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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.
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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
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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.
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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
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Seng Yue C, Scarsi C, Bettazzi E, Mautone G, Celi FS, Ducharme M. Proton Pump Inhibitors Do Not Affect the Bioavailability of a Novel Liquid Formulation of Levothyroxine. Endocr Pract 2024; 30:513-520. [PMID: 38554774 DOI: 10.1016/j.eprac.2024.03.388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE This study evaluates the impact of a representative proton pump inhibitor (PPI) (omeprazole), administered simultaneously or staggered, on the pharmacokinetics of levothyroxine (LT4) solution (Tirosint-SOL). METHODS This was a randomized, 3-way crossover, comparative bioavailability study in 36 healthy adults under fasting conditions. Omeprazole 40 mg delayed-release capsule was administered once daily from Day 1 to 6 (mornings, Treatment-A; evenings, Treatment-B; none, Treatment-C) to increase and stabilize gastric pH. In the morning of Day 5, a single dose of LT4 solution 600 mcg was administered. Blood samples were collected 0 to 48 hours post-LT4 administration. Noncompartmental pharmacokinetic parameters were calculated for total serum thyroxine using baseline-corrected data. Maximum concentration (Cmax) and area under the concentration-time curve (AUC0-48) were included in an analysis of variance to obtain geometric mean ratios and 90% confidence intervals. RESULTS For both comparisons (A/C and B/C), geometric mean ratios and 90% confidence intervals for all parameters were within the equivalence boundaries (80%-125%), indicating bioequivalence: for A/C, AUC0-48 98.98% [94%-104%], and Cmax 91.68% [87%-97%]; for B/C, AUC0-48 98.94% [95%-103%], and Cmax 94.90% [90%-100%]. Median Tmax (time associated with Cmax) was similar across treatments. CONCLUSION This study demonstrated that Tirosint-SOL bioavailability is unaffected by coadministration of a representative PPI, given simultaneously or staggered by about 12 hours, compared to administration of LT4 solution alone. For hypothyroid patients on PPI therapy, administration of LT4 solution may reduce variations in thyroid stimulating hormone levels related to intermittent use of acid-reducing drugs and consequently the need for dose adjustments.
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Affiliation(s)
| | | | | | | | - Francesco S Celi
- Department of Medicine at University of Connecticut Health, Farmington, Connecticut
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Ferrari SM, Patrizio A, Mazzi V, Ragusa F, Botrini C, Elia G, Balestri E, Barozzi E, Rugani L, Bracchitta F, Stoppini G, Frenzilli G, Baldini E, Virili C, Benvenga S, Fallahi P, Antonelli A. Lactose intolerance and levothyroxine malabsorption: a review of the literature and report of a series of patients treated with liquid L-T4 without lactose. Front Endocrinol (Lausanne) 2024; 15:1386510. [PMID: 38665263 PMCID: PMC11044000 DOI: 10.3389/fendo.2024.1386510] [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: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
In hypothyroid patients needing large doses of levothyroxine (L-T4) (>1.7-2 μg/kg/day) to reach euthyroidism, lactose intolerance (LI) needs to be excluded, owing to the high prevalence in the population. If LI is present, a lactose-free diet decreases the rate of L-T4 malabsorption. However, an increased requirement of L-T4 is described in patients with LI, which can be beneficially treated using lactose-free L-T4 formulation. The lactose-free liquid L-T4 formulation is able to circumvent LI malabsorption leading to the normalization of thyroid-stimulating hormone (TSH) in patients with subclinical hypothyroidism and long-term stable TSH levels.
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Affiliation(s)
| | - 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
| | - Francesca Ragusa
- 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
| | - Fabiana Bracchitta
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Giulio Stoppini
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Giada Frenzilli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Enke Baldini
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, “Sapienza” University of Rome, Latina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Azienda Ospedaliera Universitaria Policlinico “G. Martino”, Messina, Italy
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
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Cappelli C, Gatta E, Ippolito S. Levothyroxine personalized treatment: is it still a dream? Front Endocrinol (Lausanne) 2024; 14:1334292. [PMID: 38260167 PMCID: PMC10801080 DOI: 10.3389/fendo.2023.1334292] [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: 11/06/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Levothyroxine is a milestone in the treatment of all causes of hypothyroidism. From 19th century till today, Levothyroxine experienced a great advancement, from hypodermic injections of an extract of the thyroid gland of a sheep to novel formulations, known to circumvent malabsorption issue. However, the rate of patients on suboptimal therapy is still high. Current Guidelines are clear, daily Levothyroxine dosage should be calculated based on body weight. However, we are still far away from the possibility to administer the right dosage to the right patient, for several reasons. We retrace the history of treatment with levothyroxine, pointing out strengths and weaknesses of different formulations, with particular attention to what keeps us away from tailored therapy. In the age of digitalization, the pharmaceutical industry has been giving rising importance to Digital therapeutics, that are known to be effective in reaching target therapies. By combining current knowledge of hypothyroidism therapy with cutting-edge technology, we also hypothesized what could be the future strategies to be developed in this field.
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Affiliation(s)
- Carlo Cappelli
- Department of Clinical and Experimental Sciences, SSD Endocrinologia, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Elisa Gatta
- Department of Clinical and Experimental Sciences, SSD Endocrinologia, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Salvatore Ippolito
- Consulcesi Homnya, Head of Omnichannel Strategy & Project Management, Rome, Italy
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Liu H, Li W, Zhang W, Sun S, Chen C. Levothyroxine: Conventional and novel drug delivery formulations. Endocr Rev 2022; 44:393-416. [PMID: 36412275 PMCID: PMC10166268 DOI: 10.1210/endrev/bnac030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/18/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
Despite the fact that levothyroxine is one of the most prescribed medications in the world, its bioavailability has been reported to be impaired by many factors, including interfering drugs or foods and concomitant diseases, and persistent hypothyroidism with a high dose of levothyroxine is thus elicited. Persistent hypothyroidism can also be induced by noninterchangeability between formulations and poor compliance. To address these issues, some strategies have been developed. Novel formulations (liquid solutions and soft-gel capsules) have been designed to eliminate malabsorption. Some other delivery routes (injections, suppositories, sprays, and sublingual and transdermal administrations) are aimed at circumventing different difficulties in dosing, such as thyroid emergencies and dysphagia. Moreover, nanomaterials have been used to develop delivery systems for the sustained release of levothyroxine to improve patient compliance and reduce costs. Some delivery systems encapsulating nanoparticles show promising release profiles. In this review, we first summarize the medical conditions that interfere with the bioavailability of oral levothyroxine and discuss the underlying mechanisms and treatments. The efficacy of liquid solutions and soft-gel capsules are systematically evaluated. We further summarize the novel delivery routes for levothyroxine and their possible applications. Nanomaterials in the levothyroxine field are then discussed and compared based on their load and release profile. We hope the article provides novel insights into the drug delivery of levothyroxine.
