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Caron P, Declèves X. The Use of Levothyroxine Absorption Tests in Clinical Practice. J Clin Endocrinol Metab 2023; 108:1875-1888. [PMID: 36916146 DOI: 10.1210/clinem/dgad132] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/10/2023] [Accepted: 03/06/2023] [Indexed: 03/15/2023]
Abstract
Although levothyroxine (LT4) is a widely prescribed drug, more than 30% of LT4-treated patients fail to achieve the recommended serum level of thyrotropin with a body weight-based dose of LT4. An LT4 absorption test (LT4AT) is part of the workup for confirming normal LT4 absorption or diagnosing malabsorption. We searched PubMed with the terms levothyrox*, L-T4, LT4, TT4, FT4, FT3, TT3, test, loading, uptake, absorp*, "absorb*, bioavailab*, bioequiv* malabsorb*, and pseudomalabsorb*. A total of 43 full-text publications were analyzed. The published procedures for LT4AT differ markedly in the test dose, formulation, test duration, frequency of blood collection, analyte (total thyroxine [TT4] or free thyroxine [FT4]), metric (absolute or relative peak or increment, or area under the curve) and the threshold for normal absorption. In a standardized LT4AT for routine use, the physician could advise the patient to not consume food, beverages, or medications the morning of the test; administer 1000 µg of LT4 in the patient's usual formulation as the test dose; ensure that the patient is supervised throughout the LT4AT; perform a 4-hour test, with hourly blood samples; assay FT4; and consider that normal LT4 absorption corresponds to an FT4 increment of more than 0.40 ng/dL (5.14 pmol/L) or a TT4 increment of more than 6 μg/dL (77.23 nmol/L) for a test dose of at least 300 µg, or a percentage TT4 absorption of more than 60%. If the test indicates abnormal LT4 absorption, the physician can increase the LT4 dose, change the formulation or administration route, and/or refer the patient to a gastroenterologist.
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Affiliation(s)
- Philippe Caron
- Service d'Endocrinologie, Maladies Métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, Hôpital Larrey, CHU de Toulouse, Toulouse F-31059, France
| | - Xavier Declèves
- Service de Biologie du Médicament-Toxicologie, Hôpital Cochin, AP-HP, Paris F-75006, France
- INSERM UMR-S1144, Université Paris Cité, Paris F-75006, France
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Selim S, Pathan M, Rahman M, Saifuddin M, Qureshi N, Mir A, Afsana F, Haq T, Kamrul-Hasan AM, Ashrafuzzaman S. Bangladesh endocrine society guidelines for the diagnosis and management of thyroid disease during pregnancy and the postpartum. BANGLADESH JOURNAL OF ENDOCRINOLOGY AND METABOLISM 2023. [DOI: 10.4103/bjem.bjem_2_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
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Santos Monteiro S, Santos TS, Lopes AM, Oliveira JC, Freitas C, Couto Carvalho A. Levothyroxine malabsorption or pseudomalabsorption? A question in the management of refractory hypothyroidism. Endocr Connect 2022; 11:EC-22-0355. [PMID: 36318199 PMCID: PMC9716372 DOI: 10.1530/ec-22-0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE The levothyroxine absorption test (LT4AT) is an important tool for distinguishing hypothyroidism due to malabsorption from 'pseudomalabsorption' conditions. Our aim was to review our institution's LT4AT results and assess its role in the management of patients with refractory hypothyroidism. METHODS We performed a retrospective study of all patients evaluated for refractory hypothyroidism who underwent LT4AT in our tertiary center between 2014 and 2020. Its results and the impact on thyroid function management during follow-up were assessed. RESULTS Ten female patients were included with a mean age of 40 years (min-max: 26-62). Mean weight was 72 kg (min-max: 43-88) and baseline LT4 dosage ranged from 2.5 to 5.3 µg/kg/day. The most common causes of hypothyroidism were postsurgical in 50% (n = 5) and autoimmune in 20% (n = 2). During LT4AT, normal LT4 absorption was found in all but one individual (mean FT4 increase of 231%, min-max: 85-668). The only patient with objective LT4 absorption impairment (maximal increase of 48% by hour 5) presented also Helicobacter pylori gastritis and prior history of 'intestinal surgery' during childhood. No adverse events were reported during any of the LT4ATs. During follow-up (median 11.5 months (IQR 23)), three patients obtained euthyroidism and six had improved their hypothyroidism state. CONCLUSIONS The LT4AT is an effective and safe way to assess refractory hypothyroidism and provides valuable information to distinguish LT4 malabsorption from 'pseudomalabsorption'. Our data suggest that most patients with suspicious LT4 malabsorption perform normally during LT4AT. This test provides relevant information for better management of patients with refractory hypothyroidism.
