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Ulucan-Karnak F, Kuru Cİ, Akgöl S. Poly (hydroxyethylmethacrylate-co-methacryloyl glutamic acid) nanocarrier system for controlled release of levothyroxine. JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 2024:1-19. [PMID: 39008611 DOI: 10.1080/09205063.2024.2378610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/05/2024] [Indexed: 07/17/2024]
Abstract
The deterioration in the structure of thyroid hormones causes many thyroid-related disorders, which leads to a negative effect on the quality of life, as well as the change in metabolic rate. For the treatment of thyroid disorders, daily use of levothyroxine-based medication is essential. In the study, it is aimed to develop a polymeric nanocarrier that can provide controlled drug release of levothyroxine. In this respect, the p(HEMA-MAGA) nanopolymer was synthesized and then characterized by Scanning Electron Microscopy (SEM), Fourier Transform Infrared Spectroscopy (FTIR), and Zeta size analysis. The specific surface area of the nanopolymer was calculated as 587.68 m2/g. The pH, temperature, concentration, and time parameters were determined for levothyroxine binding to p(HEMA-MAGA) and optimum binding was determined as pH 7.4, 25 °C, 25 µg/mL concentration, and 30 min adsorption time. As a result of the release performed at pH 7.4, a release profile was observed which increased for the first 3 days and continued for 14 days. According to the results of MTT cell viability analysis, it was determined that the p(HEMA-MAGA) nanopolymeric carrier system had no cytotoxic effect. This developed polymer-based nanocarrier system is suitable for long-term and controlled release of levothyroxine. This is a unique and novel study in terms of developing poly hydroxyethylmethacrylate-co-methacryloyl glutamic acid-based polymeric nanoparticles for levothyroxine release.
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Affiliation(s)
- Fulden Ulucan-Karnak
- Department of Biochemistry, Ege University, İzmir, Turkey
- Graduate School of Natural and Applied Sciences, Department of Biomedical Technologies, Ege University, İzmir, Turkey
| | - Cansu İlke Kuru
- Department of Biochemistry, Ege University, İzmir, Turkey
- Graduate School of Natural and Applied Sciences, Department of Biotechnology, Ege University, İzmir, Turkey
| | - Sinan Akgöl
- Department of Biochemistry, Ege University, İzmir, Turkey
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2
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Neves JS, Leite AR, Conceição G, Gonçalves A, Borges-Canha M, Vale C, Von-Hafe M, Martins D, Miranda-Silva D, Leite S, Rocha-Oliveira E, Sousa-Mendes C, Chaves J, Lourenço IM, Grijota-Martínez C, Bárez-López S, Miranda IM, Almeida-Coelho J, Vasques-Nóvoa F, Carvalho D, Lourenço A, Falcão-Pires I, Leite-Moreira A. Effects of Triiodothyronine Treatment in an Animal Model of Heart Failure with Preserved Ejection Fraction. Thyroid 2023; 33:983-996. [PMID: 37140469 DOI: 10.1089/thy.2022.0717] [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: 05/05/2023]
Abstract
Background: Low levels of triiodothyronine (T3) are common in patients with heart failure (HF). Our aim was to evaluate the effects of supplementation with low and replacement doses of T3 in an animal model of HF with preserved ejection fraction (HFpEF). Methods: We evaluated four groups: ZSF1 Lean (n = 8, Lean-Ctrl), ZSF1 Obese (rat model of metabolic-induced HFpEF, n = 13, HFpEF), ZSF1 Obese treated with a replacement dose of T3 (n = 8, HFpEF-T3high), and ZSF1 Obese treated with a low-dose of T3 (n = 8, HFpEF-T3low). T3 was administered in drinking water from weeks 13 to 24. The animals underwent anthropometric and metabolic assessments, echocardiography, and peak effort testing with maximum O2 consumption (VO2max) determination at 22 weeks, and a terminal hemodynamic evaluation at 24 weeks. Afterwhile myocardial samples were collected for single cardiomyocyte evaluation and molecular studies. Results: HFpEF animals showed lower serum and myocardial thyroid hormone levels than Lean-Ctrl. Treatment with T3 did not normalize serum T3 levels, but increased myocardial T3 levels to normal levels in the HFpEF-T3high group. Body weight was significantly decreased in both the T3-treated groups, comparing with HFpEF. An improvement in glucose metabolism was observed only in HFpEF-T3high. Both the treated groups had improved diastolic and systolic function in vivo, as well