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Oteri V, Volpe S, Lopes M, Sceusa G, Tumminia A, Belfiore A, Frasca F, Gullo D. Therapeutic efficacy and patient compliance of levothyroxine liquid and softgel formulations taken with meals: a systematic review. Endocrine 2024:10.1007/s12020-024-04016-7. [PMID: 39215906 DOI: 10.1007/s12020-024-04016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Levothyroxine (L-T4) is the drug of choice for treating primary hypothyroidism. L-T4 tablets should be taken at least 30 min before breakfast. Several studies have suggested that serum thyroid profile is not affected by concomitant intake of liquid/softgel L-T4 with meals. Our aim is to review the evidence on therapeutic efficacy and patient compliance with the liquid and softgel formulation of L-T4 taken with meals, also compared with the standard tablet therapy regimen, in hypothyroid patients. METHODS We performed a systematic review of literature by searching PubMed, Embase, and Cochrane Library databases. PRISMA guidelines were applied, and the risk of bias of the included studies was assessed using the RoB 2 and ROBINS tools. The methodological quality was assessed following the GRADE criteria. RESULTS We included 13 studies, accounting for a total of 1697 patients. The timing of liquid L-T4 intake from breakfast did not affect the therapeutic efficacy of the treatment. No significant differences in the absorption of liquid L-T4 were found when administered together with different foods, beverages, drugs, or other supplements. TSH levels are not influenced by taking softgel L-T4 at breakfast; the efficacy of softgel and liquid formulation is similar when they are taken with a meal, but superior to that of tablet formulation. Shifting from L-T4 tablets taken 30 min before breakfast to liquid/softgel formulation taken with the meal improved medication adherence and perceived quality of life of patients. CONCLUSION Liquid and softgel formulation of L-T4 can be taken at breakfast or close to meals, without losing therapeutic efficacy. These formulations could also improve patient compliance and quality of life compared to L-T4 tablet therapy taken 30 min before breakfast.
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Affiliation(s)
- Vittorio Oteri
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy.
| | - Salvatore Volpe
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Mariarita Lopes
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Giulia Sceusa
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Andrea Tumminia
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Antonino Belfiore
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Francesco Frasca
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Damiano Gullo
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
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Song Y, Tao M, Wang L. Effects of low-dose levothyroxine on atrial natriuretic peptide and c-type natriuretic peptide in children with neonatal hypothyroidism. Am J Transl Res 2023; 15:6199-6207. [PMID: 37969195 PMCID: PMC10641350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/06/2022] [Indexed: 11/17/2023]
Abstract
OBJECTIVE This study was designed to explore the effects of low-dose levothyroxine (LT4) on levels of atrial natriuretic peptide (ANP) and c-type natriuretic peptide (CNP) in neonates with hypothyroidism (NH). METHODS In this retrospective study, a total of 90 cases of NH screened out and confirmed by the First Affiliated Hospital of Zhejiang Chinese Medical University from October 2014 to February 2018 were selected as a study group. 80 healthy children who underwent physical examination during the same time period were enrolled as controls. Before and after treatment with LT4, the changes in the levels of serum thyroid stimulating hormone (TSH) and free thyroxine (FT4) were observed, and the changes in the levels of ANP and CNP and their relationships to clinical efficacy were evaluated. Additionally, the growth and development of body and the scores of the China-Wechsler Younger Children Scale of Intelligence (C-WYCSI) were compared before and after the treatment, and the changes in the cardiac functions of children in the study group were evaluated. Independent risk factors for mental abnormality after treatment were analyzed by logistic regression. RESULTS After treatment, TSH levels in patients declined, while the levels of T3, T4, free triiodothyronine (FT3), and FT4 increased, without significant differences between groups. After treatment, ANP levels in patients increased but CNP levels decreased. ANP levels were negatively correlated with clinical efficacy, but CNP levels were positively correlated with it. Ultrasonic cardiography showed the improved cardiac functions. After treatment, the growth and development of body and the C-WYCSI scores increased compared to those before treatment. First visit date, T3, FT4, TSH were independent risk factors for mental disorders in children. CONCLUSION For children with NH, low-dose LT4 can correct the level of thyroid function, promote physical and mental development, and improve the levels of ANP and CNP.
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Affiliation(s)
- Yanling Song
- Department of Paediatrics, The First Affiliated Hospital of Zhejiang Chinese Medical University Hangzhou, Zhejiang, China
| | - Min Tao
- Department of Paediatrics, The First Affiliated Hospital of Zhejiang Chinese Medical University Hangzhou, Zhejiang, China
| | - Liling Wang
- Department of Paediatrics, The First Affiliated Hospital of Zhejiang Chinese Medical University Hangzhou, Zhejiang, China
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Al Kindi RM, Al Riyami RA, Juma SY, Al Kiyumi MI. Adherence to levothyroxine treatment among patients with hypothyroidism in Oman: a national cross-sectional study. Curr Med Res Opin 2023; 39:1313-1319. [PMID: 37605332 DOI: 10.1080/03007995.2023.2250256] [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: 07/06/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Hormone replacement therapy with levothyroxine is considered the treatment of choice for hypothyroidism; however, non-adherence is a major contributor to poor treatment outcomes. This study aimed to evaluate levels of drug adherence (DA) to levothyroxine therapy among Omani adults with hypothyroidism and to explore related sociodemographic and clinical factors. METHODS A national, multi-center, cross-sectional survey was carried out from August to December 2021 at 18 primary healthcare centers across all governorates of Oman. A total of 415 Omani adults were recruited. Data were collected using a pre-tested, Arabic-language questionnaire completed by trained researchers during face-to-face interviews with the participants. Level of DA was determined using the 8-item Morisky Medication Adherence Scale (MMAS-8). RESULTS A total of 400 Omani adults participated in the study (response rate: 96.4%). The mean age was 41.9 ± 12.4 years old (range: 18-78 years) and 90.3% were female. According to their MMAS-8 scores, 157 (39.2%), 139 (34.8%), and 104 (26.0%) participants demonstrated low, medium, and high DA, respectively. No significant correlations were observed between level of DA and any sociodemographic or clinical characteristics, including age, gender, education, duration of treatment, and family history of thyroid disease (p > 0.050). CONCLUSIONS Only a quarter of Omani patients with hypothyroidism reported high levels of adherence to levothyroxine treatment, likely as a result of lack of awareness of the disease and the importance of maintaining an euthyroid state. Further studies using more objective measures of DA are recommended to determine correlates of non-compliance to levothyroxine therapy among Omani patients.