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Affiliation(s)
- Sílvia Santos Monteiro
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
- Correspondence should be addressed to S Santos Monteiro:
| | - Tiago Silva Santos
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
- Correspondence should be addressed to S Santos Monteiro:
| | - Ana Martins Lopes
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - José Carlos Oliveira
- Department of Clinical Pathology, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - Cláudia Freitas
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - André Couto Carvalho
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
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Elbasan O, Gogas Yavuz D. REFRACTORY HYPOTHYROIDISM TO LEVOTHYROXINE TREATMENT: FIVE CASES OF PSEUDOMALABSORPTION. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2020; 16:339-345. [PMID: 33363657 PMCID: PMC7748222 DOI: 10.4183/aeb.2020.339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CONTEXT A persistently elevated thyroid stimulating hormone (TSH) level is a common clinical problem in primary hypothyroidism patients treated with levothyroxine (LT4). "Pseudomalabsorption", which is characterized by poor adherence,should be considered in cases of refractory hypothyroidism after excluding other causes, such as malabsorption. OBJECTIVE We reviewed the features of the patients with persistently elevated TSH despite high-dose LT4 therapy. DESIGN Symptom evaluation, medications, comorbid diseases and physical examination features of five patients who applied to our outpatient clinic between 2016-2019 and diagnosed with LT4 pseudomalabsorption were retrospectively analyzed. SUBJECTS AND METHODS The LT4 loading test was performed with an oral dose of 1,000 µg LT4. Demographic parameters, BMI, thyroid function tests, laboratory parameters for malabsorption were recorded. RESULTS We observed at least two-fold increase of free thyroxine levels during the test, which was considered pseudomalabsorption. Euthyroidism was achieved in two patients by increasing the LT4 dosage and in one patient with a change in the preparation. TSH decreased significantly after being informed about compliance in one patient. Another one was given LT4 twice weekly, but TSH remained elevated because of nonadherence. CONCLUSION The LT4 loading/absorption test is a valuable tool to confirm the diagnosis of pseudomalabsorption. Informing patients, changing the preparation, increasing the dose, supervised intake of daily/weekly LT4 forms are treatment options for managing these cases.