as improved Ca2+ transients and sarcomere shortening and relaxation in vitro. Comparing with HFpEF animals, HFpEF-T3high had increased heart rate and a higher rate of premature ventricular contractions. Animals treated with T3 had higher myocardial expression of calcium transporter ryanodine receptor 2 (RYR2) and α-myosin heavy chain (MHC), with a lower expression of β-MHC. VO2max was not influenced by treatment with T3. Myocardial fibrosis was reduced in both the treated groups. Three animals died in the HFpEF-T3high group. Conclusions: Treatment with T3 was shown to improve metabolic profile, myocardial calcium handling, and cardiac function. While the low dose was well-tolerated and safe, the replacement dose was associated with increased heart rate, and increased risk of arrhythmias and sudden death. Modulation of thyroid hormones may be a potential therapeutic target in HFpEF; however, it is important to take into account the narrow therapeutic window of T3 in this condition.
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Affiliation(s)
- João Sérgio Neves
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Ana Rita Leite
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Glória Conceição
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Alexandre Gonçalves
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Marta Borges-Canha
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Catarina Vale
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Internal Medicine, and Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Madalena Von-Hafe
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Diana Martins
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Daniela Miranda-Silva
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Sara Leite
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Estela Rocha-Oliveira
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Cláudia Sousa-Mendes
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joana Chaves
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Mariana Lourenço
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Carmen Grijota-Martínez
- Instituto de Investigaciones Biomédicas Alberto Sols, Consejo Superior de Investigaciones Científicas (CSIC)-Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Departamento de Biología Celular, Facultad de Ciencias Biológicas, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Soledad Bárez-López
- Instituto de Investigaciones Biomédicas Alberto Sols, Consejo Superior de Investigaciones Científicas (CSIC)-Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Isabel M Miranda
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - João Almeida-Coelho
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Francisco Vasques-Nóvoa
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Internal Medicine, and Centro Hospitalar Universitário de São João, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Davide Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - André Lourenço
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Falcão-Pires
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Cardiothoracic Surgery, Centro Hospitalar Universitário São João, Porto, Portugal
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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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4
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Jonklaas J. Role of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism. Endocrinol Metab Clin North Am 2022; 51:243-263. [PMID: 35662440 DOI: 10.1016/j.ecl.2021.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diverse causes potentially underlie decreased quality of life in biochemically euthyroid patients treated for hypothyroidism with levothyroxine. Once these contributing factors are addressed, if symptoms persist, there may be benefit to personalized use of combination therapy adding liothyronine. This approach should be carefully monitored: avoiding overtreatment and ensuring that therapy is only continued if it improves patient-reported quality of life. Most randomized clinical trials have not shown benefits, perhaps because of not targeting the most symptomatic patients. Sustained-release liothyronine preparations may soon be available for optimally designed studies assessing whether combination therapy provides superior therapy for hypothyroidism in select patients.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC 20007, USA.
