacy without the physician's knowledge. Even small differences between LT4 formulations can cause significant changes in TSH levels. This may be a particular concern in vulnerable populations, including elderly, pregnant, and pediatric patients. Problems that can be encountered when switching between formulations or when original products are reformulated are discussed in this review. These problems include altered efficacy and adverse events, some of which can be caused by excipients. Patients should be maintained on the same LT4 preparation if possible. If the LT4 preparation is changed, TSH levels should be evaluated and, if necessary, the dose of LT4 adjusted.Funding: Merck.Plain Language Summary: Plain language summary available for this article.
Collapse
Affiliation(s)
- Salvatore Benvenga
- Endocrinology Section, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
- Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Messina, Italy.
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women's Endocrine Health, University Hospital, AOU Policlinico G. Martino, Messina, Italy.
| | - Allan Carlé
- Department of Endocrinology and Internal Medicine, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
25
|
Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Individualised requirements for optimum treatment of hypothyroidism: complex needs, limited options. Drugs Context 2019; 8:212597. [PMID: 31516533 PMCID: PMC6726361 DOI: 10.7573/dic.212597] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/21/2022] Open
Abstract
Levothyroxine (LT4) therapy has a long history, a well-defined pharmacological profile and a favourable safety record in the alleviation of hypothyroidism. However, questions remain in defining the threshold for the requirement of treatment in patients with subclinical hypothyroidism, assessing the dose adequacy of the drug, and selecting the best treatment mode (LT4 monotherapy versus liothyronine [LT3]/LT4 combinations) for subpopulations with persisting complaints. Supplied as a prodrug, LT4 is enzymatically converted into the biologically more active thyroid hormone, triiodothyronine (T3). Importantly, tetraiodothyronine (T4) to T3 conversion efficiency may be impaired in patients receiving LT4, resulting in a loss of thyroid-stimulating hormone (TSH)-mediated feed-forward control of T3, alteration of the interlocking equilibria between serum concentrations of TSH, free thyroxine (FT4), and free triiodothyonine (FT3), and a decrease in FT3 to FT4 ratios. This downgrades the value of the TSH reference system derived in thyroid health for guiding the replacement dose in the treatment situation. Individualised conditionally defined setpoints may therefore provide appropriate biochemical targets to be clinically tested, together with a stronger focus on clinical presentation and future endpoint markers of tissue thyroid state. This cautionary note encompasses the use of aggregated statistical data from clinical trials which are not safely applicable to the individual level of patient care under these circumstances.
Collapse
Affiliation(s)
- Rudolf Hoermann
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Paulmannshöherstr. 14, 58515 Lüdenscheid, Germany
| | | | - Rolf Larisch
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Paulmannshöherstr. 14, 58515 Lüdenscheid, Germany
| | - Johannes W Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.,Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Alexandrinenstr. 5, 44791 Bochum, Germany
| |
Collapse
|
26
|
Azran C, Porat D, Fine-Shamir N, Hanhan N, Dahan A. Oral levothyroxine therapy postbariatric surgery: Biopharmaceutical aspects and clinical effects. Surg Obes Relat Dis 2019; 15:333-341. [PMID: 30704913 DOI: 10.1016/j.soard.2019.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/13/2018] [Accepted: 01/04/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bariatric surgery can lead to changes in the oral absorption of many drugs. Levothyroxine is a narrow therapeutic drug for hypothyroidism, a common condition among patients with obesity. OBJECTIVE The purpose of this work was to provide a mechanistic overview of levothyroxine absorption, and to thoroughly analyze the expected effects of bariatric surgery on oral levothyroxine therapy. METHODS We performed a systematic review of the relevant literature reporting the effects of bariatric surgery on oral levothyroxine absorption and postoperative thyroid function. A PubMed search for relevant keywords resulted in a total of 14 articles reporting levothyroxine status before versus after bariatric surgery. RESULTS Different mechanisms may support opposing trends as to levothyroxine dose adjustment postsurgery. On the one hand, based on impaired drug solubility/dissolution attributable to higher gastric pH as well as reduced gastric volume, compromised levothyroxine absorption is expected. On the other hand, the great weight loss, and altered set-point of thyroid hormone homeostasis with decreased thyroid-stimulating hormone after the surgery, may result in a decreased dose requirement. CONCLUSIONS For patients after bariatric surgery, close monitoring of both the clinical presentation and plasma thyroid-stimulating hormone and T4 levels is strongly advised. Better understanding and awareness of the science presented in this article may help to avoid preventable complications and provide optimal patient care.