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Affiliation(s)
- Rahma Mohamed Al Kindi
- Department of Family Medicine and Public Health, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - Maryam Issa Al Kiyumi
- Department of Family Medicine and Public Health, Sultan Qaboos University Hospital, Muscat, Oman
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Mehuys E, Lapauw B, T'Sjoen G, Christiaens T, De Sutter A, Steurbaut S, Van Tongelen I, Boussery K. Investigating Levothyroxine Use and Its Association with Thyroid Health in Patients with Hypothyroidism: A Community Pharmacy Study. Thyroid 2023; 33:918-926. [PMID: 37184683 DOI: 10.1089/thy.2023.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background: To gain maximum therapeutic effect while minimizing side effects, it is imperative for patients with hypothyroidism to use their levothyroxine (LT4) correctly, such as adhering to the prescribed regimen. Little is currently known about how patients actually use LT4 in real life. We investigated the use of LT4, as well as the thyroid health (thyrotropin [TSH] and health-related quality of life [HR-QoL]), and evaluated if proper LT4 use is associated with better thyroid health. Methods: A cross-sectional observational study was conducted in a Belgian community sample of adults using LT4 for hypothyroidism since ≥2 years. Participants completed a self-administered questionnaire on patient characteristics, self-reported adherence to LT4, timing of intake, and co-medication. They also completed the thyroid-specific patient-reported outcome (ThyPRO-39) questionnaire, measuring the HR-QoL. Pharmacy dispensing data were used to calculate the medication possession ratio (MPR). Results: We included 856 participants (mean age 61.4 ± 14.3 years, 86% [740/856] females). Approximately one in four participants (138/563) had out-of-range TSH levels. Generally, ThyPRO-39 scores were in the lower part of the range (indicating better HR-QoL), with the scales "emotional susceptibility" and "tiredness" showing the worst scores. Approximately 28% (178/632) of the participants were classified as non-adherent (MPR <80%), corresponding to at least 73 cumulative days per year without LT4 intake. Twenty-five percent (212/854) of participants self-reported non-adherence, with unintentional non-adherence (forgetfulness) most frequently reported (21.9%, 187/854). Only 39% (329/836) of participants complied with the recommendation of ingesting LT4 ≥ 30 minutes before eating. Additionally, 7% (58/856) of participants concurrently used molecules that bind to LT4, without applying the recommended dosing interval. There was no significant correlation between LT4 usage (adherence, timing of intake, and interaction with complex forming drugs) and TSH or HR-QoL. Conclusions: We found that many participants with hypothyroidism did not use their LT4 as effectively as possible, particularly with respect to timing of administration. However, the participants' HR-QoL seemed largely satisfactory, and there was no significant correlation between correctly using LT4 and thyroid health.
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Affiliation(s)
- Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Bruno Lapauw
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Thierry Christiaens
- Unit of Clinical Pharmacology, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Centre for Family Medicine, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research Group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Jette, Belgium
| | - Inge Van Tongelen
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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Alofi RM, Alrohaily LS, Jan RA, Alsaedi SL, Mahrous FA, Alreefi MM. Adherence to Levothyroxine Treatment Among Patients With Hypothyroidism in Madinah, Saudi Arabia: A Cross-Sectional Study. Cureus 2023; 15:e40686. [PMID: 37485132 PMCID: PMC10358293 DOI: 10.7759/cureus.40686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Hypothyroidism is one of the most prevalent chronic diseases worldwide. The key factor for a good clinical outcome for hypothyroidism is medication adherence, as the mainstay treatment of hypothyroidism is lifelong hormonal replacement therapy, Levothyroxine (LT4). Poor adherence to LT4 is not only linked to great healthcare costs but also to significant economic burdens. OBJECTIVES The aim of this study is to assess the medication adherence of patients on LT4 treatment in the Madinah region and its association with socio-demographic characteristics, participants' experience with hypothyroidism and taking LT4, and Morisky Medication Adherence Scale 8-Item (MMAS-8). METHODOLOGY A cross-sectional study was conducted on 420 hypothyroidism patients on LT4 for at least three months in the Madinah region using a self-administered electronic form. The variables in the questionnaire included socio-demographic characteristics, participants' experience with hypothyroidism and taking LT4, and MMAS-8. RESULTS This study included a total of 420 patients with 81% being females, 52.1% aged 40 years and above, and 91% living in Madinah City. The study shows an overall poor adherence rate toward taking LT4, where the vast majority, 66.7% of the participants, had a low adherence level toward taking LT4, 23.3% had a moderate adherence level, and only 10% had a high adherence level. Results of the multivariate logistic regression showed that the following factors predicted a higher rate of a high level of adherence toward taking levothyroxine, being 50-59 years old, being 60 years or older, and following up regularly in the clinic. CONCLUSION Patients with hypothyroidism showed low adherence to LT4.