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5
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Salvatore D, Porcelli T, Ettleson MD, Bianco AC. The relevance of T 3 in the management of hypothyroidism. Lancet Diabetes Endocrinol 2022; 10:366-372. [PMID: 35240052 PMCID: PMC9987447 DOI: 10.1016/s2213-8587(22)00004-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/24/2021] [Accepted: 12/17/2021] [Indexed: 12/23/2022]
Abstract
Levothyroxine monotherapy has been the standard of care for treatment of hypothyroidism for more than 40 years. However, patients treated with levothyroxine have relatively lower serum tri-iodothyronine (T3) concentrations than the general population, and symptoms of hypothyroidism persist for some patients despite normalisation of thyroid-stimulating hormone (TSH) concentrations. The understanding that maintenance of normal T3 concentrations is the priority for the thyroid axis has redirected the clinical focus to serum T3 concentrations in patients with hypothyroidism. This Personal View explores whether it is currently feasible to identify patients who could be considered for liothyronine supplementation in combination with levothyroxine. Genetic profiling stands out as a potential future tool to identify patients who do not respond well to levothyroxine due to suboptimal peripheral thyroxine (T4) activation. Moreover, new slow-release liothyronine preparations are being developed to be trialled in these symptomatic patients, in an attempt to restore T3 concentrations and provide conclusive results for the use of T4 plus T3 combination therapy.
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Affiliation(s)
- Domenico Salvatore
- Department of Public Health, University of Naples Federico II, Naples, Italy.
| | - Tommaso Porcelli
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, IL, USA
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, IL, USA
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Abstract
Hypothyroidism is a common endocrinopathy, and levothyroxine is frequently prescribed. Despite the basic tenets of initiating and adjusting levothyroxine being agreed on, there are many nuances and complexities to consistently maintaining euthyroidism. Understanding the impact of patient weight and residual thyroid function on initial levothyroxine dosage and consideration of age, comorbidities, thyrotropin goal, life stage, and quality of life as levothyroxine is adjusted can be challenging and continually evolving. Because levothyroxine is a lifelong medication, it is important to avoid risks from periods of overtreatment or undertreatment. For the subset of patients not restored to baseline health with levothyroxine, causes arising from all aspects of the patient's life (coexistent medical conditions, stressors, lifestyle, psychosocial factors) should be broadly considered. If such factors do not appear to be contributing, and biochemical euthyroidism has been successfully maintained, there may be benefit to a trial of combination therapy with levothyroxine and liothyronine. This is not supported by the majority of randomized clinical trials, but may be supported by other studies providing lower-quality evidence and by animal studies. Given this discrepancy, it is important that any trial of combination therapy be continued only as long as a patient benefit is being enjoyed. Monitoring for adverse effects, particularly in older or frail individuals, is necessary and combination therapy should not be used during pregnancy. A sustained-release liothyronine preparation has completed phase 1 testing and may soon be available for better designed and powered studies assessing whether combination therapy provides superior therapy for hypothyroidism.
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7
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Dumitrescu AM, Hanlon EC, Arosemena M, Duchon O, Ettleson M, Giurcanu M, Bianco AC. Extended Absorption of Liothyronine from Poly-Zinc-Liothyronine: Results from a Phase 1, Double-Blind, Randomized, and Controlled Study in Humans. Thyroid 2022; 32:196-205. [PMID: 34641706 PMCID: PMC8861912 DOI: 10.1089/thy.2021.0304] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: L-triiodothyronine (LT3) has been increasingly used in combination with levothyroxine in the treatment of hypothyroidism. A metal coordinated form of LT3, known as poly-zinc-liothyronine (PZL), avoided in rats the typical triiodothyronine (T3) peak seen after oral administration of LT3. Objectives: To evaluate in healthy volunteers (i) the pharmacokinetics (PK) of PZL-derived T3 after a single dose, (ii) the pharmacodynamics of PZL-derived T3, (iii) incidence of adverse events, and (iv) exploratory analysis of the sleep patterns after LT3, PZL, or placebo (PB) administration. Methods: Twelve healthy volunteers 18-50 years of age were recruited for a Phase 1, double-blind, randomized, single-dose PB-controlled, crossover study to compare PZL against LT3 or PB. Subjects were admitted three separate times to receive a randomly assigned capsule containing PB, 50 μg LT3, or 50 μg PZL, and were observed for 48 hours. A 2-week washout period separated each admission. Results: LT3-derived serum T3 levels exhibited the expected profile, with a Tmax at 2 hours and return to basal levels by 24-36 hours. PZL-derived serum T3 levels exhibited ∼30% lower Cmax that was 1 hour delayed and extended into a plateau that lasted up to 6 hours. This was followed by a lower but much longer plateau; by 24 hours serum T3 levels still exceeded ½ of Cmax. Thyrotropin levels were similarly reduced in both groups. Conclusion: PZL possesses the necessary properties to achieve a much improved T3 PK. PZL is on track to provide hypothyroid patients with stable levels of serum T3.