Collapse
Affiliation(s)
| | - Daniel Porat
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Noa Fine-Shamir
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nirvana Hanhan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| |
Collapse
|
27
|
Fallahi P, Ferrari SM, Materazzi G, Ragusa F, Ruffilli I, Patrizio A, Miccoli P, Antonelli A. Oral L-thyroxine liquid versus tablet in patients submitted to total thyroidectomy for thyroid cancer (without malabsorption): A prospective study. Laryngoscope Investig Otolaryngol 2018; 3:405-408. [PMID: 30410995 PMCID: PMC6209618 DOI: 10.1002/lio2.186] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/07/2018] [Accepted: 04/25/2018] [Indexed: 12/11/2022] Open
Abstract
Objective No consistent data are present in literature about the effectiveness of Levothyroxine (L‐T4) liquid formulation in patients without malabsorption after thyroidectomy. The aim of this study is to compare the effectiveness of L‐T4 liquid formulation, with L‐T4 tablets, in thyroid cancer patients after thyroidectomy (without malabsorption or drug interference). Methods One hundred five patients were recruited; 52 patients were treated with liquid L‐T4 formulation, while 53 with L‐T4 tablets, at the same dosage (1.5 mcg/kg/day). Patients started to assume the drug the day after surgery, 30 min before breakfast. In both groups circulating levels of thyrotropic hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) were dosed at week 6 (first control), and then at week 12 (second control). Results We obtained significantly lower TSH values in the liquid L‐T4 group patients, compared to the tablet L‐T4 group, at the first control (P < .05), and at the second control (P < .01), while FT4 and FT3 levels were not significantly different. Hypothyroid range (TSH > 3.6 mcU/mL) was significantly more prevalent in the patients treated with L‐T4 tablet. Conclusions A better control of TSH was observed in thyroidectomized patients (without malabsorption, gastric disorders, or drug interference) with liquid L‐T4 regimen. Level of Evidence 2c–Outcomes Research
Collapse
Affiliation(s)
- Poupak Fallahi
- Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | | | - Gabriele Materazzi
- Department of Surgical, Medical, Molecular Pathology and Critical Area University of Pisa Pisa Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | - Ilaria Ruffilli
- Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | - Armando Patrizio
- Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | - Paolo Miccoli
- Department of Surgical, Medical, Molecular Pathology and Critical Area University of Pisa Pisa Italy
| | | |
Collapse
|
28
|
Conte L, Monti E, Gay S, Marroni P, Adorno A, Mittica M, Mussap M, Giusti M. Evaluation of adequacy of levo-thyroxine dosage in patients with differentiated thyroid carcinoma: correlation between morning and afternoon TSH determination. J Endocrinol Invest 2018; 41:1193-1197. [PMID: 29476411 DOI: 10.1007/s40618-018-0852-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/13/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of this study was to judge the reliability of evaluating thyroid-stimulating hormone (TSH) and free thyroxine (f-T4) in the morning and afternoon in differentiated thyroid carcinoma (DTC) patients. METHODS We evaluated 153 DTC patients, aged 61 ± 13 years, in active follow-up in our center after primary treatments and under stabilized levo-thyroxine (L-T4) posology. In each patient, morning and afternoon examinations were performed 1-3 months apart. Blood samples were collected at 08:00-09:00 h and 15:00-16:00 h. TSH and f-T4 were evaluated in both samples. Thyroglobulin (Tg), Tg-antibodies and neck ultrasonography were also evaluated. RESULTS According to clinical and laboratory examinations, 92% of patients were disease-free, 6% had biochemical disease, and 2% structural disease. L-T4 dosages (1.64 ± 0.38 µg/kg b.w.) proved the same on both occasions, despite slight changes in body weight or L-T4 posology in 15% of patients. Free-T4 values were significantly higher in the afternoon (21.5 ± 0.3 pmol/L) than in the morning (18.8 ± 0.4 pmol/L; P < 0.0001), whereas TSH values were statistically unchanged (morning 0.85 ± 0.25 mIU/L; afternoon 0.72 ± 0.20 mIU/L). There was a significant correlation (P < 0.0001) between the two TSH determinations in the same patients. CONCLUSIONS In DTC patients, follow-up examination consists of clinical and laboratory evaluations. The majority of patients have good disease control. Our study suggests that the adequacy of L-T4 therapy can be monitored equally well either in the morning or in the afternoon. Afternoon examinations can alleviate crowding in hospital ambulatories in the morning.