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Affiliation(s)
- Hanqing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wei Li
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wen Zhang
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
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Virili C, Bruno G, Santaguida MG, Gargano L, Stramazzo I, De Vito C, Cicenia A, Scalese G, Porowska B, Severi C, Centanni M. Levothyroxine treatment and gastric juice pH in humans: the proof of concept. Endocrine 2022; 77:102-111. [PMID: 35477833 PMCID: PMC9242941 DOI: 10.1007/s12020-022-03056-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/04/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE Despite the absorption of oral thyroxine (T4) occurs in the small bowel, several patients with gastric disorders show an increased need for T4. In vitro evidence suggested that medium pH variations interfere with T4 dissolution. This study was aimed at finding the proof of concept of a direct relationship between the minimal effective dose of T4 and the actual gastric juice pH. PATIENTS AND METHODS Among 311 consecutively thyroxine-treated patients, 61 bearing Hashimoto's thyroiditis (52 F/9 M; median age = 51 years) who complained persistent dyspepsia and/or upper abdominal symptoms following a noninvasive workup for gastrointestinal disorders, underwent EGDS with multiple biopsies and gastric juice pH measurement. All patients accepted to take thyroxine in fasting conditions, abstaining from eating or drinking for one hour. RESULTS Thyroxine requirement increased along with the rising gastric pH (ρ = 0.4229; p = 0.0007). A multivariate analysis revealed that gastric pH was, beside body mass index, the far more important independent variable in determining the effective dose of T4 (p = 0.001). The ROC curve revealed that the pH threshold for an increased thyroxine requirement was at 2.28, being the AUC by 78%. Subdividing patients by the histologic findings, it appeared a significant increase (p = 0.0025) along with the progressive damage of gastric mucosa. CONCLUSION The in vivo measurement of gastric pH highlighted its key role in determining the minimal effective dose of oral T4 and may explain the interference of food, of some drugs and gut disorders on levothyroxine treatment.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Giovanni Bruno
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | | | | | - Ilaria Stramazzo
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, University of Rome, Rome, Italy
| | - Alessia Cicenia
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Giulia Scalese
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Barbara Porowska
- General and Specialistic Surgery 'Paride Stefanini', University of Rome, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.
- Endocrine Unit, AUSL Latina, Latina, Italy.
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Li X, Feng M, Yuan G. Clinical efficacy of Weisu granule combined with Weifuchun tablet in the treatment of chronic atrophic gastritis and its effect on serum G-17, PG I and PG II levels. Am J Transl Res 2022; 14:275-284. [PMID: 35173844 PMCID: PMC8829644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/16/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The aim of this prospective study was to explore the clinical efficacy of Weisu granules combined with Weifuchun tablets in the treatment of chronic atrophic gastritis and its effect on serum gastrin-17 (G-17), pepsinogen I (PG I), and II (PG II) levels. METHODS Totally, 120 patients with chronic atrophic gastritis admitted to our hospital from February 2019 to February 2020 were enrolled and randomized into a control group (n=60) treated with Weifuchun tablets, and a experimental group given Weisu granules. Serum G-17, PG I, and PG II levels, inflammatory factor levels, TCM syndrome scores, gastric mucosa pathological scores, and clinical efficacy were compared between the two groups. Gastric tissue changes were observed using gastroscopy and HE staining. RESULTS After treatment, the levels of serum G-17, PG I, and PG II of the experimental group were significantly better than those of the control group (P<0.001). The levels of inflammatory factors, traditional Chinese medicine (TCM) syndrome scores, and gastric mucosal pathology scores of the experimental group were significantly lower than those of the control group (P<0.001). The overall response rate of the experimental group was significantly higher than that of the control group (P<0.05). The experimental group showed a lower HP positive result and a higher HP negative conversion ratio than the control group (all P<0.05). HE staining results revealed that after treatment, the number of glands was basically restored to the level of normal gastric mucosa, and the improvement of inflammatory cell infiltration in the experimental group was significantly better than that in the control group. CONCLUSION Weisu granule combined with Weifuchun tablets can ameliorate serum G-17, PG I, and PG II levels in patients with chronic atrophic gastritis, relieve inflammatory responses and clinical symptoms, and improve the treatment effect, which is worth promoting in clinical practice. CLINICAL TRIAL REGISTRATION Chinese Registry of Clinical Trials. TRIAL REGISTRATION NUMBER ChiCTR200002548416. Trial URL: http://www.chictr.org.cn/showproj.aspx?proj=26516901.
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Affiliation(s)
- Xiaolan Li
- Department of Gastroenterology, Zhangjiagang Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine HospitalNanjing 215600, Jiangsu, China
| | - Minxiao Feng
- Department of Gastroenterology, Zhangjiagang Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine HospitalNanjing 215600, Jiangsu, China
| | - Gang Yuan
- Department of Geriatrics, Luyuan HospitalZhangjiagang 215600, Jiangsu, China
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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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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.
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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
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11
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Gianoukakis AG, Gupta S, Tran TN, Richards P, Yehuda M, Tomassetti SE. Graves' disease patients with iron deficiency anemia: serologic evidence of co-existent autoimmune gastritis. AMERICAN JOURNAL OF BLOOD RESEARCH 2021; 11:238-247. [PMID: 34322286 PMCID: PMC8303011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/12/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Graves' disease (GD) has been associated with iron deficiency anemia (IDA). Atrophic gastritis leads to IDA and has been associated with autoimmune thyroid disease. This study prospectively determined the prevalence of atrophic gastritis markers and the relationship between these markers and markers of IDA in GD subjects. METHODS Newly diagnosed GD patients (90) and controls (41) were studied. Of the newly diagnosed GD patients, 65 were consecutively enrolled and identified with GD irrespective of anemia, 25 had GD and IDA. Thyroid function, hematologic indices, and atrophic gastritis markers [parietal-cell antibodies (PCab), Helicobacter pylori antibodies (H. pylori ab), mean serum gastrin levels] were examined. RESULTS GD patients presenting with IDA were twice as likely (64% vs. 32%, P=0.049) to harbor PCabs when compared to all other GD subjects. Unselected GD subjects (n=65) had significantly higher PCab (37% vs. 7%, P<0.001) compared to controls. Gastrin levels were significantly elevated in all GD subjects compared to controls (105 vs. 39 pg/ml, P<0.0001). This difference was magnified in PCab+ subjects (202 vs. 64 pg/ml, P=0.003). In all GD subjects, PCabs were associated with increased gastrin levels (202 vs. 75 pg/ml, P=0.0004) and lower ferritin levels (52 vs. 95, P=0.05). In GD anemic subjects, PCabs were associated with lower mean corpuscular volume (75 vs. 81, P=0.001). Gastrin levels correlated inversely with ferritin levels in all GD subjects and positively with TIBC in GD anemic subjects. CONCLUSIONS A significant subset of patients presenting with GD may suffer from IDA due to concurrent autoimmune atrophic gastritis.