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Affiliation(s)
- Alexandra M. Dumitrescu
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Chicago, Illinois, USA
- Address correspondence to: Alexandra M. Dumitrescu, MD, PhD, Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago Medical Center, 5841 S. Maryland Avenue, MC1027, Room M267, Chicago, IL 60637, USA
| | - Erin C. Hanlon
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Chicago, Illinois, USA
| | - Marilyn Arosemena
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Chicago, Illinois, USA
| | - Olga Duchon
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Chicago, Illinois, USA
| | - Matthew Ettleson
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Chicago, Illinois, USA
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Antonio C. Bianco
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Chicago, Illinois, USA
- Antonio C. Bianco, MD, PhD, Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago Medical Center, 5841 S. Maryland Avenue, MC1027, Room M267, Chicago, IL 60637, USA
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Permana AD, Stewart SA, Domínguez-Robles J, Amir MN, Bahar MA, Donnelly RF, Larraneta E. Development and validation of a high-performance liquid chromatography method for levothyroxine sodium quantification in plasma for pre-clinical evaluation of long-acting drug delivery systems. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2021; 13:5204-5210. [PMID: 34676387 DOI: 10.1039/d1ay01049b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Levothyroxine (LEVO) sodium is an FDA-approved drug that is used to treat underactive thyroid (hypothyroidism) and other conditions. It is generally used as a thyroid-stimulating hormone administered orally. However, this approach has some drawbacks such as this drug should be taken every day 30 min to 1 h prior to breakfast with an empty stomach, moreover, some food interactions must be monitored. Thus, alternative innovative approaches capable of providing sustained LEVO release should be developed. Our research was designed to establish a simple quantitative determination method for LEVO in rat plasma for pre-clinical evaluation of long acting formulations using a high-performance liquid chromatography method, to validate the analytical method according to ICH guidelines and to characterise its pharmacokinetic behavior in rats. After simple protein precipitation with acetonitrile, LEVO was eluted on a Xselect CSH™ C18 column (Waters, 3.0 × 150 mm) with a particle size of 3.5 μm using a mobile phase of water and acetonitrile at a ratio of 65 : 35% v/v, including 0.1% v/v of trifluoracetic acid. The calibration standards used for plasma ranged between 0.5-1000 ng mL-1 with a correlation coefficient (r2) of ≥0.998. The limit of detection was 0.44 ng mL-1 and the lower limit of quantitation was 1.33 ng mL-1. The extraction recovery of LEVO in rat plasma samples by this method was between 80 and 85%. The method was selective, sensitive, accurate and precise for detecting and quantifying LEVO in a pharmacokinetic study carried out in rats for pre-clinical evaluation of long acting formulations. The validated HPLC method meets the ICH established requirements and therefore offers a wide range of potential applications in pre-clinical therapeutic drug monitoring, pharmacokinetics and toxicology.
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Affiliation(s)
- Andi Dian Permana
- Department of Pharmaceutics, Faculty of Pharmacy, Hasanuddin University, Makassar, 90245, Indonesia.
| | - Sarah A Stewart
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK.
| | | | - Muh Nur Amir
- Department of Pharmacology-Toxicology, Faculty of Pharmacy, Hasanuddin University, Makassar, 90245, Indonesia
| | - Muh Akbar Bahar
- Department of Pharmacology-Toxicology, Faculty of Pharmacy, Hasanuddin University, Makassar, 90245, Indonesia
| | - Ryan F Donnelly
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK.
| | - Eneko Larraneta
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK.