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Affiliation(s)
- Rasha M Alofi
- Family Medicine, Ministry of Health in Saudi Arabia, Madinah, SAU
| | | | - Raghad A Jan
- College of Medicine, Taibah University, Madinah, SAU
| | | | - Fai A Mahrous
- College of Medicine, Taibah University, Madinah, SAU
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Yavuz DG, Yazan CD, Hekimsoy Z, Aydin K, Gokkaya N, Ersoy C, Akalın A, Topaloglu O, Aydogan BI, Dilekci ENA, Alphan Uc Z, Cansu GB, Ozsari L, Iyidir OT, Olgun ME, Keskin L, Mert M, Can B, Gungor K, Galip T, Cantürk Z, Elbuken G, Pekkolay Z, Kutbay NO, Yorulmaz G, Kalkan AT, Unsal YA, Yay A, Karagun B, Bozkur E. Assesment of attainment of recommended TSH levels and levothyroxine compliance in differentiated thyroid cancer patients. Clin Endocrinol (Oxf) 2022; 97:833-840. [PMID: 35639050 DOI: 10.1111/cen.14787] [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: 01/10/2022] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Thyroid-stimulating hormone (TSH) suppression treatment can induce signs and symptoms of hyperthyroidism and hypothyroidism due to inappropriate treatment or poor compliance to the treatment. The current study aimed to investigate TSH levels, frequency of being on target TSH, adherence to levothyroxine (LT4) suppression treatment in differentiated thyroid cancer (DTC) patients after surgery in a multicentric setting. DESIGN AND PATIENTS This multicentric cross-sectional study was conducted at 21 medical centres from 12 cities in Turkey. DTC patients followed at least one year in the same center included in the study. Clinical data, serum TSH, free thyroxine (FT4), thyroglobulin (Tg) and anti-Tg levels were recorded during the most recent visit. Body mass index, systolic and diastolic blood pressures, pulse rate were measured. LT4 doses were recorded and doses per kilogram of bodyweight were calculated. Pill ingestion habits recorded and adherence to the therapy were evaluated using the Morisky Medication Adherence Scale and categorized as good, moderate or poor compliant based on their scores. Risk stratification forpredicting the disease persistance and/or reccurence was assessed using the American Joint Committee on Cancer-7th edition thyroid cancer staging calculator. TSH serum concentrations were classified as severe suppression (TSH < 0.01 mU/L), moderate suppression (TSH: 0.01-0.1 mU/L), mild suppression (TSHL 0.1-0.5 mU/L), euthyroid (TSH: 0.5-4 mU/L) and hypothyroid (TSH > 4 mU/L). TSH levels can also be classified as on being on target, under the target, or beyond over the target, according to the American Thyroid Association recommendations. RESULTS A group of 1125 patients (F/M: 941/184, 50.7 ± 11.7 years) were included in the study. The mean LT4 daily dosage was 132.4 ± 39.6 mcg/day. TSH levels showed severe suppression in 99 (%8.8) patients, moderate suppression in 277 (%24.6) patients and mild suppression in 315 (%28) patients and euthyroid range in 332 (%29.5) patients and hypothyroid range in 97 (8.6%). TSH levels were in target in 29.2% of the patients 20.4% of the patients were undertreated, 50.4% overtreated. The daily LT4 dose and LT4 dose/kg were significantly higher in the severe suppression group (p < .001, p < .001). According to the Morisky scale, 564 patients (50.1%) were good compliant, 368 patients (32.7%) were moderate compliant, and 193 patients (17.1%) were noncompliant. Patients with poor compliance need a higher dose of LT4 compared to the good compliance group (p < .001). TSH levels of patients with good compliance were 0.67 ± 1.96 mU/L and TSH with poor compliance was 2.74 ± 7.47 mU/L (p < .001). TSH levels were similar in patients on fixed and alternating dosages. CONCLUSION In 29.2% of the DTC patients, serum TSH levels were at target levels. Remaining of the study group have TSH levels under or over treatment range, exposing the patient to medication side effects. Majorty of the study group 82.8% have good or moderate adherence to LT4 therapy. Reaching TSH targets requires simplified and applicable guidelines and following the guideline recommendations.
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Affiliation(s)
- Dilek Gogas Yavuz
- Department of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Turkey
| | - Ceyda D Yazan
- Department of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Turkey
| | - Zeliha Hekimsoy
- Department of Endocrinology and Metabolism, Celal Bayar University, Manisa, Turkey
| | - Kadriye Aydin
- Department of Endocrinology and Metabolism, Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Naile Gokkaya
- Department of Endocrinology and Metabolism, Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Canan Ersoy
- Department of Endocrinology and Metabolism, Uludag University School of Medicine, Bursa, Turkey
| | - Aysen Akalın
- Department of Endocrinology and Metabolism, Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Omercan Topaloglu
- Department of Endocrinology and Metabolism, Kocaeli Derince Research and Training Hospital, Kocaeli, Turkey
| | - Berna I Aydogan
- Department of Endocrinology and Metabolism, Batman Research and Training Hospital, Batman, Turkey
| | - Esra N A Dilekci
- Department of Endocrinology and Metabolism, Bolu Abant Izzet Baysal University School of Medicine, Bolu, Turkey
| | - Ziynet Alphan Uc
- Department of Endocrinology and Metabolism, Usak Research and Training Hospital, Usak, Turkey
| | - Guven B Cansu
- Department of Endocrinology and Metabolism, Kutahya Health Sciences University, Kütahya, Turkey
| | - Levent Ozsari
- Department of Endocrinology and Metabolism, Sultan Abdulhamid Han Research and Training Hospital, Istanbul, Turkey
| | - Ozlem T Iyidir
- Department of Endocrinology and Metabolism, Baskent University School of Medicine, Ankara, Turkey
| | - Mehtap E Olgun
- Department of Endocrinology and Metabolism, Cukurova University School of Medicine, Adana, Turkey
| | - Lezzan Keskin
- Department of Endocrinology and Metabolism, Malatya Research and Training Hospital, Malatya, Turkey
| | - Meral Mert
- Department of Endocrinology and Metabolism, Bakirkoy Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Bulent Can
- Department of Endocrinology and Metabolism, Medeniyet University School of Medicine, Istanbul, Turkey
| | - Kaan Gungor
- Department of Endocrinology and Metabolism, Medeniyet University School of Medicine, Istanbul, Turkey
| | - Tayfun Galip
- Department of Endocrinology and Metabolism, Medical Park Pendik Hospital, Istanbul, Turkey
| | - Zeynep Cantürk
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Gulsah Elbuken
- Department of Endocrinology and Metabolism, School of Medicine, Namik Kemal University, Tekirdag, Turkey
| | - Zafer Pekkolay
- Department of Endocrinology and Metabolism, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Nilufer O Kutbay
- Department of Endocrinology and Metabolism, Celal Bayar University, Manisa, Turkey
| | - Goknur Yorulmaz