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Affiliation(s)
- Andrew G Gianoukakis
- Division of Endocrinology and Metabolism, Division of Hematology and Oncology, Harbor-UCLA Medical Center and The David Geffen School of Medicine at UCLALos Angeles, CA, USA
- The Lundquist Research InstituteTorrance, CA, USA
| | - Shelly Gupta
- Division of Endocrinology and Metabolism, Division of Hematology and Oncology, Harbor-UCLA Medical Center and The David Geffen School of Medicine at UCLALos Angeles, CA, USA
| | - Theresa N Tran
- Division of Endocrinology and Metabolism, Division of Hematology and Oncology, Harbor-UCLA Medical Center and The David Geffen School of Medicine at UCLALos Angeles, CA, USA
| | - Patrick Richards
- Division of Endocrinology and Metabolism, Division of Hematology and Oncology, Harbor-UCLA Medical Center and The David Geffen School of Medicine at UCLALos Angeles, CA, USA
| | - Marelle Yehuda
- Division of Endocrinology and Metabolism, Division of Hematology and Oncology, Harbor-UCLA Medical Center and The David Geffen School of Medicine at UCLALos Angeles, CA, USA
| | - Sarah E Tomassetti
- Division of Endocrinology and Metabolism, Division of Hematology and Oncology, Harbor-UCLA Medical Center and The David Geffen School of Medicine at UCLALos Angeles, CA, USA
- The Lundquist Research InstituteTorrance, CA, USA
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12
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Nagy EV, Perros P, Papini E, Katko M, Hegedüs L. New Formulations of Levothyroxine in the Treatment of Hypothyroidism: Trick or Treat? Thyroid 2021; 31:193-201. [PMID: 33003978 DOI: 10.1089/thy.2020.0515] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Levothyroxine (LT4) as a medication is used by up to 5.3% of the adult population. For optimal efficacy, the traditional tablet formulation (LT4tab) requires that patients avoid concomitant ingestion with food, drinks, and certain medications, as well as excellent patient compliance. Some comorbidities influence bioavailability of LT4 and may mandate repeated dose adjustments. Summary: New LT4 formulations (soft gel [LT4soft] and liquid [LT4liq]) containing predissolved LT4 are claimed to improve bioavailability, presumably by facilitating absorption. Thus, these formulations may well be more suitable than LT4tab for patients whose daily requirements are subjected to variations in bioavailability. Here, we review the evidence and indications for use of new LT4 formulations and highlight areas of uncertainty that are worthy of further investigation. While bioequivalence is established for LT4soft and LT4liq administered to healthy volunteers compared with LT4tab in pharmacokinetic (PK) studies, therapeutic equivalence of the new formulations seems to be different in several clinical settings. Some evidence suggests that new formulations of LT4 may mitigate against the strict requirements relating to concomitant ingestion with food, drinks, and certain medications, which apply to traditional LT4 tablets. The principal indication is in selected patients with disease fluctuations and intermittent therapies with interfering medications, where the need for frequent dose adjustments and office visits may be diminished. Whether the use of LT4soft or LT4liq in patients with impaired gastric acid secretion results in better control of hypothyroidism than LT4tab remains unclear. Conclusions: The evidence in favor of using LT4soft and LT4liq in clinical practice over LT4tab is weak, and the underlying putative PK mechanisms unclear. Additional studies to investigate these potential benefits, define the cost-effectiveness, and understand the PK mechanisms involved with new LT4 formulations are needed.
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Affiliation(s)
- Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - Monika Katko
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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13
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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.
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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
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14
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Fallahi P, Ferrari SM, Elia G, Ragusa F, Paparo SR, Antonelli A. L-T4 Therapy in Enteric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2021; 12:626371. [PMID: 33708175 PMCID: PMC7940821 DOI: 10.3389/fendo.2021.626371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
Levothyroxine (L-T4) absorption can be impaired by various causes: a) L-T4 ingestion during breakfast, or with food; b) conditions of reduced gastric acidity; c) intestinal procedures and diseases such as bariatric surgery, lactose intolerance (LI), celiac disease (CD), inflammatory bowel disease; d) drugs that alter L-T4 absorption, increasing the gastric pH, or preventing the dissolution of tablets. The development of new oral formulations, i.e. the liquid preparation and the soft gel capsule, represents the most recent advance regarding L-T4 therapy. Treating hypothyroidism with L-T4 tablets can lead to an improper control of thyroid-stimulating hormone (TSH) in ~10%-15% of patients. The improperly elevated TSH is usually managed by increasing the L-T4 daily dose, and revaluating TSH upon 2-6 months. The increase of the L-T4 dosage may cause iatrogenic hyperthyroidism, especially when the underlying disorders are cured. Liquid L-T4 can be administered in patients unable to swallow capsules or tablets, and this is one of its major benefits. Liquid L-T4 can: 1- overcome food and beverages interference; 2- bypass the malabsorption associated with an increased gastric pH; 3- circumvent the issue of malabsorption in patients who underwent bariatric surgery; 4-maintain TSH values under control better than L-T4 tablets in hypothyroid patients with typical or atypical CD, or in patients with LI. Few clinical studies evaluated soft gel L-T4 with encouraging findings in patients with gastric- or coffee-related malabsorption, or hypothyroid patients without malabsorption. Additional research is necessary to investigate liquid L-T4, or soft gel capsule, in other conditions of altered L-T4 absorption.