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Jonklaas J, Bianco AC, Cappola AR, Celi FS, Fliers E, Heuer H, McAninch EA, Moeller LC, Nygaard B, Sawka AM, Watt T, Dayan CM. Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document. Eur Thyroid J 2021; 10:10-38. [PMID: 33777817 PMCID: PMC7983670 DOI: 10.1159/000512970] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies. METHODS The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members. RESULTS Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 µg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations. DISCUSSION This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, District of Columbia, USA
- *Jacqueline Jonklaas, Division of Endocrinology, Georgetown University, 4000 Reservoir Road, NW, Washington, DC 20007 (USA),
| | - Antonio C. Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Anne R. Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesco S. Celi
- Division of Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Heike Heuer
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | | | - Lars C. Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | - Birte Nygaard
- Center for Endocrinology and Metabolism, Department of Internal Medicine, Herlev and Gentofte Hospitals, Herlev, Denmark
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Torquil Watt
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Colin M. Dayan
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, United Kingdom
- **Colin M. Dayan, Thyroid Research Group, School of Medicine, Cardiff University, C2 Link, Heath Park, Cardiff CF14 4XN (UK),
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10
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Jonklaas J, Bianco AC, Cappola AR, Celi FS, Fliers E, Heuer H, McAninch EA, Moeller LC, Nygaard B, Sawka AM, Watt T, Dayan CM. Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document. Thyroid 2021; 31:156-182. [PMID: 33276704 PMCID: PMC8035928 DOI: 10.1089/thy.2020.0720] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies. Methods: The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members. Results: Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 μg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations. Discussion: This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, District of Columbia, USA
- Address correspondence to: Jacqueline Jonklaas, MD, PhD, Division of Endocrinology, Georgetown University, 4000 Reservoir Road, NW, Washington, DC 20007, USA
| | - Antonio C. Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Anne R. Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesco S. Celi
- Division of Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Center, Netherlands
| | - Heike Heuer
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | | | - Lars C. Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | - Birte Nygaard
- Center for Endocrinology and Metabolism, Department Internal Medicine, Herlev and Gentofte Hospitals, Herlev, Denmark
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, Canada
| | - Torquil Watt
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Colin M. Dayan
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, United Kingdom
- Address correspondence to: Colin M. Dayan, MD, PhD, Thyroid Research Group, School of Medicine, Cardiff University, C2 Link, Heath Park, Cardiff CF14 4XN, UK
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Abstract
Background: The basis for the treatment of hypothyroidism with levothyroxine (LT4) is that humans activate T4 to triiodothyronine (T3). Thus, while normalizing serum thyrotropin (TSH), LT4 doses should also restore the body's reservoir of T3. However, there is evidence that T3 is not fully restored in LT4-treated patients. Summary: For patients who remain symptomatic on LT4 therapy, clinical guidelines recommend, on a trial basis, therapy with LT4+LT3. Reducing the LT4 dose by 25 mcg/day and adding 2.5-7.5 mcg liothyronine (LT3) once or twice a day is an appropriate starting point. Transient episodes of hypertriiodothyroninemia with these doses of LT4 and LT3 are unlikely to go above the reference range and have not been associated with adverse drug reactions. Trials following almost a 1000 patients for almost 1 year indicate that similar to LT4, therapy with LT4+LT3 can restore euthyroidism while maintaining a normal serum TSH. An observational study of 400 patients with a mean follow-up of ∼9 years did not indicate increased mortality or morbidity risk due to cardiovascular disease, atrial fibrillation, or fractures after adjusting for age when compared with patients taking only LT4. Desiccated thyroid extract (DTE) is a form of combination therapy in which the LT4/LT3 ratio is ∼4:1; the mean daily dose of DTE needed to normalize serum TSH contains ∼11 mcg T3, but some patients may require higher doses. The DTE remains outside formal FDA oversight, and consistency of T4 and T3 contents is monitored by the manufacturers only. Conclusions: Newly diagnosed hypothyroid patients should be treated with LT4. A trial of combination therapy with LT4+LT3 can be considered for those patients who have unambiguously not benefited from LT4.