- Department of Endocrinology and Metabolism, Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Ahmet T Kalkan
- Department of Endocrinology and Metabolism, Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Yasemin A Unsal
- Department of Endocrinology and Metabolism, Uludag University School of Medicine, Bursa, Turkey
| | - Adnan Yay
- Department of Endocrinology and Metabolism, Sultan Abdulhamid Han Research and Training Hospital, Istanbul, Turkey
| | - Baris Karagun
- Department of Endocrinology and Metabolism, Cukurova University School of Medicine, Adana, Turkey
| | - Evin Bozkur
- Department of Endocrinology and Metabolism, Bakirkoy Sadi Konuk Research and Training Hospital, Istanbul, Turkey
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Liu H, Li W, Zhang W, Sun S, Chen C. Levothyroxine: Conventional and novel drug delivery formulations. Endocr Rev 2022; 44:393-416. [PMID: 36412275 PMCID: PMC10166268 DOI: 10.1210/endrev/bnac030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/18/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
Despite the fact that levothyroxine is one of the most prescribed medications in the world, its bioavailability has been reported to be impaired by many factors, including interfering drugs or foods and concomitant diseases, and persistent hypothyroidism with a high dose of levothyroxine is thus elicited. Persistent hypothyroidism can also be induced by noninterchangeability between formulations and poor compliance. To address these issues, some strategies have been developed. Novel formulations (liquid solutions and soft-gel capsules) have been designed to eliminate malabsorption. Some other delivery routes (injections, suppositories, sprays, and sublingual and transdermal administrations) are aimed at circumventing different difficulties in dosing, such as thyroid emergencies and dysphagia. Moreover, nanomaterials have been used to develop delivery systems for the sustained release of levothyroxine to improve patient compliance and reduce costs. Some delivery systems encapsulating nanoparticles show promising release profiles. In this review, we first summarize the medical conditions that interfere with the bioavailability of oral levothyroxine and discuss the underlying mechanisms and treatments. The efficacy of liquid solutions and soft-gel capsules are systematically evaluated. We further summarize the novel delivery routes for levothyroxine and their possible applications. Nanomaterials in the levothyroxine field are then discussed and compared based on their load and release profile. We hope the article provides novel insights into the drug delivery of levothyroxine.
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Affiliation(s)
- Hanqing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wei Li
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wen Zhang
- Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (Ministry of Education), School of Pharmaceutical Sciences, Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
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Gottwald-Hostalek U, Razvi S. Getting the levothyroxine (LT4) dose right for adults with hypothyroidism: opportunities and challenges in the use of modern LT4 preparations. Curr Med Res Opin 2022; 38:1865-1870. [PMID: 35484983 DOI: 10.1080/03007995.2022.2071059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Lifelong treatment with levothyroxine (LT4) is the mainstay of management for individuals with hypothyroidism. Many hypothyroid patients start LT4 treatment at a low dose (e.g. 25-50 µg), especially the elderly, those with residual thyroid function, those with low body weight, and those with significant (especially cardiac) comorbidities. Almost half of patients on LT4 replacement therapy demonstrate either under- or over-treatment. Many LT4 preparations have relatively large intervals between tablet strengths at the lower end of their dose ranges (providing 25 µg, 50 µg, and 75 µg tablets), which may represent a barrier to achieving the optimum maintenance treatment for some patients. The availability of intermediate tablet strengths of LT4 in the 25-75 µg range may facilitate precise and effective dose titration of LT4 and may also enable convenient maintenance regimens based on a single LT4 tablet daily, to support adherence to therapy.
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Affiliation(s)
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
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Heim M, Nixon IJ, Emmerson E, Callanan A. From hormone replacement therapy to regenerative scaffolds: A review of current and novel primary hypothyroidism therapeutics. Front Endocrinol (Lausanne) 2022; 13:997288. [PMID: 36277721 PMCID: PMC9581390 DOI: 10.3389/fendo.2022.997288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Primary hypothyroidism severely impacts the quality of life of patients through a decrease in the production of the thyroid hormones T3 and T4, leading to symptoms affecting cardiovascular, neurological, cognitive, and metabolic function. The incidence rate of primary hypothyroidism is expected to increase in the near future, partially due to increasing survival of patients that have undergone radiotherapy for head and neck cancer, which induces this disease in over half of those treated. The current standard of care encompasses thyroid hormone replacement therapy, traditionally in the form of synthetic T4. However, there is mounting evidence that this is unable to restore thyroid hormone signaling in all tissues due to often persistent symptoms. Additional complications are also present in the form of dosage difficulties, extensive drug interactions and poor patience compliance. The alternative therapeutic approach employed in the past is combination therapy, which consists of administration of both T3 and T4, either synthetic or in the form of desiccated thyroid extract. Here, issues are present regarding the lack of regulation concerning formulation and lack of data regarding safety and efficacy of these treatment methods. Tissue engineering and regenerative medicine have been applied in conjunction with each other to restore function of various tissues. Recently, these techniques have been adapted for thyroid tissue, primarily through the fabrication of regenerative scaffolds. Those currently under investigation are composed of either biopolymers or native decellularized extracellular matrix (dECM) in conjunction with either primary thyrocytes or stem cells which have undergone directed thyroid differentiation. Multiple of these scaffolds have successfully restored an athyroid phenotype in vivo. However, further work is needed until clinical translation can be achieved. This is proposed in the form of exploration and combination of materials used to fabricate these scaffolds, the addition of peptides which can aid restoration of tissue homeostasis and additional in vivo experimentation providing data on safety and efficacy of these implants.
