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Oteri V, Volpe S, Lopes M, Sceusa G, Tumminia A, Belfiore A, Frasca F, Gullo D. Therapeutic efficacy and patient compliance of levothyroxine liquid and softgel formulations taken with meals: a systematic review. Endocrine 2024:10.1007/s12020-024-04016-7. [PMID: 39215906 DOI: 10.1007/s12020-024-04016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Levothyroxine (L-T4) is the drug of choice for treating primary hypothyroidism. L-T4 tablets should be taken at least 30 min before breakfast. Several studies have suggested that serum thyroid profile is not affected by concomitant intake of liquid/softgel L-T4 with meals. Our aim is to review the evidence on therapeutic efficacy and patient compliance with the liquid and softgel formulation of L-T4 taken with meals, also compared with the standard tablet therapy regimen, in hypothyroid patients. METHODS We performed a systematic review of literature by searching PubMed, Embase, and Cochrane Library databases. PRISMA guidelines were applied, and the risk of bias of the included studies was assessed using the RoB 2 and ROBINS tools. The methodological quality was assessed following the GRADE criteria. RESULTS We included 13 studies, accounting for a total of 1697 patients. The timing of liquid L-T4 intake from breakfast did not affect the therapeutic efficacy of the treatment. No significant differences in the absorption of liquid L-T4 were found when administered together with different foods, beverages, drugs, or other supplements. TSH levels are not influenced by taking softgel L-T4 at breakfast; the efficacy of softgel and liquid formulation is similar when they are taken with a meal, but superior to that of tablet formulation. Shifting from L-T4 tablets taken 30 min before breakfast to liquid/softgel formulation taken with the meal improved medication adherence and perceived quality of life of patients. CONCLUSION Liquid and softgel formulation of L-T4 can be taken at breakfast or close to meals, without losing therapeutic efficacy. These formulations could also improve patient compliance and quality of life compared to L-T4 tablet therapy taken 30 min before breakfast.
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Affiliation(s)
- Vittorio Oteri
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy.
| | - Salvatore Volpe
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Mariarita Lopes
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Giulia Sceusa
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Andrea Tumminia
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Antonino Belfiore
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Francesco Frasca
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Damiano Gullo
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
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Tian L, Ma X. Green Tea Intake: A Protective Factor Against Postsurgical Hypothyroidism and Hypoparathyroidism. J Perianesth Nurs 2024:S1089-9472(23)01101-2. [PMID: 38402475 DOI: 10.1016/j.jopan.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 12/01/2023] [Accepted: 12/09/2023] [Indexed: 02/26/2024]
Abstract
PURPOSE Tea and coffee are the most commonly consumed types of drinks, identified with multiple health benefits. However, the association between tea and coffee intake and postsurgical hypothyroidism and hypoparathyroidism (PHypoTP) is still unclear. Therefore, the objective of this study is to explore the effect of tea and coffee intake on the risk of PHypoTP. DESIGN Two-sample Mendelian randomization (MR). METHODS The primary approach for MR estimates was the inverse-variance-weighted method. MR-Egger, MR Pleiotropy RESidual Sum and Outlier (PRESSO), weighted median, simple mode, and weighted mode were used to detect pleiotropy and heterogeneity. FINDINGS We found that green tea intake was causally associated with the decreased risk of PHypoTP (β = -0.019; 95% confidence interval: -0.038 to -0.001; P = .029). However, there was no significant association between coffee intake and the risk of PHypoTP. No heterogeneity or pleiotropy in these results was detected. CONCLUSIONS Our findings provide the genetic evidence supporting that green tea intake was a protective factor against PHypoTP. Accordingly, we may suggest that patients after thyroidectomy to add green tea into their habitual diet during nursing education.