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Affiliation(s)
- Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- *Correspondence: Poupak Fallahi,
| | | | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
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15
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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
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16
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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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17
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Virili C, Brusca N, Capriello S, Centanni M. Levothyroxine Therapy in Gastric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2020; 11:621616. [PMID: 33584549 PMCID: PMC7876372 DOI: 10.3389/fendo.2020.621616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/11/2020] [Indexed: 12/19/2022] Open
Abstract
Oral levothyroxine sodium is absorbed in the small intestine, mainly in the jejunum and the ileum being lower the absorption rate at duodenal level. The time interval between the ingestion of oral thyroxine and its appearance in the plasma renders unlike a gastric absorption of the hormone. However, several evidence confirm the key role of the stomach as a prerequisite for an efficient absorption of oral levothyroxine. In the stomach, in fact, occur key steps leading to the dissolution of thyroxine from the solid form, the process bringing the active ingredient from the pharmaceutical preparation to the aqueous solution. In particular, gastric juice pH, volume, viscosity, as well as gastric emptying time seem to be the most important limiting factors. These hypotheses are confirmed by the detection of an increased need for levothyroxine in patients with Helicobacter pylori infection, chronic atrophic gastritis, gastroparesis, or in simultaneous treatment with drugs interfering with gastric acidic output. The aim of the present article is to focus on the knowledge of pathophysiologic events that determine the absorptive fate of traditional (tablet) and alternative thyroxine preparations (softgel capsule and liquid solution) in patients bearing gastric disorders.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Nunzia Brusca
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Capriello
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
- *Correspondence: Marco Centanni,
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18
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Benvenga S. Liquid and softgel capsules of l-thyroxine results lower serum thyrotropin levels more than tablet formulations in hypothyroid patients. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2019; 18:100204. [PMID: 31844631 PMCID: PMC6896494 DOI: 10.1016/j.jcte.2019.100204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 12/14/2022]
Abstract
Objective Evidence indicates that L-T4 in liquid and softgel capsule are absorbed better than tablets in hypothyroid patients, even when patients are under medications that impair the intestinal absorption of L-T4. However, no study has evaluated all three L-T4 formulations in the same hypothyroid patients. This study aims to fill this gap. The outcome was the degree of TSH change in the liquid and softgel formulations, using tablet L-T4 as the reference, regardless of sequence of formulation and regardless of whether patients were co-ingesting with interfering medications. Methods We recorded serum TSH levels in two groups of L-T4 replaced patients with primary hypothyroidism (23 subjects who did not co-ingest interfering medications, and 20 subjects who did). Either group of patients took one formulation of L-T4 at a time with variable sequences. In the first group, the median durations of exposure to tablet, liquid or softgel L-T4 were 14, 9 and 10 months, respectively. In the second group the corresponding durations were 13, 11 and 10 months, during which patients co-ingested interfering medications. Results In the 23 patients, there were 78, 74 or 101 TSH determinations during liquid, softgel capsule or tablet L-T4 regimens. Serum TSH levels associated with liquid, capsule or tablet L-T4 were 1.62 ± 0.51, 1.77 ± 0.44 mU/L (P = 0.049 vs liquid) or 2.38 ± 0.69 mU/L (P < 0.0001 vs liquid or capsule). Rates of TSH ≤ 2.50 mU/L were 97.4% (liquid), 95.9% (softgel) or 64.4% (tablet, P < 0.0001 vs liquid or capsule). Rates of TSH ≤ 4.12 mU/L were 100%, 100% or 98.0%. In the 20 patients, the corresponding TSH determinations were 56, 57 and 41, and corresponding TSH levels were 2.74 ± 0.98, 2.70 ± 0.79 or 7.53 ± 2.82 mU/L. Rates of TSH ≤ 2.50 mU/L were 51.8% (liquid), 47.4% (capsule, P = 0.64) or 2.4% (tablet, P < 0.0001 vs liquid or capsule). Rates of TSH ≤ 4.12 mU/L were 92.8% (liquid), 94.7% (capsule, P = 0.68) or 12.2% (tablet, P < 0.0001 vs liquid or capsule). Conclusions L-T4 ingested as liquid solution or softgel capsule is more bioavailable compared to L-T4 ingested as tablet, and it is slightly superior to capsule L-T4 only in the absence of co-ingestion of interfering medications.
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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 & Clinical Endocrinology, and Women's Endocrine Health, University Hospital, AOU Policlinico G. Martino, Messina, Italy
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19
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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.
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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.
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20
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Virili C, Trimboli P, Centanni M. Novel thyroxine formulations: a further step toward precision medicine. Endocrine 2019; 66:87-94. [PMID: 31617168 DOI: 10.1007/s12020-019-02049-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/05/2019] [Indexed: 02/06/2023]
Abstract
Levothyroxine (T4) is a critical-dose drug, because little variations in the blood concentration may cause treatment failure as well as iatrogenic thyrotoxicosis. Despite the dose response of this drug being more carefully titrated nowadays, several papers still report that a significant fraction of patients treated with levothyroxine demonstrate a TSH which is not on target. Moreover, some widespread gastrointestinal disorders as well as interfering drugs and foods may cause the "refractoriness" of a significant number of patients to an expected dose of thyroxine. The increasing awareness of the mechanisms interfering with the oral thyroid hormone bioavailability and the body of evidence regarding the complexity of treatment in certain classes of patients prompted pharmaceutical research to identify new hormonal formulations to optimize the performance of this drug. In this brief review, the progression of the scientific knowledge of novel T4 formulations use has been analyzed.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Thyroid Center and Nuclear Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.
- Endocrinology Unit, AUSL Latina, Latina, Italy.
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21
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Virili C, Antonelli A, Santaguida MG, Benvenga S, Centanni M. Gastrointestinal Malabsorption of Thyroxine. Endocr Rev 2019; 40:118-136. [PMID: 30476027 DOI: 10.1210/er.2018-00168] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/12/2018] [Indexed: 02/07/2023]
Abstract
Levothyroxine, a largely prescribed drug with a narrow therapeutic index, is often a lifelong treatment. The therapeutic efficacy of T4 may be marred by behavioral, pharmacologic, and pathologic issues acting as interfering factors. Despite a continuous search for an optimal T4 treatment, a significant number of patients fail to show a complete chemical and/or clinical response to this reference dose of T4. Gastrointestinal malabsorption of oral T4 represents an emerging cause of refractory hypothyroidism and may be more frequent than previously reputed. In this review, we examine the pharmacologic features of T4 preparations and their linkage with the intestinal absorption of the hormone. We have stressed the major biochemical and pharmacologic characteristics of T4 and its interaction with the putative transporter at the intestinal level. We have examined the interfering role of nutrients, foods, and drugs on T4 absorption at the gastric and intestinal levels. The impact of gastrointestinal disorders on T4 treatment efficacy has been also analyzed, in keeping with the site of action and the interfering mechanisms. Based on the evidence obtained from the literature, we also propose a schematic diagnostic workup for the most frequent and often hidden gastrointestinal diseases impairing T4 absorption.