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Affiliation(s)
- Maria Heim
- Institute for Bioengineering, School of Engineering, The University of Edinburgh, Edinburgh, United Kingdom
- Centre for Regenerative Medicine, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, United Kingdom
| | - Ian J. Nixon
- Department of ENT, Head and Neck Surgery, NHS Lothian, Edinburgh, United Kingdom
| | - Elaine Emmerson
- Centre for Regenerative Medicine, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, United Kingdom
| | - Anthony Callanan
- Institute for Bioengineering, School of Engineering, The University of Edinburgh, Edinburgh, United Kingdom
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Ducharme M, Scarsi C, Bettazzi E, Mautone G, Lewis Y, Celi FS. A Novel Levothyroxine Solution Results in Similar Bioavailability Whether Taken 30 or Just 15 Minutes Before a High-Fat High-Calorie Meal. Thyroid 2022; 32:897-904. [PMID: 35469428 PMCID: PMC9419984 DOI: 10.1089/thy.2021.0604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Levothyroxine (LT4) sodium is a standard treatment for hypothyroidism. Its absorption and bioavailability when taken as a tablet have been shown to be significantly decreased with concomitant food ingestion. Therefore, LT4 formulations are recommended to be taken on an empty stomach, at least 30, ideally 60, minutes before breakfast, potentially affecting adherence to therapy. A novel LT4 solution (Tirosint®-SOL) has been shown to result in a faster absorption process than tablets or soft-gel capsule formulations. The objective of this trial was to evaluate the bioavailability of this preparation taken 15 minutes before a high-fat high-calorie meal in comparison with the minimally recommended 30-minute interval. Methods: Thirty-six (33 completers, 24 males and 9 females) healthy volunteers participating in the randomized study took 600 mcg of LT4 oral solution, single doses after a 10-hour fast, 15 or 30 minutes before a high-fat, high-calorie, FDA-approved standardized meal in a controlled research setting. We measured serum total thyroxine using Liquid Chromatography with Tandem Mass Spectrometry at baseline and multiple time points up to 72 hours after LT4 administration. The predefined equivalence boundaries for the extent of exposure reflected by the area under the curve (AUC) were 80-125%. The washout period was at least 35 days. Results: The geometric mean ratios and confidence intervals (CIs) for the baseline-adjusted extent of exposure represented by AUCs truncated at both 48 and 72 hours after dosing (AUC0-48: 90% [90% CI 86-94]; and AUC0-72: 92% [90% CI 87-97]) were within the prespecified equivalence boundaries. The baseline-adjusted peak concentration was also clinically similar (Cmax: 85% [90% CI 80-90]). The median tmax was 1.5 hours in each group. The rate of adverse events was similar between groups. Conclusions: We observed no significant difference in the pharmacokinetic properties of a novel LT4 solution administered 15 and 30 minutes before a high-fat high-calorie meal in normal subjects. Further research is needed to evaluate (a) the differences in overall bioavailability at other time points (including immediately premeal) and (b) the real-world effectiveness of this preparation in newly proposed administration conditions to optimize treatment outcomes in hypothyroid patients.
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Affiliation(s)
- Murray Ducharme
- Faculté de Pharmacie, University of Montreal and Learn and Confirm, Inc., St. Laurent, Quebec, Canada
- Address correspondence to: Murray Ducharme, PharmD, FCCP, FCP, Faculté de Pharmacie, University of Montreal, Learn and Confirm, Inc., 750 Marcel-Laurin, Suite 235, St. Laurent, QC H4M 2M4, Canada
| | | | | | | | - Yvette Lewis
- Learn and Confirm, Inc., St. Laurent, Quebec, Canada
| | - Francesco S. Celi
- Division of Endocrinology Diabetes and Metabolism, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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Bocale R, Desideri G, Barini A, D’Amore A, Boscherini M, Necozione S, Lombardi CP. Long-Term Adherence to Levothyroxine Replacement Therapy in Thyroidectomized Patients. J Clin Med 2022; 11:jcm11154296. [PMID: 35893387 PMCID: PMC9332058 DOI: 10.3390/jcm11154296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/29/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Background: We evaluated the long term adherence to two distinct formulations of levothyroxine (L-T4), liquid or solid, which are differently influenced by concomitant food ingestion. (2) Methods: A total of 106 thyroidectomized patients (82 female, mean age 58.2 ± 13.3 years) on L-T4 replacement therapy in either liquid (n = 52) or solid formulation (n = 54) were administered the four-item Medication Adherence Questionnaire (MAQ). (3) Results: The study population had 59.4% adherers and 40.6% non-adherers. The global MAQ score was significantly better in patients under liquid L-T4 in comparison to those under solid L-T4 (0.42 ± 0.82 vs. 0.83 ± 0.95, respectively, p = 0.0085). The patients on tablet L-T4 forgot to take their medication more frequently than those on liquid LT4 treatment (p = 0.0159) and were more often careless at times about taking their medication (p = 0.007), whilst about one in two thyroidectomized patients preferred tablets for lifetime medication therapy. The global MAQ score was directly correlated with the circulating TSH levels in the whole study population (0.700, p < 0.0001) and inversely correlated with both the FT3 (−0.220, p = 0.0232) and FT4 (−0.327, p = 0.0006) serum concentrations. (4) Conclusions: Long-term adherence to L-T4 treatment was globally satisfactory although it was better for the liquid formulation, which appears to represent an easier-to-manage L-T4 replacement therapy for most thyroidectomized patients, particularly for those with difficulties in taking L-T4 while fasting.