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Affiliation(s)
- Lixia Tian
- Department of Operating Room, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; Department of Nursing, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojing Ma
- Department of Operating Room, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; Department of Nursing, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Trimboli P, Piticchio T, Dadda Z, Stramazzo I, Gamarra E, Ruinelli L, Virili C. Analysis of dose-TSH response effect of levothyroxine soft-gel formulation. Front Endocrinol (Lausanne) 2024; 15:1340204. [PMID: 38449850 PMCID: PMC10915021 DOI: 10.3389/fendo.2024.1340204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/30/2024] [Indexed: 03/08/2024] Open
Abstract
Background Hypothyroidism is treated with daily levothyroxine (LT4). In recent years, soft gel caps of LT4 (LT4-C) have been commercialized, and their performance has been optimized. Since guidelines recommend dose LT4 according to the tablet preparation efficacy, the present study was undertaken to obtain data about the daily requirement, normalized per body weight, of LT4-C. Methods Patients undergoing LT4-C after total thyroidectomy and radioiodine treatment for differentiated thyroid carcinoma were selected. There was no specific indication of suppression of TSH (i.e., <0.5 or <0.1 mIU/L). Patients were required to maintain a stable LT4 dose during the study period. Patients with interfering factors were excluded from this study. Results Thirty patients were enrolled (18 females and 12 males; median age, 50 years; median body weight, 71 kg; median LT4-C dose, 1.71 µg/kg/day). The analysis of patient age did not reveal any differences. The LT4-C dose correlated with free-T4 p = 0.03), but not with TSH (p = 0.42) and free-T3 (p = 0.13). TSH was <1.0 mIU/L in 90% of the cases. The LT4-C dose-TSH response effect was analysed by probit regression model: the probability to achieve TSH <1.0 mIU/l was 99% with a dose of 1.84 (95%CI 1.57-2.12) µg/kg/day, 75% with a dose of 1.38 µg/kg/day (95%CI 1.17-1.59), and 50% with a dose of 1.20 (95%CI 0.96-1.43). At ROC curve analysis, the most accurate cut-off of LT4-C dose to achieve TSH <1.0 mIU/l was 1.53 ug/kg/day with 70% sensitivity and 100% specificity. Conclusions Athyreotic patients can be initially treated with an LT4-C dose lower than previously stated. Therefore, further prospective studies are warranted.
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Affiliation(s)
- Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Tommaso Piticchio
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Zeno Dadda
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Ilaria Stramazzo
- Endocrinology Section, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Elena Gamarra
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Lorenzo Ruinelli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Team Data Science and Research, Area ICT, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Camilla Virili
- Endocrinology Section, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
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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.
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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
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Liu H, Li W, Zhang W, Sun S, Chen C. Levothyroxine: Conventional and novel drug delivery formulations. Endocr Rev 2022; 44:393-416. [PMID: 36412275 PMCID: PMC10166268 DOI: 10.1210/endrev/bnac030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/18/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
Despite the fact that levothyroxine is one of the most prescribed medications in the world, its bioavailability has been reported to be impaired by many factors, including interfering drugs or foods and concomitant diseases, and persistent hypothyroidism with a high dose of levothyroxine is thus elicited. Persistent hypothyroidism can also be induced by noninterchangeability between formulations and poor compliance. To address these issues, some strategies have been developed. Novel formulations (liquid solutions and soft-gel capsules) have been designed to eliminate malabsorption. Some other delivery routes (injections, suppositories, sprays, and sublingual and transdermal administrations) are aimed at circumventing different difficulties in dosing, such as thyroid emergencies and dysphagia. Moreover, nanomaterials have been used to develop delivery systems for the sustained release of levothyroxine to improve patient compliance and reduce costs. Some delivery systems encapsulating nanoparticles show promising release profiles. In this review, we first summarize the medical conditions that interfere with the bioavailability of oral levothyroxine and discuss the underlying mechanisms and treatments. The efficacy of liquid solutions and soft-gel capsules are systematically evaluated. We further summarize the novel delivery routes for levothyroxine and their possible applications. Nanomaterials in the levothyroxine field are then discussed and compared based on their load and release profile. We hope the article provides novel insights into the drug delivery of levothyroxine.