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Affiliation(s)
- O. Elbasan
- Marmara University School of Medicine, Department of Endocrinology and Metabolism, Istanbul, Turkey
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Gonzales KM, Stan MN, Morris JC, Bernet V, Castro MR. The Levothyroxine Absorption Test: A Four-Year Experience (2015-2018) at The Mayo Clinic. Thyroid 2019; 29:1734-1742. [PMID: 31680654 DOI: 10.1089/thy.2019.0256] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Levothyroxine (LT4) is the mainstay of therapy for hypothyroidism. Yet, despite physician efforts at dose titration, some patients remain hypothyroid on LT4 doses in excess of weight-based calculations, a condition known as refractory hypothyroidism. The LT4 absorption test (LT4AT) has been proposed to have utility in these patients by enabling distinction of LT4 malabsorption from pseudomalabsorption, a condition of intentional nonadherence. Given its rare use in clinical practice, we reviewed our institution's experience with the LT4AT to assess its impact on management of refractory hypothyroidism. Methods: We reviewed the charts of 16 patients diagnosed with refractory hypothyroidism and who had completed the LT4AT between January 2015 to January 2019. The primary aim was to determine the utility of this test in distinguishing LT4 malabsorption from pseudomalabsorption. Secondary aims were to determine whether the results of this test impacted physicians' management decisions, as well as to report on clinical outcomes at follow-up. Our LT4AT is a six-hour test wherein patients receive a weight-based dose of LT4 followed by serial measurements of total thyroxine (TT4) and thyrotropin (TSH). Percentage absorption is calculated using the following formula, with normal absorption being ≥60%: [Formula: see text] Results: Percentage absorption was calculated in 13 of 16 patients due to lack of TT4 data for 3 patients. Absorption was impaired in one patient (% absorbed = 0), who had known causes of malabsorption. The remaining 12 patients had normal absorption by hour 4 of the test (% absorption 60-158) in conjunction with upward TT4 trends. Clinical follow-up ranged from 1 to 32 months (median 6.5 months), with 11 patients having follow-up data. Six of these had normal or suppressed TSH values at most recent follow-up, and four had improved but persistent TSH elevations. The one said patient with malabsorption improved with intravenous LT4. Conclusions: The LT4AT can provide valuable information for distinguishing malabsorption from pseudomalabsorption. Our findings support the combined use of calculated percentage absorptions with TT4 trends for at least a four-hour time frame when making determinations regarding absorption.
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Peynirci H, Taskiran B, Erturk E, Sisman P, Ersoy C. Is Parenteral Levothyroxine Therapy Safe in Intractable Hypothyroidism? J Natl Med Assoc 2018; 110:245-249. [PMID: 29778126 DOI: 10.1016/j.jnma.2017.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/07/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
Abstract
CASE A 32-year old woman was admitted to the hospital due to intractable hypothyroidism refractory to high dose of oral l-thyroxine therapy. She underwent total thyroidectomy and radioactive iodine therapy due to papillary thyroid cancer. After excluding poor adherence to therapy and malabsorption, levothyroxine absorption test was performed. No response was detected. Transient neurologic symptoms developed during the test. She developed 3 attacks consisting of neurologic symptoms during high dose administration. The patient was considered a case of isolated l-thyroxine malabsorption. She became euthyroid after intramuscular twice weekly l-thyroxine therapy. DISCUSSION There are a few case reports regarding isolated l-thyroxine. We report successful long term results of twice weekly administered intramuscular l-thyroxine therapy. We also draw attention to neurologic side effects of high dose l-thyroxine therapy.
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Affiliation(s)
- Hande Peynirci
- Kastamonu State Hospital, Department of Endocrinology, Turkey
| | - Bengur Taskiran
- Yunus Emre State Hospital, Department of Endocrinology, Turkey.
| | - Erdinc Erturk
- Uludag University, Department of Endocrinology and Metabolic Disorders, Turkey
| | - Pınar Sisman
- Uludag University, Department of Endocrinology and Metabolic Disorders, Turkey
| | - Canan Ersoy
- Uludag University, Department of Endocrinology and Metabolic Disorders, Turkey
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Centanni M, Benvenga S, Sachmechi I. Diagnosis and management of treatment-refractory hypothyroidism: an expert consensus report. J Endocrinol Invest 2017; 40:1289-1301. [PMID: 28695483 PMCID: PMC5680379 DOI: 10.1007/s40618-017-0706-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/01/2017] [Indexed: 12/17/2022]
Abstract
There is a frequently encountered subset of hypothyroid patients who are refractory to standard thyroid hormone replacement treatment and require unexpectedly high doses of levothyroxine. In addition to clinical situations where hypothyroid patients are non-compliant, or where there is the possibility of excipient-induced disease exacerbation (gluten/celiac disease), therapeutic failure may be due to impaired absorption of the administered drug. The common approach to managing patients with unusual thyroxine needs is to escalate the dose of levothyroxine until targeted TSH levels are achieved. This approach can increase the risk for prolonged exposure to supratherapeutic doses of levothyroxine, which increase the chances of adverse outcomes. Repeated adjustments of levothyroxine can also escalate the costs of treatment, as frequent office visits and laboratory tests are required to determine and maintain the desired dose. Clinicians should take a systematic approach to managing patients whom they suspect of having treatment-refractory hypothyroidism. This may include searching for, and adjusting, occult medical conditions and/or other factors that may affect the absorption of levothyroxine, before up-titrating the dose of traditional levothyroxine therapy. Depending on the underlying pathology, another approach that may be considered is to try alternative formulations of levothyroxine that are less susceptible to intolerance issues related to excipients, or, in some cases, to malabsorption. The early discovery of these factors via a thoughtful patient work-up may avoid unnecessary thyroid medication adjustments and their consequences for both patients and clinicians.