Collapse
Affiliation(s)
- L Conte
- Endocrine Unit, Policlinico San Martino, Viale Benedetto XV, 6, 16100, Genoa, Italy.
| | - E Monti
- Endocrine Unit, Policlinico San Martino, Viale Benedetto XV, 6, 16100, Genoa, Italy
| | - S Gay
- Endocrine Unit, Policlinico San Martino, Viale Benedetto XV, 6, 16100, Genoa, Italy
| | - P Marroni
- Laboratory Medicine Unit, Policlinico San Martino, Genoa, Italy
| | - A Adorno
- Endocrine Unit, Policlinico San Martino, Viale Benedetto XV, 6, 16100, Genoa, Italy
| | - M Mittica
- Endocrine Unit, Policlinico San Martino, Viale Benedetto XV, 6, 16100, Genoa, Italy
| | - M Mussap
- Laboratory Medicine Unit, Policlinico San Martino, Genoa, Italy
| | - M Giusti
- Endocrine Unit, Policlinico San Martino, Viale Benedetto XV, 6, 16100, Genoa, Italy
| |
Collapse
|
29
|
Benvenga S, Capodicasa G, Perelli S, Ferrari SM, Fallahi P, Antonelli A. Increased Requirement of Replacement Doses of Levothyroxine Caused by Liver Cirrhosis. Front Endocrinol (Lausanne) 2018; 9:150. [PMID: 29720960 PMCID: PMC5915540 DOI: 10.3389/fendo.2018.00150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/20/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Since hypothyroidism is a fairly common dysfunction, levothyroxine (L-T4) is one of the most prescribed medications. Approximately 70% of the administered L-T4 dose is absorbed. The absorption process takes place in the small intestine. Some disorders of the digestive system and some medicines, supplements, and drinks cause L-T4 malabsorption, resulting in failure of serum TSH to be normal. Only rarely liver cirrhosis is mentioned as causing L-T4 malabsorption. CASE REPORT In this study, we report increased requirement of daily doses of l-thyroxine in two patients with the atrophic variant of Hashimoto's thyroiditis and liver cirrhosis. In one patient, this increased requirement could have been contributed by the increased serum levels of the estrogen-dependent thyroxine-binding globulin (TBG), which is the major plasma carrier of thyroid hormones. In the other patient, we switched from tablet L-T4 to liquid L-T4 at the same daily dose. Normalization of TSH levels was achieved, but TSH increased again when she returned to tablet L-T4. CONCLUSION Liver cirrhosis can cause increased L-T4 requirements. In addition to impaired bile secretion, the mechanism could be increased serum TBG. A similar increased requirement of L-T4 is observed in other situations characterized by elevation of serum TBG. Because of better intestinal absorption, L-T4 oral liquid formulation is able to circumvent the increased need of L-T4 in these patients.