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Affiliation(s)
- Hanqing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wei Li
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wen Zhang
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
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Gottwald-Hostalek U, Razvi S. Getting the levothyroxine (LT4) dose right for adults with hypothyroidism: opportunities and challenges in the use of modern LT4 preparations. Curr Med Res Opin 2022; 38:1865-1870. [PMID: 35484983 DOI: 10.1080/03007995.2022.2071059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Lifelong treatment with levothyroxine (LT4) is the mainstay of management for individuals with hypothyroidism. Many hypothyroid patients start LT4 treatment at a low dose (e.g. 25-50 µg), especially the elderly, those with residual thyroid function, those with low body weight, and those with significant (especially cardiac) comorbidities. Almost half of patients on LT4 replacement therapy demonstrate either under- or over-treatment. Many LT4 preparations have relatively large intervals between tablet strengths at the lower end of their dose ranges (providing 25 µg, 50 µg, and 75 µg tablets), which may represent a barrier to achieving the optimum maintenance treatment for some patients. The availability of intermediate tablet strengths of LT4 in the 25-75 µg range may facilitate precise and effective dose titration of LT4 and may also enable convenient maintenance regimens based on a single LT4 tablet daily, to support adherence to therapy.
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Affiliation(s)
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
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Trimboli P, Mouly S. Pharmacokinetics and Clinical Implications of Two Non-Tablet Oral Formulations of L-Thyroxine in Patients with Hypothyroidism. J Clin Med 2022; 11:jcm11123479. [PMID: 35743549 PMCID: PMC9224574 DOI: 10.3390/jcm11123479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Increased knowledge of the pharmacokinetic characteristics of orally administered levothyroxine (L-T4) has improved individualization of dosing regimens. However, up to 40-45% of patients, depending on the leading cause of hypothyroidism, are still over- or, more often, undertreated. Unintentional non-adherence to L-T4 replacement therapy includes all situations of unintended drug-drug and drug-food interactions as well as fasting conditions that are not necessarily respected by patients. RESULTS In this specific context, the overall information concerning those factors with the potential to affect L-T4 absorption refers only to tablet formulation. Indeed, this is the reason why new non-tablet formulations of L-T4 were introduced some years ago. In this regard, the current literature review was designed to summarize pharmacokinetic, drug and food interactions and clinical data focusing on two new oral L-T4 formulations, i.e., liquid and soft-gel capsule in healthy volunteers and patients with primary hypothyroidism. The non-tablet L-T4 soft-gel capsules and solution have proven bioequivalence with the usual L-T4 tablet Princeps and generic formulations. Clinical studies have suggested higher performance of non-tablet formulations than tablet in those patients with suboptimal adherence. The impact of gastrointestinal conditions and variation of gastric pH was lower with either soft gel/solution than with tablets. In addition, the extent of drug-drug and drug-food interactions remains low and of uncertain clinical relevance. CONCLUSIONS Pending further studies allowing one to extend the use of soft-gel/solution preparations in unselected patients, non-tablet L-T4 formulations should be considered as a first-line choice, especially in those patients with moderate-to-high potential of suboptimal tablet performance.
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Affiliation(s)
- Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ente Ospedaliero Cantonale (EOC), 6500 Bellinzona, Switzerland;
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Stéphane Mouly
- Assistance Publique-Hôpitaux de Paris Nord, Département Médico-Universitaire (DMU) INVICTUS, Département de Médecine Interne, Hôpital Lariboisière, INSERM UMRS-1144, Université de Paris Cité, 75010 Paris, France
- Correspondence: ; Tel.: +33-1-49-95-81-26; Fax: +33-1-49-95-84-46
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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.
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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.