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Affiliation(s)
- M. Centanni
- Section of Endocrinology, Department of Medico-surgical Services and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - S. Benvenga
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women’s Endocrine Health, A.O.U. Policlinico G Martino, Messina, Italy
| | - I. Sachmechi
- Division of Endocrinology, Queens Hospital Center, Icahn School of Medicine, Jamaica, NY USA
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Oliver C, Grino M, Moatti Vacher-Coponat P, Morange I, Retornaz F. [Once weekly L-thyroxine treatment in non-compliance: A case report]. Rev Med Interne 2017; 38:766-768. [PMID: 28688760 DOI: 10.1016/j.revmed.2017.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/21/2017] [Accepted: 06/01/2017] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The non-adherence to substitutive treatment by L-thyroxine is the main cause of the discordance between high thyrotropin values and high doses of the drug. OBSERVATION In a 36-year-old patient with post-surgery hypothyroidism, thyrotropin values ranged between 100 and 400 mUI/L, although daily replacement therapy included 300 μg of L-thyroxine and 75 μg of L-triiodothyronine. The oral loading test with L-thyroxine was normal and thyrotropin serum level returned to normal values under weekly oral administration of 1000 μg L-thyroxine. CONCLUSION The strategy of non-adherence treatment in hypothyroidism is well defined with oral testing of L-thyroxine, followed by oral or parenteral weekly administration of the drug. The L-thyroxine oral test is the gold standard for diagnosis after eliminating of the other conventional causes: drug interactions or digestive malabsorption. L-thyroxine treatment should be discussed on a case-by-case basis, either daily under surveillance or once weekly oral or parenteral high dose.
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Affiliation(s)
- C Oliver
- Département de médecine gériatrique, centre gériatrique départemental, 176, avenue de Montolivet, 13012 Marseille, France; Institut Silvermed, 176, avenue de Montolivet, 13012 Marseille, France.
| | - M Grino
- Institut Silvermed, 176, avenue de Montolivet, 13012 Marseille, France
| | | | - I Morange
- Service d'endocrinologie, diabète et maladies métaboliques, 147, boulevard Baille, 13385 Marseille cedex 05, France
| | - F Retornaz
- Département de médecine gériatrique, centre gériatrique départemental, 176, avenue de Montolivet, 13012 Marseille, France; Institut Silvermed, 176, avenue de Montolivet, 13012 Marseille, France; Département de santé publique, EA3279 Aix-Marseille université, faculté de médecine, 27, boulevard Jean-Moulin, 13385 Marseille cedex 05, France; Département de médecine interne, hôpital européen, 6, rue Désirée-Clary, 13003 Marseille, France
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Van Wilder N, Bravenboer B, Herremans S, Vanderbruggen N, Velkeniers B. Pseudomalabsorption of Levothyroxine: A Challenge for the Endocrinologist in the Treatment of Hypothyroidism. Eur Thyroid J 2017; 6:52-56. [PMID: 28611949 PMCID: PMC5465681 DOI: 10.1159/000452489] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/14/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hypothyroidism due to non-compliance with levothyroxine therapy (pseudomalabsorption) is rare. The diagnosis is considered in patients with persistent severe hypothyroidism despite treatment with large doses of levothyroxine. Intestinal malabsorption, drug and dietary interference with levothyroxine absorption and nephrotic syndrome should be excluded. The diagnosis of pseudomalabsorption can be demonstrated by using "an oral 1,000 µg of levothyroxine test" showing a rapid decrease in thyroid-stimulating hormone and increase in thyroxine. There are however few data on the sensitivity and specificity of the test in large cohorts of hypothyroid patients. Treatment of pseudomalabsorption is controversial, with reports using parenteral, intramuscular or single weekly oral dosing of levothyroxine. CASES We report 3 patients who presented with persistent clinical and biochemical signs of hypothyroidism despite replacement therapy with high doses of levothyroxine. Pseudomalabsorption was diagnosed by a systematic approach, including prior exclusion of digestive, liver and kidney diseases. A peroral challenge test was positive in all cases. Patients denied non-compliance, and a psychiatric approach was elusive. Two of the patients were treated successfully with a single supervised weekly 1,000-µg administration of levothyroxine, while non-supervised weekly administration resulted in hypothyroidism confirming pseudomalabsorption. CONCLUSIONS Non-compliance with medical therapy should be considered in patients with treatment-refractory hypothyroidism. Supervised once weekly levothyroxine treatment is a safe and well-tolerated treatment option, obviating the need for parenteral administration of the drug. Apart from the medical treatment, there is also a need for psychiatric evaluation and care.