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Affiliation(s)
- Raffaella Bocale
- Division of Endocrine Surgery, “Agostino Gemelli” School of Medicine, University Foundation Polyclinic, Catholic University of the Sacred Heart, 00198 Rome, Italy; (R.B.); (A.D.); (M.B.); (C.P.L.)
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
- Correspondence: ; Tel.: +39-339-330-9326
| | - Angelina Barini
- Institute of Biochemistry and Clinical Biochemistry, Department of Laboratory Medicine, “Agostino Gemelli” School of Medicine, University Foundation Polyclinic, Catholic University of the Sacred Heart, 00198 Rome, Italy;
| | - Annamaria D’Amore
- Division of Endocrine Surgery, “Agostino Gemelli” School of Medicine, University Foundation Polyclinic, Catholic University of the Sacred Heart, 00198 Rome, Italy; (R.B.); (A.D.); (M.B.); (C.P.L.)
| | - Mauro Boscherini
- Division of Endocrine Surgery, “Agostino Gemelli” School of Medicine, University Foundation Polyclinic, Catholic University of the Sacred Heart, 00198 Rome, Italy; (R.B.); (A.D.); (M.B.); (C.P.L.)
| | - Stefano Necozione
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Celestino Pio Lombardi
- Division of Endocrine Surgery, “Agostino Gemelli” School of Medicine, University Foundation Polyclinic, Catholic University of the Sacred Heart, 00198 Rome, Italy; (R.B.); (A.D.); (M.B.); (C.P.L.)
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12
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Díez JJ, Iglesias P, Gómez-Mateos MÁ. Management of primary hypothyroidism in adults: An analysis of the results of a survey in 546 primary care physicians. ENDOCRINOL DIAB NUTR 2022; 69:289-298. [PMID: 35636913 DOI: 10.1016/j.endien.2022.03.001] [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: 01/22/2021] [Accepted: 04/10/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To document current practices in the management of adult patients with hypothyroidism in the setting of primary healthcare. METHODS We designed a web-based survey to inquire information on real-life practices regarding management of hypothyroidism by primary care physicians in the region of Madrid (Spain). RESULTS In total, 546 out of 3897 (14%) physicians (aged 50.9±8.5 yr, 404 females) completed the survey. More than 90% of respondents requested serum thyrotropin measurement in subjects with symptoms of thyroid hypofunction, family history of thyroid disease and history of autoimmune disease. A thyroid ultrasound was requested to evaluate subclinical and overt hypothyroidism by 27.1% and 69.6% of respondents, respectively. Only 22.1% of respondents stated that they do not treat subclinical hypothyroidism with thyrotropin values less than 10mU/l. Most physicians use brand-name formulations of levothyroxine and advise patients on how to take the tablets. To start treatment, the gradual replacement rate was the option chosen by most of the respondents, even in young patients. The thyrotropin target preferred by most respondents was 0.5-5.0mU/l, especially in older patients. In patients with persistent symptoms, 61.4% search for the causes through complementary investigations. A longer professional practice time was not always accompanied by better adherence to guidelines and expert recommendations. CONCLUSION Our results reveal a proactive attitude in the diagnosis and of therapy by most of the respondents. However, we observed a tendency to perform unnecessary diagnostic tests and an excessive propensity to treat mild subclinical hypothyroidism.
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Affiliation(s)
- Juan J Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Spain.
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain
| | - María Ángeles Gómez-Mateos
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain; Medical Management, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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13
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Díez JJ, Iglesias P, Gómez-Mateos MÁ. Management of primary hypothyroidism in adults: An analysis of the results of a survey in 546 primary care physicians. ENDOCRINOL DIAB NUTR 2021; 69:S2530-0164(21)00188-9. [PMID: 34483069 DOI: 10.1016/j.endinu.2021.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/19/2021] [Accepted: 04/10/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To document current practices in the management of adult patients with hypothyroidism in the setting of primary healthcare. METHODS We designed a web-based survey to inquire information on real-life practices regarding management of hypothyroidism by primary care physicians in the region of Madrid (Spain). RESULTS In total, 546 out of 3897 (14%) physicians (aged 50.9±8.5 yr, 404 females) completed the survey. More than 90% of respondents requested serum thyrotropin measurement in subjects with symptoms of thyroid hypofunction, family history of thyroid disease and history of autoimmune disease. A thyroid ultrasound was requested to evaluate subclinical and overt hypothyroidism by 27.1% and 69.6% of respondents, respectively. Only 22.1% of respondents stated that they do not treat subclinical hypothyroidism with thyrotropin values less than 10mU/l. Most physicians use brand-name formulations of levothyroxine and advise patients on how to take the tablets. To start treatment, the gradual replacement rate was the option chosen by most of the respondents, even in young patients. The thyrotropin target preferred by most respondents was 0.5-5.0mU/l, especially in older patients. In patients with persistent symptoms, 61.4% search for the causes through complementary investigations. A longer professional practice time was not always accompanied by better adherence to guidelines and expert recommendations. CONCLUSION Our results reveal a proactive attitude in the diagnosis and of therapy by most of the respondents. However, we observed a tendency to perform unnecessary diagnostic tests and an excessive propensity to treat mild subclinical hypothyroidism.