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Tzifi F, Iliadi A, Voutetakis A, Platis D, Girginoudis P, Kanaka-Gantenbein C. Non-inferiority of liquid thyroxine in comparison to tablets formulation in the treatment of children with congenital hypothyroidism. J Pediatr Endocrinol Metab 2022; 35:239-247. [PMID: 34653328 DOI: 10.1515/jpem-2021-0458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aim of the current prospective randomized control study was to assess efficacy, safety, and non-inferiority of a new liquid L-thyroxine formulation dissolved in glycerol and water (T4® drops, produced by a Greek pharmaceutical Company, Uni-Pharma, Athens, Greece) in comparison to the standard Tablets form (T4® tablets, Uni-Pharma, Athens, Greece) in the substitutive treatment of children with congenital hypothyroidism (CH). METHODS Thirty-nine children with CH, aged 3-12 years old, were enrolled in the study, after parental Informed Consent has been obtained, while three patients were lost from follow-up. At baseline, all participants had normal thyroid-stimulating hormone (TSH) and Free T4 values. Patients were randomly subdivided according to the assigned treatment in Group A (n=17)-Tablet Form and Group B (n=19)-Liquid Form. TSH and Free T4 levels were evaluated at 0, 2, 4, and 6 months. RESULTS TSH values showed a statistically significant difference (p=0.017) between groups only at six months (Group A having higher TSH levels than Group B, albeit within the normal range), while Free T4 levels had no statistical difference throughout the six month study period and were always within the normal range. Moreover, dose adjustments were more frequent in Group A (p=0.038) during the six months. Liquid L-thyroxine substitutive treatment exhibited no statistically significant adverse effects in comparison to the widely used tablets. CONCLUSIONS Levothyroxine (LT4) as liquid solution formulation is safe and noninferior to the widely used L-thyroxine Tablets, with less need for dose adjustment, and can therefore be safely used in the treatment of children with CH.
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Affiliation(s)
- Flora Tzifi
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics Medical School, National and Kapodistrian University of Athens, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Alexandra Iliadi
- Institute of Child Health, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Antonis Voutetakis
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics Medical School, National and Kapodistrian University of Athens, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Dimitris Platis
- Institute of Child Health, "Aghia Sophia" Children's Hospital, Athens, Greece
| | | | - Christina Kanaka-Gantenbein
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics Medical School, National and Kapodistrian University of Athens, "Aghia Sophia" Children's Hospital, Athens, Greece
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Tuli G, Munarin J, de Sanctis L. Comparison Among Two Liquid Formulations of L-thyroxine in the Treatment of Congenital Hypothyroidism in the First Month of Life: A Pilot Study. Front Endocrinol (Lausanne) 2022; 13:860775. [PMID: 35480479 PMCID: PMC9037062 DOI: 10.3389/fendo.2022.860775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/14/2022] [Indexed: 11/15/2022] Open
Abstract
The liquid formulation of L-thyroxine is the most used in the substitutive treatment of congenital hypothyroidism (CH). This formulation has higher TSH suppression rates with respect of L-thyroxine tablets and thus lower doses are indicated. Two types of liquid L-thyroxine (Tirosint© and Tifactor©) are currently approved in Italy for use in pediatric age and to date there are no data available in the Literature comparing the two liquid formulations. The aim of this study is to compare the efficacy of both formulations in normalizing TSH and fT4 levels in the first month of life and to compare the L-thyroxine requirement for both formulations over the same period. All newborns diagnosed with primary CH at the neonatal screening program in the Piedmont region of Italy in the period May 2020 - May 2021 were enrolled and divided into two groups according to the liquid formulation used: TS Group with Tirosint© and TF Group with Tifactor©. No difference was observed between the two groups considering the TSH at dried blood spot (DBS) at neonatal screening, the serum levels of TSH, fT4 and fT3 and initial dose of L-thyroxine. At 15 days the serum TSH in the TF Group was 0.08 ± 0.02 mcUI/ml, while in the TS Group it was 36.7 ± 14.7 mcUI/ml p=0.04). No differences were observed between the two groups considering fT4 levels and L-thyroxine requirement. Among the subjects in the TF Group, 5/9 showed suppressed TSH at 15 days after starting treatment, while none of the subjects in the TS Group showed TSH levels below the normal lower limit (p=0.011). Among the subjects in the TF Group, 5/9 patients showed suppressed TSH at 30 days after starting treatment, while 1/12 subjects in the TS Group showed TSH levels below the normal lower limit (p=0.017). In conclusion, this study confirms the efficacy in normalizing the thyroid hormonal profile in newborns with CH among the liquid solutions although the response seem to be different in timing therefore an individual approach is necessary considering the type of formulation used, the diagnostic category of CH and clinical features.