Collapse
Affiliation(s)
- 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 & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Giovanni Capodicasa
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
- *Correspondence: Giovanni Capodicasa,
| | - Sarah Perelli
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
| | | | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
30
|
Cappelli C, Castello R, Marini F, Paoletta A, Marchetti M, Saullo M, Cristiano A, Pirola I, Gandossi E, Ferlin A, Castellano M. Adherence to Levothyroxine Treatment Among Patients With Hypothyroidism: A Northeastern Italian Survey. Front Endocrinol (Lausanne) 2018; 9:699. [PMID: 30532737 PMCID: PMC6265311 DOI: 10.3389/fendo.2018.00699] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 11/06/2018] [Indexed: 11/13/2022] Open
Abstract
Background: A significant number of patients show sub-optimal adherence to levothyroxine (LT4) therapy, mainly because they have to postpone their breakfast by at least 30 min. The aim of this observational cross-sectional study was to assess the therapeutic compliance of patients on LT4 treatment and to verify the preference of a lifetime treatment in tablet or liquid form. Patients and Methods: Ambulatory care patients aged 18 years or older, affected by hypothyroidism and on LT4 treatment (in tablet or liquid form) were administered the eight-item Morisky Medication Adherence Scale (MMAS-8). The MMAS-8 questionnaire was supplemented with 3 further items to specifically evaluate preference between tablet and liquid forms of LT4 for lifetime treatment. Results: A total of 320 patients (272 female), median age 47.9 ± 15.6 years (range, 20-78 years), completed the MMAS-8 questionnaire. Eighty-seven percent of the participants were adhering to their treatment for both tablet and liquid LT4 formulations, although significant differences emerged. Patients on LT4 tablets forgot to take their medication more frequently (p < 0.001), felt hassled about sticking to their treatment plan (p < 0.001), and had difficulty remembering to take all their medication(s) (p < 0.001) than those on liquid LT4 treatment. Conclusions: Adherence to LT4 treatment was high for both tablet and liquid formulations. Taking LT4 at breakfast was the most convenient option for most patients.
Collapse
Affiliation(s)
- Carlo Cappelli
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
- *Correspondence: Carlo Cappelli
| | - Roberto Castello
- General Medicine and Endocrinology, University Hospital, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Fiorella Marini
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Agostino Paoletta
- Endocrinology Outpatient Service, Azienda ULSS 6 Euganea, Cittadella, Italy
| | - Massimo Marchetti
- General Medicine and Endocrinology, Ospedale Bassano del Grappa, Bassano del Grappa, Italy
| | - Maura Saullo
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessandra Cristiano
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Ilenia Pirola
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Elena Gandossi
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alberto Ferlin
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Maurizio Castellano
- Department of Clinical and Experimental Sciences, SSD Medicina ad Indirizzo Endocrino-Metabolico, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| |
Collapse
|
31
|
Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Relational Stability in the Expression of Normality, Variation, and Control of Thyroid Function. Front Endocrinol (Lausanne) 2016; 7:142. [PMID: 27872610 PMCID: PMC5098235 DOI: 10.3389/fendo.2016.00142] [Citation(s) in RCA: 22] [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: 09/16/2016] [Accepted: 10/21/2016] [Indexed: 12/31/2022] Open
Abstract
Thyroid hormone concentrations only become sufficient to maintain a euthyroid state through appropriate stimulation by pituitary thyroid-stimulating hormone (TSH). In such a dynamic system under constant high pressure, guarding against overstimulation becomes vital. Therefore, several defensive mechanisms protect against accidental overstimulation, such as plasma protein binding, conversion of T4 into the more active T3, active transmembrane transport, counter-regulatory activities of reverse T3 and thyronamines, and negative hypothalamic-pituitary-thyroid feedback control of TSH. TSH has gained a dominant but misguided role in interpreting thyroid function testing in assuming that its exceptional sensitivity thereby translates into superior diagnostic performance. However, TSH-dependent thyroid disease classification is heavily influenced by statistical analytic techniques such as uni- or multivariate-defined normality. This demands a separation of its conjoint roles as a sensitive screening test and accurate diagnostic tool. Homeostatic equilibria (set points) in healthy subjects are less variable and do not follow a pattern of random variation, rather indicating signs of early and progressive homeostatic control across the euthyroid range. In the event of imminent thyroid failure with a reduced FT4 output per unit TSH, conversion efficiency increases in order to maintain FT3 stability. In such situations, T3 stability takes priority over set point maintenance. This suggests a concept of relational stability. These findings have important implications for both TSH reference limits and treatment targets for patients on levothyroxine. The use of archival markers is proposed to facilitate the homeostatic interpretation of all parameters.
Collapse
Affiliation(s)
- Rudolf Hoermann
- Department of Nuclear Medicine, Klinikum Luedenscheid, Luedenscheid, Germany
| | | | - Rolf Larisch
- Department of Nuclear Medicine, Klinikum Luedenscheid, Luedenscheid, Germany
| | - Johannes W. Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Witten/Herdecke University, Bochum, Germany
| |
Collapse
|