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Affiliation(s)
- Nancy Van Wilder
- Department of Endocrinology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Bert Bravenboer
- Department of Endocrinology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Sarah Herremans
- Department of Psychiatry, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nathalie Vanderbruggen
- Department of Psychiatry, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Balla M, Jhingan RM, Rubin DJ. Rapid Levothyroxine Absorption Testing: A Case Series of Nonadherent Patients. Int J Endocrinol Metab 2015; 13:e31051. [PMID: 26633982 PMCID: PMC4659333 DOI: 10.5812/ijem.31051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 07/28/2015] [Accepted: 08/22/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nonadherence to levothyroxine therapy is one cause of persistent hypothyroidism. To distinguish nonadherence from malabsorption, a levothyroxine absorption test is required. Typically, this test measures the serum free thyroxine (FT4) response to 1000 mcg of oral levothyroxine over 4 to 24 hours. Published data indicate that serum levels of FT4 are at or near their peak 2 hours after levothyroxine ingestion. OBJECTIVES We present the successful completion of 2-hour levothyroxine absorption testing in 3 patients as a retrospective case series. PATIENTS AND METHODS Serum levels of thyroid stimulating hormone (TSH), FT4, and free triiodothyronine (FT3) were drawn at 0, 60, and 120 minutes after 1000 mcg of oral levothyroxine. RESULTS In all 3 cases, baseline thyroid function indicated the patients had taken their prescribed doses of levothyroxine prior to the absorption test. Despite high baseline levels both FT3 and FT4 increased during each absorption test, providing more evidence of adequate levothyroxine absorption. Subsequently, patients achieved normal TSH levels on lower doses of levothyroxine. CONCLUSIONS Levothyroxine absorption testing over 2 hours may offer a more rapid alternative to the commonly used longer protocols to rule out malabsorption. Scheduling a levothyroxine absorption test may induce some patients to start adhering to levothyroxine therapy.