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Affiliation(s)
- Gerdi Tuli
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Turin, Italy
- Department of Health and Pediatric Sciences, Postgraduate Program in Biomedical Sciences and Oncology, University of Turin, Turin, Italy
| | - Jessica Munarin
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Turin, Italy
- Department of Health and Pediatric Sciences, Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Luisa de Sanctis
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Turin, Italy
- Department of Health and Pediatric Sciences, University of Turin, Turin, Italy
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Liu J, Chang X, Wang Q, Ding X, Jiang T, Wang G. Magnetic resonance T1-mapping quantitatively assesses the severity of thyroid destruction in patients with autoimmune thyroiditis. Front Endocrinol (Lausanne) 2022; 13:1028588. [PMID: 36387897 PMCID: PMC9663821 DOI: 10.3389/fendo.2022.1028588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Autoimmune thyroiditis (AIT) is a common organ-specific autoimmune disease. Longitudinal relaxation time mapping (T1-mapping) analyzed by magnetic resonance imaging is a new method for evaluating inflammation or fibrosis. This study aimed to investigate the relationship between thyroid T1-mapping value and degree of intrathyroidal inflammation and destruction in euthyroid AIT patients. METHODS This case-control study recruited 28 drug-naïve AIT patients and 18 healthy controls. Thyroid specimens were collected for assessing the mRNA expression of inflammatory factors and histopathologic examination. T1-mapping values were measured using a modified look-locker inversion-recovery sequence in all participants. RESULTS The positive rate of pathological diagnosed AIT was only 83.3% in the AIT group diagnosed by positive TPOAb and/or TgAb and typical ultrasonic manifestations, while 7.1% of the control group was diagnosed as AIT by pathological manifestations. Receiver operating characteristic curve analysis revealed a very high diagnostic value of thyroid T1-mapping values for pathological diagnosed AIT (area under the curve was 0.950, 95%CI: 0.843 - 0.993, P < 0.001). In the patients with pathological diagnosed AIT, thyroid T1-mapping values were significantly associated with the mRNA expression of INF-γ (r = 0.343, P < 0.05), TNF-α (r = 0.352, P < 0.01), and IL-1β (r = 0.673, P < 0.01) in thyroid tissues. Moreover, histopathologic examination showed that thyroid T1-mapping values can properly reflect the degree of thyroid destruction in AIT patients. CONCLUSIONS Thyroid T1-mapping values had a very high diagnostic value for AIT. In euthyroid AIT patients, thyroid T1-mapping values better reflect degree of intrathyroidal inflammation and destruction.
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Affiliation(s)
- Jia Liu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaona Chang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qiu Wang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Ding
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Tao Jiang
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- *Correspondence: Guang Wang, ; Tao Jiang,
| | - Guang Wang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- *Correspondence: Guang Wang, ; Tao Jiang,
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Gatta E, Bambini F, Buoso C, Gava M, Maltese V, Anelli V, Delbarba A, Pirola I, Cappelli C. Liquid levothyroxine formulations in patients taking drugs interfering with L-T4 absorption. Front Endocrinol (Lausanne) 2022; 13:1080108. [PMID: 36561558 PMCID: PMC9764388 DOI: 10.3389/fendo.2022.1080108] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To describe the current knowledge on thyroid hormonal profile in patients on liquid L-T4 therapy and drugs known to interfere with L-T4 absorption. METHODS A PubMed/MEDLINE, Web of Science, and Scopus research was performed. Case reports, case series, original studies and reviews written in English and published online up to 31 August 2022 were selected and reviewed. The final reference list was defined based on the relevance of each paper to the scope of this review. RESULTS The available data showed that novel levothyroxine formulations circumvent gastric pH impairment due to multiple interfering drugs such as proton pump inhibitors, calcium or iron supplements, sevelamer, aluminum/magnesium hydroxide and sodium alginate. CONCLUSION New formulations can be taken simultaneously with drugs interfering with L-T4 absorption, in particular liquid formulations. Softgel capsules need more studies to support these data.