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Affiliation(s)
- Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Interdepartmental Program of Molecular and Clinical Endocrinology, and Women's Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
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22
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Virili C, Stramazzo I, Santaguida MG, Bruno G, Brusca N, Capriello S, Cellini M, Severi C, Gargano L, Centanni M. Ulcerative Colitis as a Novel Cause of Increased Need for Levothyroxine. Front Endocrinol (Lausanne) 2019; 10:233. [PMID: 31040825 PMCID: PMC6476912 DOI: 10.3389/fendo.2019.00233] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Thyroxine absorption takes place at the small intestine level and several disorders affecting this intestinal tract lead to thyroxine malabsorption. An increased need for thyroxine has also been observed in gastric disorders due to variations in drug dissolution and/or in its ionization status. Ulcerative colitis (UC) is an inflammatory bowel disease that has been postulated as a potential cause of the increased need for thyroxine, but there is a lack of evidence on this topic. This study is aimed at measuring the thyroxine requirement in hypothyroid patients with UC. Patients and Methods: Among 8,573 patients with thyroid disorders consecutively seen in our referral center from 2010 to 2017, we identified 34 patients with a definite diagnosis of UC. Thirteen of them were hypothyroid (12 F/1 M; median age = 53 years), bearing UC during the remission phase and in need for thyroxine treatment, thus representing the study group. The dose of T4 required by UC patients has been compared to the one observed in 51 similarly treated age- and weight-matched patients, compliant with treatment and clearly devoid of any gastrointestinal and /or pharmacological interference. Results: To reach the target serum TSH, the dose of thyroxine had to be increased in twelve out of thirteen (92%) hypothyroid patients with ulcerative colitis. The median thyroxine dose required by UC patients was 1.54 μg/kg weight/day, that is 26% higher than the control patients, to reach a similar TSH (1.23 μg/kg weight/day; p = 0.0002). Since half of our study group consisted of patients aged over 60 years old, we analyzed the effect of age on the subdivision in two classes. Six out of seven (86%) adult patients (<60 years) required more T4 than those in the respective control group (1.61 vs. 1.27 μg/kg weight/day; +27%; p < 0.0001). An increased dose (+17%; p = 0.0026) but to a lesser extent, was also observed in all patients over 60 years, as compared to the control group. Conclusions: In almost all hypothyroid patients with UC, the therapeutic dose of thyroxine is increased. Therefore, ulcerative colitis, even during clinical remission, should be included among the gastrointestinal causes of an increased need for oral thyroxine.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- *Correspondence: Camilla Virili
| | - Ilaria Stramazzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | | | - Giovanni Bruno
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Nunzia Brusca
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Silvia Capriello
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Miriam Cellini
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Carola Severi
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Lucilla Gargano
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
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23
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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
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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
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24
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Laurent I, Tang S, Astère M, Wang KR, Deng S, Xiao L, Li QF. Liquid L-thyroxine versus tablet L-thyroxine in patients on L- thyroxine replacement or suppressive therapy: a meta-analysis. Endocrine 2018; 61:28-35. [PMID: 29572710 DOI: 10.1007/s12020-018-1574-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/04/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To compare the effectiveness of liquid L-T4 (L-thyroxine) and tablet L-T4 in patients on L-T4 replacement or suppressive therapy. METHODS The Cochrane Library, PubMed, Embase, and Web of Science databases were searched to identify relevant articles. All prospective or randomized controlled studies (RCTs) comparing liquid L-T4 and tablet L-T4 in patients on L-T4 replacement or suppressive therapy were included in the analysis. RESULTS Overall, the initial search of the four databases identified 1278 published studies; of these, eight studies were ultimately included in the meta-analysis. TSH (thyroid stimulating hormone) levels were significantly suppressed in patients on liquid L-T4 compared with those on tablet L-T4, in patients on L-T4 suppressive therapy with L-T4 malabsorption (Mean Difference (MD) = -2.26, 95% Confidence Interval (CI): -3.59, -0.93; P = 0.0009)). However, liquid L-T4 and tablet L-T4 did not show a statistically significant difference in patients on L-T4 suppressive therapy without malabsorption (MD = 0.08, 95% CI: -0.31, 0.47; P = 0.69). TSH levels were significantly normalized in patients on liquid L-T4 compared with those on tablet L-T4, in Patients on L-T4 replacement therapy with L-T4 malabsorption (MD = -3.20, 95% CI: -5.08, -1.32; P = 0.0009). However, liquid L-T4 and tablet L-T4 did not show a statistically significant difference in patients on L-T4 replacement therapy without malabsorption (MD = 0.91, 95% CI: -0.03, 1.86; P = 0.06). CONCLUSION Liquid L-T4 is more efficient than tablet L-T4 in patients on L-T4 replacement or suppressive therapy with malabsorption. No significant differences were observed in patients without malabsorption. Further studies should be conducted to verify these findings.
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Affiliation(s)
- Irakoze Laurent
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Kabezi Hospital, Ministry of Public Health and Fighting AIDS, Kabezi, Burundi
| | - Siying Tang
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Manirakiza Astère
- Department of Oncology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kan Ran Wang
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuhua Deng
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ling Xiao
- Department of Nursing, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Fu Li
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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25
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Guglielmi V, Bellia A, Bianchini E, Medea G, Cricelli I, Sbraccia P, Lauro D, Cricelli C, Lapi F. Drug interactions in users of tablet vs. oral liquid levothyroxine formulations: a real-world evidence study in primary care. Endocrine 2018; 59:585-592. [PMID: 28905202 DOI: 10.1007/s12020-017-1412-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/28/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Several medications may interact with levothyroxine (LT4) intestinal absorption or metabolism, thus reducing its bioavailability. We investigated the variability of thyroid stimulating hormone (TSH) levels and prescribed daily dosages (PDDs) of LT4 before and during potential drug-drug interactions (DDIs) in users of tablets vs. oral liquid LT4 formulations. METHODS By using the Italian general practice Health Search Database (HSD), we retrospectively selected adult patients with at least one LT4 prescription from 2012 to 2015 and at least 1 year of clinical history recorded. The incident prescription of interacting medications (e.g., proton pump inhibitors, calcium or iron salts) was the index date. Analysis was carried out using a self-controlled study design. RESULTS Overall, 3965 users of LT4 formed the study cohort (84.1% women, mean age 56 ± 16.5 years). TSH variability on the entry date was greater among liquid LT4 users than in those prescribed with tablets as shown by the difference between 75th and 25th centile, which were 3.01 and 3.8, respectively. The incidence rate ratio (IRR) for TSH variability did not differ between groups, before and during exposure to DDIs. In contrast, PDDs less likely increased during the exposure to DDI with oral liquid LT4 compared with tablets (IRR = 0.84; 95% CI: 0.77-0.92), especially in patients with post-surgical hypothyroidism (IRR = 0.75; 95% CI: 0.64-0.85). CONCLUSIONS In clinical practice, the use of oral liquid LT4 is not associated with increased PDDs, compared with tablets formulation, during exposure to DDIs. These results support the need for individualizing LT4 formulation to prescribe, especially in patients with various comorbidities and complex therapeutic regimens.