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Affiliation(s)
| | | | - Daniel J. Rubin
- School of Medicine, Temple University, Philadelphia, USA
- Corresponding author: Daniel J. Rubin, School of Medicine, Temple University, Philadelphia, USA. Tel: +1-2157074746, Fax: +1-2157075599, E-mail:
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Abstract
Thyroid hormone deficiency can have important repercussions. Treatment with thyroid hormone in replacement doses is essential in patients with hypothyroidism. In this review, we critically discuss the thyroid hormone formulations that are available and approaches to correct replacement therapy with thyroid hormone in primary and central hypothyroidism in different periods of life such as pregnancy, birth, infancy, childhood, and adolescence as well as in adult patients, the elderly, and in patients with comorbidities. Despite the frequent and long term use of l-T4, several studies have documented frequent under- and overtreatment during replacement therapy in hypothyroid patients. We assess the factors determining l-T4 requirements (sex, age, gender, menstrual status, body weight, and lean body mass), the major causes of failure to achieve optimal serum TSH levels in undertreated patients (poor patient compliance, timing of l-T4 administration, interferences with absorption, gastrointestinal diseases, and drugs), and the adverse consequences of unintentional TSH suppression in overtreated patients. Opinions differ regarding the treatment of mild thyroid hormone deficiency, and we examine the recent evidence favoring treatment of this condition. New data suggesting that combined therapy with T3 and T4 could be indicated in some patients with hypothyroidism are assessed, and the indications for TSH suppression with l-T4 in patients with euthyroid multinodular goiter and in those with differentiated thyroid cancer are reviewed. Lastly, we address the potential use of thyroid hormones or their analogs in obese patients and in severe cardiac diseases, dyslipidemia, and nonthyroidal illnesses.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery (B.B.), University of Naples Federico II, 80131 Naples, Italy; and Washington Hospital Center (L.W.), Washington, D.C. 20010
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12
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Groener JB, Lehnhoff D, Piel D, Nawroth PP, Schanz J, Rudofsky G. Subcutaneous application of levothyroxine as successful treatment option in a patient with malabsorption. AMERICAN JOURNAL OF CASE REPORTS 2013; 14:48-51. [PMID: 23569562 PMCID: PMC3614336 DOI: 10.12659/ajcr.883788] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 02/08/2013] [Indexed: 12/03/2022]
Abstract
Background: Hypothyroidism can usually be treated effectively by oral levothyroxine supplementation. There are, however, some rare circumstances, when oral levothyroxine application is not sufficient, for example malabsorption, interactions with food or other medications, or various gastrointestinal diseases. Case Report: We present a 42 year old woman with refractory and severe symptomatic hypothyroidism after subtotal thyroidectomy in spite of high dose oral levothyroxine supplementation. By stepwise increasing oral levothyroxine dosage up to 2200 micrograms plus 80 micrograms of thyronine, no sufficient substitution could be achieved. After suspicion of enteral malabsorption due to a pathological D-Xylose-test, subcutaneous levothyroxine supplementation was started. Finally, a sustained euthyroid state could be achieved. Conclusions: For selected patients who do not respond to oral treatment subcutaneous application of levothyroxine can be a suitable and effective therapy.
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Affiliation(s)
- Jan B Groener
- Department Medicine, Endocrinology and Clinical Chemistry, University of Heidelberg, Heidelberg, Germany
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13
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Damle N, Bal C, Soundararajan R, Kumar P, Durgapal P. A curious case of refractory hypothyroidism due to selective malabsorption of oral thyroxine. Indian J Endocrinol Metab 2012; 16:466-468. [PMID: 22629524 PMCID: PMC3354865 DOI: 10.4103/2230-8210.95716] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
There are very few cases in the literature in which refractory persistent hypothyroidism responded only to parenteral doses of levothyroxine and no evidence of any malabsorptive disorder could be identified. Here, we present a rare case of a 35-year-old woman with refractory hypothyroidism who responded only to intravenous doses of levothyroxine. We also discuss possible causes for the same.
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Affiliation(s)
- Nishikant Damle
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ramya Soundararajan
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Durgapal
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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Elwadeh I, Elmazouni Z, Kabbaj F, Iraqi H, Gharbi MH, Chraïbi A. [A persistent hypothyroidism]. Presse Med 2012; 41:675-7. [PMID: 22405604 DOI: 10.1016/j.lpm.2012.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 10/20/2011] [Accepted: 01/19/2012] [Indexed: 11/30/2022] Open
Affiliation(s)
- Imane Elwadeh
- CHU, service d'endocrinologie diabétologie, maladie métaboliques et nutrition, Rabat, Maroc.