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Affiliation(s)
- Juan J Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Spain.
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain
| | - María Ángeles Gómez-Mateos
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain; Medical Management, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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14
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Haskard-Zolnierek K, Wilson C, Pruin J, Deason R, Howard K. The Relationship Between Brain Fog and Medication Adherence for Individuals With Hypothyroidism. Clin Nurs Res 2021; 31:445-452. [PMID: 34348493 DOI: 10.1177/10547738211038127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Individuals with hypothyroidism suffer from symptoms including impairments to cognition (i.e., "brain fog"). Medication can help reduce symptoms of hypothyroidism; however, brain fog may hinder adherence. The aim of this study was to determine if memory impairment and cognitive failures are related to treatment nonadherence in 441 individuals with hypothyroidism. Participants with a diagnosis of hypothyroidism and currently prescribed a thyroid hormone replacement medication were placed in two groups according to adherence level and compared on validated scales assessing impairments to memory and cognition. Results indicated a significant association between treatment nonadherence and self-reported brain fog, represented by greater cognitive and memory impairments. Nonadherent individuals indicated impairments with prospective, retrospective, and short- and long-term memory; and more cognitive failures, compared to adherent individuals. Findings suggest the importance of interventions to enhance adherence for individuals with brain fog, such as encouraging the use of reminders.
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15
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Topaloğlu Ö, Yavuz A, Tiryaki Aylıkcı AB. Evaluation of adherence to levothyroxine and out-of-range thyroid-stimulating hormone levels in pregnant women with primary hypothyroidism. Int J Clin Pract 2021; 75:e14312. [PMID: 33999516 DOI: 10.1111/ijcp.14312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/28/2021] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Adherence to levothyroxine (LT4) and attaining thyroid-stimulating hormone (TSH) goal in pregnancy has not been well-defined yet. We aimed to investigate adherence to LT4, success to reach TSH goal, and association between them in pregnant women with primary hypothyroidism. MATERIALS AND METHODS Eight-item Morisky Medication Adherence Scale (MMAS-8) was applied in third trimester in pregnant women with primary hypothyroidism (Hashimoto's thyroiditis, surgical hypothyroidism or iodine deficiency) whom LT4 was given for at least 3 months. Those with chronic illness or thyroid cancer were excluded. We grouped the patients according to MMAS-8 score (<6, low adherence vs ≥6, medium/high adherence), and TSH measurement in third trimester (in-range vs out-of-range). RESULTS Of total (n = 85), 57.64% (n = 49) had medium/high adherence to LT4, and 41.17% (n = 35) out-of-range TSH, but no association was found among them (P = .937). LT4 initiation in pregestational period, surgical hypothyroidism, high LT4 dose in second/third trimester and alternate-day dosing were associated with medium/high adherence. Age, number of visits, and less time between ingestion of LT4 and breakfast were associated with medium/high adherence. LT4 dose in second trimester and dose increment at the beginning of pregnancy were positively associated with in-range TSH. CONCLUSION Non-adherence and treatment failure are frequent in LT4-treated pregnant women. Adherence seems not to be associated with treatment success. Regular follow-up may improve adherence. Our study is the first to analyse both treatment success and adherence to LT4 in pregnancy.
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Affiliation(s)
- Ömercan Topaloğlu
- Endocrinology Clinics, Kocaeli Derince Training and Research Hospital, University of Health Sciences, Kocaeli, Turkey
| | - Arzu Yavuz
- Gynecology and Obstetrics Clinics, Kocaeli Derince Training and Research Hospital, University of Health Sciences, Kocaeli, Turkey
| | - Ahsen Banu Tiryaki Aylıkcı
- Internal Medicine Clinics, Kocaeli Derince Training and Research Hospital, University of Health Sciences, Kocaeli, Turkey
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16
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Hallit S, Haddad C, Sacre H, Rahme C, Akel M, Saleh N, Chalhoub C, Salameh P. Medication adherence among Lebanese adult patients with hypothyroidism: Validation of the Lebanese Medication Adherence Scale and correlates. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2021. [DOI: 10.1016/j.cegh.2020.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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17
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Razvi S, Mrabeti S, Luster M. Managing symptoms in hypothyroid patients on adequate levothyroxine: a narrative review. Endocr Connect 2020; 9:R241-R250. [PMID: 33112818 PMCID: PMC7774765 DOI: 10.1530/ec-20-0205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022]
Abstract
The current standard of care for hypothyroidism is levothyroxine (LT4) monotherapy to reduce levels of thyrotropin (thyroid-stimulating hormone, TSH) within its reference range and amelioration of any symptoms. A substantial minority continues to report hypothyroid-like symptoms despite optimized TSH, however. These symptoms are not specific to thyroid dysfunction and are frequent among the euthyroid population, creating a therapeutic dilemma for the treating clinician as well as the patient. We present a concise, narrative review of the clinical research and evidence-based guidance on the management of this challenging population. The clinician may endeavor to ensure that the serum TSH is within the target range. However, the symptomatic patient may turn to alternative non-evidence-based therapies in the hope of obtaining relief. Accordingly, it is important for the clinician to check for conditions unrelated to the thyroid that could account for the ongoing symptoms such as other autoimmune conditions, anemia or mental health disorders. Systematic and thorough investigation of the potential causes of persistent symptoms while receiving LT4 therapy will resolve the problem for most patients. There may be some patients that may benefit from additional treatment with liothyronine (LT3), although it is unclear as yet as to which patient group may benefit the most from combined LT4 + LT3 therapy. In the future, personalized treatment with LT4 + LT3 may be of benefit for some patients with persistent symptoms of hypothyroidism such as those with polymorphisms in the deiodinase enzyme 2 (DIO2). For now, this remains a subject for research.