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Affiliation(s)
- Valeria Guglielmi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Elisa Bianchini
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Gerardo Medea
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Iacopo Cricelli
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Paolo Sbraccia
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy.
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26
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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.
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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
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27
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Virili C, Giovanella L, Fallahi P, Antonelli A, Santaguida MG, Centanni M, Trimboli P. Levothyroxine Therapy: Changes of TSH Levels by Switching Patients from Tablet to Liquid Formulation. A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2018; 9:10. [PMID: 29434573 PMCID: PMC5790785 DOI: 10.3389/fendo.2018.00010] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/09/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In the last years, levothyroxine (LT4) has been commercialized also in liquid formulation, which is less sensitive to the factors known to reduce the absorption of tablet LT4. To date, there is no robust information that liquid LT4 can improve pharmacologic thyroid homeostasis of patients with reduced efficacy of tablet LT4. This analysis aimed at achieving solid evidence that switching thyroxine treatment from tablet to liquid preparation improves patients' TSH levels. METHODS The search was performed in PubMed/MEDLINE and Scopus database based on the terms "thyroid," "levothyroxine," and "liquid," and updated until September 25, 2017. Studies were included only if they described patients with suboptimal TSH on tablet LT4, subsequently switched to liquid LT4. RESULTS The literature search retrieved 462 articles and six were finally included. The pooled mean difference of TSH value between tablet and liquid LT4 was 4.23 mIU/L (95% CI from 3.69 to 4.77). Mild heterogeneity was found (I2 60%). Overall mean difference of TSH was significant (p < 0.0001). CONCLUSION The present meta-analysis showed that patients with suboptimal TSH on tablet LT4 can have a significantly improved TSH by switching to liquid LT4 formulation at unchanged dose.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- *Correspondence: Camilla Virili,
| | - Luca Giovanella
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - 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
| | - Maria Giulia Santaguida
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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28
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Ferrara R, Ientile V, Arcoraci V, Ferrajolo C, Piccinni C, Fontana A, Benvenga S, Trifirò G. Treatment pattern and frequency of serum TSH measurement in users of different levothyroxine formulations: a population-based study during the years 2009-2015. Endocrine 2017; 58:143-152. [PMID: 28155170 DOI: 10.1007/s12020-017-1242-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/17/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several conditions can modify the intestinal absorption of levothyroxine tablets, with potential consequences on their therapeutic effect. Pre-dosed ampoules and oral drops have been recently made available to overcome this limitation. AIMS To describe the pattern of use of different formulations of levothyroxine in a general population of Southern Italy and to perform an exploratory analysis investigating the effect of switching from levothyroxine tablets to oral liquid formulations. METHODS Data were extracted from the Caserta Local Health Unit database. All patients receiving at least one levothyroxine prescription during the years 2009-2015 were identified. 1-year incidence of use of formulation-specific levothyroxine was calculated. Switchers between levothyroxine tablets and oral liquid formulations were identified and the frequency of thyroid-stimulating hormone measurement within 2 years prior and after the switch date was explored. RESULTS Overall, 56,354 levothyroxine users were included in the study. Of these, 55,147 patients received at least one prescription for tablets (97.9%), 1867 pre-dosed ampoules (3.3%) and 1550 oral drops (2.8%). The proportion of levothyroxine users receiving oral liquid formulations slightly increased over time. Patients switching from tablets to oral liquid formulations showed a statistically significant reduction in the number of thyroid-stimulating hormone measurements after switching from tablets, especially in presence of drugs interacting with levothyroxine potentially altering its absorption. CONCLUSIONS Use of levothyroxine oral liquid formulations is increasing over time even though their use is still limited in a general population of Southern Italy. Our exploratory analysis showed that the frequency of thyroid-stimulating hormone measurement was reduced in patients switching from levothyroxine tablet to new formulations.
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Affiliation(s)
- Rosarita Ferrara
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
| | - Valentina Ientile
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
| | - Vincenzo Arcoraci
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmen Ferrajolo
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Carlo Piccinni
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gianluca Trifirò
- Unit of Clinical Pharmacology, Academic Hospital G. Martino, Messina, Italy.
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy.
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29
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Ribichini D, Fiorini G, Repaci A, Castelli V, Gatta L, Vaira D, Pasquali R. Tablet and oral liquid L-thyroxine formulation in the treatment of naïve hypothyroid patients with Helicobacter pylori infection. Endocrine 2017; 57:394-401. [PMID: 27848196 DOI: 10.1007/s12020-016-1167-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/01/2016] [Indexed: 12/20/2022]
Abstract
To compare the clinical efficacy of tablet and oral liquid L-thyroxine (LT4) formulation in naïve hypothyroid subjects with Helicobacter pylori infection. Forty-seven adult naïve hypothyroid subjects with dyspeptic symptoms were investigated with upper endoscopy and divided into: 28 patients with Helicobacter pylori infection (Group A); 15 patients without gastric alterations (group B); 4 patients with autoimmune gastritis were excluded from the study. Subjects were randomly treated with a same dose of LT4 tablet (TAB) or oral liquid formulation (SOL), for 9 months on group A and 6 months on group B. Helicobacter pylori infection was eradicated after 3 months of LT4 treatment. On group A, after 3 months (before Helicobacter pylori eradication), subjects treated with SOL showed a greater thyroid-stimulating hormone reduction (ΔTSH3-0: TAB = -4.1 ± 4.6 mU/L; SOL = -7.7 ± 2.5 mU/L; p = 0.029) and a greater homogeneity in the thyroid-stimulating hormone values (TSH3mo: TAB = 5.7 ± 4.9 mU/L; SOL = 4.1 ± 2.0 mU/L; p = 0.025), compared to LT4 tablet. At 9 months (after 6 months of Helicobacter pylori eradication) mean thyroid-stimulating hormone values were lower in subjects treated with LT4 tablet (TSH9mo: TAB = 1.8 ± 1.2 mU/L; SOL = 3.2 ± 1.7 mU/L; p = 0.006). On group B no difference were observed, at each time point, in the mean thyroid-stimulating hormone values and thyroid-stimulating hormone variations between two LT4 formulations. LT4 liquid formulation may produce a better clinical response compared to the tablet formulation in hypothyroid subjects with Helicobacter pylori infection.