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Affiliation(s)
- Abdulaziz Ramadhan
- Division of Endocrinology and Metabolism, Department of Medicine, Jewish General Hospital, McGill University, Montréal, Que
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Srinivas V, Oyibo SO. Levothyroxine pseudomalabsorption and thyroxine absorption testing with use of high-dose levothyroxine: case report and discussion. Endocr Pract 2011; 16:1012-5. [PMID: 21041167 DOI: 10.4158/ep10224.cr] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the case of a 55-year-old woman who had been prescribed a daily dose of 1,000 μg of levothyroxine for the treatment of hypothyroidism but still had severe biochemical hypothyroidism and to discuss the use of thyroxine absorption testing to diagnose pseudomalabsorption. METHODS The patient was admitted to the hospital for supervised thyroxine absorption testing. Baseline thyroid function tests were performed. An oral dose of 1,000 μg of levothyroxine was administered while the patient had an empty stomach, and thyroid function tests were repeated at 2, 4, and 6 hours after administration. She was also given all her prescribed antihypertensive medications, and the blood pressure (which had been persistently high) was measured every 2 hours. RESULTS After administration of 1,000 μg of levothyroxine, a rapid improvement in the results of her thyroid function tests was noted. Similarly, a rapid decrease in her blood pressure was observed after supervised administration of her antihypertensive medications. A diagnosis of nonadherence to treatment (pseudomalabsorption of levothyroxine) was made. After reduction of her levothyroxine dosage to 100 μg daily, results of thyroid function tests showed improvement. The doses of her antihypertensive medications were likewise altered. CONCLUSION We suggest that patients who are receiving doses of levothyroxine of more than 2 μg/kg of body weight, with persistently increased thyroid-stimulating hormone levels, should undergo testing for malabsorption and pseudomalabsorption of levothyroxine. Thyroxine absorption testing with use of high-dose levothyroxine is useful in diagnosing pseudomalabsorption but needs formal evaluation and validation.
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Affiliation(s)
- Vidya Srinivas
- Department of Diabetes and Endocrinology, Peterborough and Stamford National Health Service Trust, Edith Cavell Hospital, Peterborough, UK
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Livadariu E, Valdes-Socin H, Burlacu MC, Vulpoi C, Daly AF, Beckers A. Pseudomalabsorption of thyroid hormones: case report and review of the literature. ANNALES D'ENDOCRINOLOGIE 2007; 68:460-3. [DOI: 10.1016/j.ando.2007.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 08/28/2007] [Accepted: 09/05/2007] [Indexed: 10/22/2022]
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Rangan S, Tahrani AA, Macleod AF, Moulik PK. Once weekly thyroxine treatment as a strategy to treat non-compliance. Postgrad Med J 2007; 83:e3. [PMID: 17916865 DOI: 10.1136/pgmj.2007.060244] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Hypothyroidism is a common disorder, which is mainly treated in primary rather than secondary care. Once daily thyroxine replacement restores euthyroidism in most patients; some patients, however, remain hypothyroid despite adequate thyroxine replacement. Non-compliance is the most common cause of lack of response to thyroxine treatment. We describe two cases of primary hypothyroidism in which daily thyroxine treatment did not restore biochemical euthyroidism but once weekly thyroxine treatment was successful. In addition we review the evidence and discuss the differential diagnosis of lack of response to thyroxine treatment. Once weekly thyroxine treatment can be a safe, well-tolerated, and effective therapy for patients with non-compliance.