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Affiliation(s)
- Salman Razvi
- Translational and Clinical Research Institute, University of Newcastle, Newcastle-upon-Tyne, UK
- Correspondence should be addressed to S Razvi:
| | - Sanaa Mrabeti
- Medical Affairs EMEA, Merck Serono Middle East FZ-LLC, Dubai, United Arab Emirates
| | - Markus Luster
- Department of Nuclear Medicine, University Hospital Marburg, Marburg, Germany
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18
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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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Alam MA, Quamri MA, Sofi G, Ansari S. Update of hypothyroidism and its management in Unani medicine. J Basic Clin Physiol Pharmacol 2020; 32:1-10. [PMID: 32776903 DOI: 10.1515/jbcpp-2020-0121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/22/2020] [Indexed: 06/11/2023]
Abstract
Hypothyroidism is a clinical syndrome caused by thyroid hormone deficiency due to reduced production, deranged distribution, or lack of effects of thyroid hormone. The prevalence of hypothyroidism in developed countries is around 4-5%, whereas it is about 11% in India, only 2% in the UK, and 4·6% in the USA. It is more common in women than in men. Hypothyroidism has multiple etiologies and manifestations. The most common clinical manifestations are weight gain, loss of hair, cold intolerance, lethargy, constipation, dry skin, and change in voice. The signs and symptoms of hypothyroidism differ with age, gender, severity of condition, and some other factors. The diagnosis is based on clinical history, physical examination and serum level of FT3, FT4, and thyroid-stimulating hormone, imaging studies, procedures, and histological findings. The treatment of choice for hypothyroidism is levothyroxine, however; in this review article, we have discussed the epidemiology, etiology, clinical sign and symptoms, diagnosis, complications, and management of hypothyroidism in modern medicine and a comparative treatment by the Unani system of medicine (USM). In the USM, the main emphasis of the principle of treatment (Usool-e-Ilaj) is to correct the abnormal constitution (Su-e-Mizaj) and alter the six prerequisites for existence (Asbab-e-Sitta Zarooriya) to restore normal health. It is a packaged treatment, that is, different components of treatment are given as a package form which includes different drugs, dosages form, and regimens.
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Affiliation(s)
- Md Anzar Alam
- Department of Moalajat, National Institute of Unani Medicine, Bangalore, India
| | | | - Ghulamuddin Sofi
- Department of Ilmul Advia, National Institute of Unani Medicine, Bangalore, India
| | - Shabnam Ansari
- Department of Biotechnology, Natural Sciences, Jamia Millia Islamia, Central University, New Delhi, India
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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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Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Individualised requirements for optimum treatment of hypothyroidism: complex needs, limited options. Drugs Context 2019; 8:212597. [PMID: 31516533 PMCID: PMC6726361 DOI: 10.7573/dic.212597] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/21/2022] Open
Abstract
Levothyroxine (LT4) therapy has a long history, a well-defined pharmacological profile and a favourable safety record in the alleviation of hypothyroidism. However, questions remain in defining the threshold for the requirement of treatment in patients with subclinical hypothyroidism, assessing the dose adequacy of the drug, and selecting the best treatment mode (LT4 monotherapy versus liothyronine [LT3]/LT4 combinations) for subpopulations with persisting complaints. Supplied as a prodrug, LT4 is enzymatically converted into the biologically more active thyroid hormone, triiodothyronine (T3). Importantly, tetraiodothyronine (T4) to T3 conversion efficiency may be impaired in patients receiving LT4, resulting in a loss of thyroid-stimulating hormone (TSH)-mediated feed-forward control of T3, alteration of the interlocking equilibria between serum concentrations of TSH, free thyroxine (FT4), and free triiodothyonine (FT3), and a decrease in FT3 to FT4 ratios. This downgrades the value of the TSH reference system derived in thyroid health for guiding the replacement dose in the treatment situation. Individualised conditionally defined setpoints may therefore provide appropriate biochemical targets to be clinically tested, together with a stronger focus on clinical presentation and future endpoint markers of tissue thyroid state. This cautionary note encompasses the use of aggregated statistical data from clinical trials which are not safely applicable to the individual level of patient care under these circumstances.
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Affiliation(s)
- Rudolf Hoermann
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Paulmannshöherstr. 14, 58515 Lüdenscheid, Germany
| | | | - Rolf Larisch
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Paulmannshöherstr. 14, 58515 Lüdenscheid, Germany
| | - Johannes W Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.,Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Alexandrinenstr. 5, 44791 Bochum, Germany
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22
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Abstract
Introduction Patients with hypothyroidism are managed with life-long levothyroxine (LT4) therapy. However, as with other chronic illnesses, drug adherence (DA) is a prominent issue in these patients. The aim of this study is to identify the extent of DA to LT4 in hypothyroidism patients and study the clinical factors contributing to DA in these patients. Methods This cross-sectional study assessed patient adherence to LT4 therapy by Modified Morisky Adherence Scale (MMAS). Factors predicting the pattern of medication adherence were also assessed in all patients. Data were entered and analyzed using SPSS v. 22.0. Results On MMAS, 79 (27.3%) participants indicated low adherence, 117 (40.48%) indicated medium adherence, and 93 (32.2%) participants indicated high adherence. Regular endocrinologist visits and knowledge about medication were highest in high adherent patients (p < 0.05). Need for assistance in taking medication, avoidance of medication with symptomatic relief and busy work schedule was highest in low adherent patients (p < 0.05). Conclusion Patients with hypothyroidism showed moderate adherence to their treatment.
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Affiliation(s)
- Rohan Kumar
- Medical Education and Simulation, Jinnah Sindh Medical University, Karachi, PAK
| | - Faizan Shaukat
- Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
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