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Affiliation(s)
- Danilo Ribichini
- Division of Endocrinology (DE), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy.
| | - Giulia Fiorini
- Division of Internal Medicine (IM), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Andrea Repaci
- Division of Endocrinology (DE), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Valentina Castelli
- Division of Internal Medicine (IM), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Luigi Gatta
- Gastroenterogy & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Dino Vaira
- Division of Internal Medicine (IM), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy
| | - Renato Pasquali
- Division of Endocrinology (DE), Department of Medical & Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126, Bologna, Italy.
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30
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Fallahi P, Ferrari SM, Marchi S, De Bortoli N, Ruffilli I, Antonelli A. Patients with lactose intolerance absorb liquid levothyroxine better than tablet levothyroxine. Endocrine 2017; 57:175-178. [PMID: 27577569 DOI: 10.1007/s12020-016-1090-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 08/11/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Santino Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Nicola De Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Ilaria Ruffilli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy.
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31
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Lombardi CP, Bocale R, Barini A, Barini A, D'Amore A, Boscherini M, Bellantone R. Comparative study between the effects of replacement therapy with liquid and tablet formulations of levothyroxine on mood states, self-perceived psychological well-being and thyroid hormone profile in recently thyroidectomized patients. Endocrine 2017; 55:51-59. [PMID: 27388589 DOI: 10.1007/s12020-016-1003-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/26/2016] [Indexed: 01/29/2023]
Abstract
Following thyroid surgery, levothyroxine therapy is used to replace deficient thyroid hormones and prevent postoperative thyroid hypofunction. We compared the effects of replacement therapy with either liquid or tablet formulation of levothyroxine on mood states, self-perceived mental well-being and thyroid hormone profile in recently thyroidectomized patients. Profile of mood states, General Heath Questionnaire 12-items and thyroid hormone profile were assessed in recently (5-7 days) thyroidectomized patients at baseline and 2 months after randomization to replacement therapy with either liquid (n = 77) or tablet (n = 78) formulation of levothyroxine. After 2 months under levothyroxine replacement treatment, significant improvements of Positive Affect Scale (p < 0.001) and Negative Affect Scale (p < 0.001) of Profile of mood states, as well as of General Heath Questionnaire 12-items (p < 0.001) were observed in the study population. However, there were greater variations observed in patients assigned to liquid levothyroxine formulation in comparison to those who were assigned to levothyroxine in the form of tablet (time × treatment interaction: Positive Affect Scale of Profile of mood states, p = 0.030; Negative Affect Scale of Profile of mood states, p < 0.0001; General Heath Questionnaire 12-items, p = 0.003). As expected, circulating TSH levels significantly decreased (p <0.001) while FT3 and FT4 levels significantly increased (p < 0.0001 for both) under levothyroxine replacement therapy. These changes were significantly greater in patients treated with liquid levothyroxine formulation (time × treatment interaction: TSH, p = 0.011; FT3, p = 0.016; FT4, p = 0.028). Our data indicate a greater efficacy of liquid formulation of levothyroxine in ameliorating mood states and self-perception of mental well-being and thyroid hormone profile after 2 months of replacement therapy in recently thyroidectomized patients.
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Affiliation(s)
- Celestino Pio Lombardi
- Division of Endocrine and Metabolic Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaella Bocale
- Division of Endocrine and Metabolic Surgery, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Angelina Barini
- Institute of Biochemistry and Clinical Biochemistry, Department of Laboratory Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Barini
- Institute of Biochemistry and Clinical Biochemistry, Department of Laboratory Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Annamaria D'Amore
- Division of Endocrine and Metabolic Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Boscherini
- Division of Endocrine and Metabolic Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rocco Bellantone
- Division of Endocrine and Metabolic Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
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Cappelli C, Pirola I, Gandossi E, Casella C, Lombardi D, Agosti B, Marini F, Delbarba A, Castellano M. TSH Variability of Patients Affected by Differentiated Thyroid Cancer Treated with Levothyroxine Liquid Solution or Tablet Form. Int J Endocrinol 2017; 2017:7053959. [PMID: 28572820 PMCID: PMC5441121 DOI: 10.1155/2017/7053959] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/13/2017] [Accepted: 03/22/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent guidelines from the American Thyroid Association (ATA) indicate that, in many patients affected by differentiated thyroid cancer (DTC), the serum TSH should be maintained between 0.1 and 0.5 mU/L. The purpose of this study was to evaluate the TSH variability of patients affected by DTC treated with liquid L-T4 formulation or in tablet form. PATIENTS AND METHODS Patients were eligible if (a) they were submitted to a total thyroidectomy and 131I remnant ablation for DTC in our institution and (b) they were classified low-risk patients according to ATA guidelines 2009. Patients were randomized (1 : 1) to receive treatment of hypothyroidism with liquid L-T4 or tablet form. The first check-up evaluation was made from 8 to 12 months after 131I remnant ablation. TSH values were established again after further 12 months. RESULTS A significant increase in TSH values (median) was observed in patients taking tablets [TSH (min-max): 0.28 (0.1-0.45) versus 0.34 (0.01-0.78) mIU/L, p = 0.041] as compared to those taking liquid formulation [TSH (min-max): 0.28 (0.1-0.47) versus 0.30 (0.1-0.55) mIU/L, p = 0.345]. CONCLUSIONS The use of L-T4 liquid formulation, as compared to that of tablets, resulted in a significantly higher number of DTC patients maintaining TSH values in range for the ATA risk score, reducing TSH variability over the time.
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Affiliation(s)
- Carlo Cappelli
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
- *Carlo Cappelli:
| | - Ilenia Pirola
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Elena Gandossi
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, 3rd Division of General Surgery, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Davide Lombardi
- Department of Otorhinolaryngology, Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Barbara Agosti
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Fiorella Marini
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Andrea Delbarba
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Maurizio Castellano
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
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Cellini M, Santaguida MG, Virili C, Capriello S, Brusca N, Gargano L, Centanni M. Hashimoto's Thyroiditis and Autoimmune Gastritis. Front Endocrinol (Lausanne) 2017; 8:92. [PMID: 28491051 PMCID: PMC5405068 DOI: 10.3389/fendo.2017.00092] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/07/2017] [Indexed: 12/16/2022] Open
Abstract
The term "thyrogastric syndrome" defines the association between autoimmune thyroid disease and chronic autoimmune gastritis (CAG), and it was first described in the early 1960s. More recently, this association has been included in polyglandular autoimmune syndrome type IIIb, in which autoimmune thyroiditis represents the pivotal disorder. Hashimoto's thyroiditis (HT) is the most frequent autoimmune disease, and it has been reported to be associated with gastric disorders in 10-40% of patients while about 40% of patients with autoimmune gastritis also present HT. Some intriguing similarities have been described about the pathogenic mechanism of these two disorders, involving a complex interaction among genetic, embryological, immunologic, and environmental factors. CAG is characterized by a partial or total disappearance of parietal cells implying the impairment of both hydrochloric acid and intrinsic factor production. The clinical outcome of this gastric damage is the occurrence of a hypochlorhydric-dependent iron-deficient anemia, followed by pernicious anemia concomitant with the progression to a severe gastric atrophy. Malabsorption of levothyroxine may occur as well. We have briefly summarized in this minireview the most recent achievements on this peculiar association of diseases that, in the last years, have been increasingly diagnosed.