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Affiliation(s)
- S Rangan
- Department of Diabetes and Endocrinology, Royal Shrewsbury Hospital, Shrewsbury, UK
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Tönjes A, Karger S, Koch CA, Paschke R, Tannapfel A, Stumvoll M, Fuhrer D. Impaired enteral levothyroxine absorption in hypothyroidism refractory to oral therapy after thyroid ablation for papillary thyroid cancer: case report and kinetic studies. Thyroid 2006; 16:1047-51. [PMID: 17042692 DOI: 10.1089/thy.2006.16.1047] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We present a 49-year-old patient suffering from hypothyroidism (thyrotropin [TSH], 20-80 mU/L) refractory to oral levothyroxine (LT(4)) substitution after total thyroidectomy and radioiodine therapy for papillary thyroid cancer. Extensive, repetitive work-up excluded small bowel, liver, and pancreatic disease and drug interactions. Triiodothyronine/thyroxine (T(3)/T(4)) antibodies were negative and reverse T(3) levels were normal. Supervised absorption tests of several LT(4) preparations in increasing dosages (250-1500 microg/d) confirmed an insufficient rise in serum T(4) levels following oral drug administration. Thus, intravenous LT(4) application (5 times per week) was commenced to restore at least normal range TSH levels. Repetition of absorption tests 1 year later, after a documented period of more than 3 months of stable euthyroidism, showed a considerable improvement of intestinal LT(4) uptake. Subsequently, the patient was managed on large doses of oral LT(4) (1500-2100 microg/d) alone, but this was found to be insufficient so that continuous intravenous LT(4) was administered via a morphine pump device to ultimately achieve stable euthyroidism. Of note, at 4-year follow-up there was no evidence of recurrent or metastasized papillary thyroid cancer. The reason for the disturbed intestinal LT(4) absorption in this patient remains unresolved. However, we would like to suggest the possibility of a specific intestinal uptake deficit, which will only become apparent in the case of previous thyroid ablation.
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Affiliation(s)
- Anke Tönjes
- Medizinische Klinik III, Universität Leipzig, Leipzig, Germany
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Abstract
Uma mulher de 49 anos, em tratamento de hipotireoidismo com levotiroxina, após diagnóstico de tireoidite de Hashimoto e tireoidectomia total para bócio multinodular atóxico, foi avaliada devido a hipotireoidismo persistente apesar do uso de altas doses de levotiroxina (600µg/dia). Clinicamente, a paciente apresentava sinais e sintomas de hipotireoidismo, e os exames laboratoriais mostravam tiroxina livre de 0,20ng/dL; hormônio tireoestimulante de 351µUI/mL; triiodotironina total de 27ng/dL. Foi confirmada a não aderência ao tratamento e considerados os diagnósticos de sindrome de Munchausen e transtorno factício, levando ao quadro de pseudomalabsorção de levotiroxina.
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Affiliation(s)
- William Pedrosa
- Instituto Mineiro de Endocrinologia, Rua Tomé de Souza 830, 30140-131 Belo Horizonte, MG.
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Kubota S, Fukata S, Matsuzuka F, Kuma K, Miyauchi A. Successful management of a patient with pseudomalabsorption of levothyroxine. Int J Psychiatry Med 2004; 33:183-8. [PMID: 12968832 DOI: 10.2190/0ywr-8drv-hhp4-ue2e] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pseudomalabsorption of levothyroxine is a factitious disorder. Despite the administration of large doses of levothyroxine, patients with this disorder show hypothyroidism due to noncompliance. These patients are different from the patients with simple noncompliance in that they have a psychiatric disorder. Because their psychological identities are rooted in their being a "patient," they go to great lengths to become and stay a patient. We report a case of pseudomalabsorption of levothyroxine. A 28-year-old woman was referred to us because she was believed to have unusual malabsorption of levothyroxine. We diagnosed the patient as having this factitious disorder, and as treatment, had her visit a hospital twice a week to take medicine under the observation of nurses so that she would not lose her status as a "patient." Her serum free T4 level normalized during three years with twice weekly dosing of thyroxine after hospital discharge. Our approach could be a therapeutic choice for this intractable disorder. To our knowledge, this is the first report of successful management of a patient with pseudomal-absorption of levothyroxine.
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Abstract
The comparative bioavailability of oral doses of levothyroxine (LT(4)) formulation taken as tablets, after being crushed, or chewed before swallowing has not been well studied. Three patients with hypothyroidism who showed persistent elevation of serum thyrotropin (TSH) despite taking 200, 150, and 125 microg of LT(4) tablets per day are presented. They did not show signs and symptoms of gastrointestinal illness that could interfere with the absorption of LT(4) nor history of such a condition. They did not concurrently take medications known to affect the absorption of LT(4) from the gut. Their serum TSH levels normalized when the tablets were taken after being pulverized. The difference appeared attributable to the slow dissolution of the tablets in the gut of these patients.
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