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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.
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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
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14
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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.
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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
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Kaur N, Suryanarayanan R. Levothyroxine sodium pentahydrate tablets - formulation considerations. J Pharm Sci 2021; 110:3743-3756. [PMID: 34384799 DOI: 10.1016/j.xphs.2021.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 12/16/2022]
Abstract
Even though levothyroxine sodium pentahydrate tablets have been in the market since 1955, there continue to be recalls due to sub potency. We have comprehensively reviewed the factors affecting its stability in solid oral dosage forms. A compilation of marketed formulation compositions enabled the identification of the potential 'problem excipients'. Two excipient properties, hygroscopicity and microenvironmental acidity, appeared to be responsible for inducing drug instability. In drug products, depending on the formulation composition and storage conditions, the pentahydrate can dehydrate to highly reactive levothyroxine sodium monohydrate, or undergo salt disproportionation to the free acid form of the drug. The USP assay method (HPLC based) is insensitive to these different physical forms of the drug. The influence of physical form of levothyroxine on its chemical stability is incompletely understood. The USP has five product-specific dissolution tests reflecting the complexity in its evaluation.
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Affiliation(s)
- Navpreet Kaur
- Department of Pharmaceutics, College of Pharmacy, University of Minnesota-Twin Cities, 9-177 WDH, 308 Harvard Street Southeast, Minneapolis, Minnesota 55455, United States
| | - Raj Suryanarayanan
- Department of Pharmaceutics, College of Pharmacy, University of Minnesota-Twin Cities, 9-177 WDH, 308 Harvard Street Southeast, Minneapolis, Minnesota 55455, United States.
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Liquid Levothyroxine Formulation Taken during Lunch in Italy: A Case Report and Review of the Literature. Case Rep Endocrinol 2020; 2020:8858887. [PMID: 32963845 PMCID: PMC7492953 DOI: 10.1155/2020/8858887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 12/27/2022] Open
Abstract
Levothyroxine (L-T4) is among the most widely prescribed medications in the world, and it is considered by the World Health Organization an essential medicine for basic health care. Replacement therapy has always been considered straightforward although different factors may interfere with intestinal absorption of L-T4, including food, dietary fibre, coffee, drugs, and gastrointestinal diseases. For these reasons, current guidelines recommend that L-T4 should be taken in a fasting state because its absorption is maximised when it is taken on an empty stomach, reflecting the importance of gastric acidity in the absorption process. In addition to sodium L-T4 in tablet form, various formulations (soft-gel capsules and liquid solutions) have become available for clinical use in the last years promising improved absorption. We described a 31-year-old Italian man who took liquid levothyroxine formulation during lunch. He was under replacement therapy with liquid levothyroxine 75 mcg daily for hypothyroidism due to Hashimoto thyroiditis for three years. During confirmation of the L-T4 replacement therapy, the patient stated that he was going to continue to “take liquid levothyroxine during (his) lunch every day.” We recommended taking the medication correctly in the morning at least thirty minutes before breakfast and repeating TSH, fT4, and fT3 after three months. The thyroid hormonal profiles taken after 3 and 6 months were comparable to those when the patient was taking the medication during lunch. In conclusion, liquid levothyroxine formulation should be preferred in case of malabsorption or potential malabsorption. Liquid formulation should be preferred due to the possibility of taking it during breakfast, which significantly improves the compliance of patients. Further studies are needed to evaluate the possibility of taking liquid L-T4 during lunch.
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