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Affiliation(s)
- Miriam Cellini
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Silvia Capriello
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Nunzia Brusca
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Lucilla Gargano
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- *Correspondence: Marco Centanni,
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Fallahi P, Ferrari SM, Antonelli A. IN PATIENTS WITH SUBCLINICAL HYPOTHYROIDISM WHILE IN THERAPY WITH TABLET L-T4, THE LIQUID L-T4 FORMULATION IS MORE EFFECTIVE IN RESTORING EUTHYROIDISM. Endocr Pract 2016; 23:170-174. [PMID: 27849377 DOI: 10.4158/ep161545.or] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Levothyroxine (L-T4) is the standard therapy of hypothyroidism. Our purpose was to compare the effectiveness of the L-T4 liquid formulation with respect to L-T4 tablet in hypothyroid patients without malabsorption or drug interference. Twenty-one subjects with high thyroid-stimulating hormone (TSH) values under therapy with L-T4 tablets were switched to liquid L-T4 at the same dosage given 30 minutes before breakfast. RESULTS TSH values significantly declined 2 months after from the switch to liquid L-T4, reaching the normal range in most cases. In 15 (of the 21 patients) who switched back to tablets, TSH increased again to the hypothyroid range. Since the liquid L-T4 formulation resulted in better TSH level control, all patients were finally treated with the liquid L-T4, and TSH, free tri-iodothyronine and free thyroxine were evaluated again after 6 and 12 months, resulting in normal ranges in all subjects. CONCLUSIONS The change from tablets to liquid oral formulation normalized serum TSH levels, while switching back to tablets caused thyrotropin levels to worsen. These results suggest that the liquid L-T4 formulation is more effective than tablets in controlling TSH levels in hypothyroid patients in the absence of malabsorption, gastric disorders, or drug interference. ABBREVIATIONS BMI = body mass index FT3 = free tri-iodothyronine FT4 = free thyroxine L-T4 = levothyroxine PPIs = proton-pump inhibitors TSH = thyroid-stimulating hormone.
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Virili C, Trimboli P, Romanelli F, Centanni M. Liquid and softgel levothyroxine use in clinical practice: state of the art. Endocrine 2016; 54:3-14. [PMID: 27473098 DOI: 10.1007/s12020-016-1035-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/22/2016] [Indexed: 12/23/2022]
Abstract
Levothyroxine is recognized as the treatment of choice for hypothyroidism. So far, the tablet levothyroxine has been the formulation almost exclusively used, even though an optimal daily dose of levothyroxine has been unsuccessfully sought and a consensus not achieved. Due to progressive use of a more individually tailored levothyroxine dose, increasing evidence has instead displayed that many gastrointestinal disorders, polypharmacy, and food interference may raise the daily levothyroxine requirement. In recent years, alternative levothyroxine formulations have become available and have rapidly gained attention because of their pharmacokinetic properties. This study aims to provide an overview regarding the use of softgel capsule and/or liquid levothyroxine solution while performing a review of published studies about such topic. A comprehensive computer literature search of the PubMed/MEDLINE, Scopus, and Google Scholar databases has been conducted to find published articles on this topic. The search algorithm was based on the combinations of the following terms: "oral solution" or "soft gel" or "liquid", and "levothyroxine". The computer search resulted in 75 articles; through a critical review of such titles and abstracts and a screening of their references lists, the review included 18 original articles relating to 800 patients treated with alternative formulations. Despite some limits, the results obtained using softgel and liquid levothyroxine were consistent with each other. In selected categories of levothyroxine-treated patients (pediatric, suffering from hypo-achlorhydria, polypharmacy, undergone bariatric surgery, fed through enteric tube) these new formulations have shown promising attributes in improving a treatment that needs to be individually tailored.
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Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Francesco Romanelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.
- Endocrinology Unit, AUSL Latina, Latina, Italy.
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Fallahi P, Ferrari SM, Ruffilli I, Ragusa F, Biricotti M, Materazzi G, Miccoli P, Antonelli A. Advancements in the treatment of hypothyroidism with L-T4 liquid formulation or soft gel capsule: an update. Expert Opin Drug Deliv 2016; 14:647-655. [PMID: 27552635 DOI: 10.1080/17425247.2016.1227782] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The most recent advance concerning levothyroxine (L-T4) therapy is the development of novel oral formulations: the liquid preparation, and the soft gel capsule. Areas covered: This review evaluates the most recent clinical studies about these new formulations. The liquid formulation has been shown to overcome: the food and beverages intereference with L-T4 tablets absorption, caused by food or coffee at breakfast; malabsorption induced by the increased gastric pH, resulting from atrophic gastritis, or due to proton-pump inhibitors; and malabsorption after bariatric surgery. The use of liquid L-T4 has been studied also in pregnancy, newborns and infants, suggesting a better bioequivalence than tablets. Finally, liquid L-T4 is more active than tablets in the control of thyroid-stimulating hormone (TSH) in hypothyroid patients without malabsorption, drug interference, or gastric disorders, leading to a hypothesized higher absorption of liquid L-T4 also in these patients. Few studies have evaluated soft gel L-T4 with promising results in patients with malabsorption related to coffee or gastritis. Expert opinion: Liquid L-T4 (and soft gel capsules) are more active than the tablet L-T4 in the control of TSH in hypothyroid patients with gastric disorders, malabsorption, or drug interference, but also in patients without absorption disorders.
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Affiliation(s)
- Poupak Fallahi
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | | | - Ilaria Ruffilli
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Francesca Ragusa
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Marco Biricotti
- b Department of Surgical, Medical, Molecular Pathology and Critical Area , University of Pisa , Pisa , Italy
| | - Gabriele Materazzi
- b Department of Surgical, Medical, Molecular Pathology and Critical Area , University of Pisa , Pisa , Italy
| | - Paolo Miccoli
- b Department of Surgical, Medical, Molecular Pathology and Critical Area , University of Pisa , Pisa , Italy
| | - Alessandro Antonelli
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
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