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Affiliation(s)
- Thaer Idrees
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Scott Palmer
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Rui M.B. Maciel
- Division of Endocrinology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Antonio C. Bianco
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago, Chicago, Illinois, USA
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Patient Experiences and Perceptions Associated with the Use of Desiccated Thyroid Extract. ACTA ACUST UNITED AC 2020; 56:medicina56040161. [PMID: 32260044 PMCID: PMC7230696 DOI: 10.3390/medicina56040161] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/23/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
Background and objectives: It is unclear why many patients with hypothyroidism prefer the use of desiccated thyroid extract (DTE) as a thyroid hormone replacement formulation over levothyroxine (LT4) treatment, as recommended by clinical practice guidelines. We analyzed patient-reported information from patient online forums to better understand patient preferences for and attitudes toward the use of DTE to treat hypothyroidism. Materials and Methods: We conducted a mixed-methods study by evaluating the content of online posts from three popular hypothyroidism forums from patients currently taking DTE (n = 673). From these posts, we extracted descriptive information on patient demographics and clinical characteristics and qualitatively analyzed posts’ content to explore patient perceptions on DTE and other therapies further. Results: Nearly half (46%) of the patients reported that a clinician initially drove their interest in trying DTE. Patients described many reasons for switching from a previous therapeutic approach to DTE, including lack of improvement in hypothyroidism-related symptoms (58%) and the development of side effects (22%). The majority of patients described DTE as moderately to majorly effective overall (81%) and more effective than the previous therapy (77%). The most frequently described benefits associated with DTE use were an improvement in symptoms (56%) and a change in overall well-being (34%). One-fifth of patients described side effects related to the use of DTE. Qualitative analysis of posts’ content supported these findings and raised additional issues around the need for individualizing therapy approaches for hypothyroidism (e.g., a sense of each patient has different needs), as well as difficulties obtaining DTE (e.g., issues with pharmacy availability). Conclusions: Lack of individualized treatment and a feeling of not been listened to were recurrent themes among DTE users. A subset of patients may prefer DTE to LT4 for many reasons, including perceived better effectiveness and improved overall well-being, despite the risks associated with DTE.
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Azizi F, Amouzegar A, Mehran L, Abdi H. LT4 and Slow Release T3 Combination: Optimum Therapy for Hypothyroidism? Int J Endocrinol Metab 2020; 18:e100870. [PMID: 32636887 PMCID: PMC7322563 DOI: 10.5812/ijem.100870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Levothyroxine (LT4) is recommended as replacement therapy for thyroid hormone deficiency. However, some hypothyroid patients receiving LT4 therapy do not feel as well as healthy subjects. This article aimed to review current knowledge regarding LT4 monotherapy versus LT4+LT3 combination therapy and propose future directions regarding LT4+slow release T3 combination treatment for hypothyroidism. EVIDENCE ACQUISITION We searched PubMed and Scopus using related keywords. RESULTS The LT4 monotherapy causes higher serum free T4 (fT4), subnormal serum free T3 (fT3), and fT3/fT4 ratio in one-fourth of patients. The LT4+LT3 combination therapy increases serum T3 and fT3 concentrations and may normalize the fT3/fT4 ratio. However, the primary outcomes, including thyroid hormone deficiency, anxiety, depression, and quality of life, may not be better in LT4+LT3 combination therapy than in LT4 monotherapy. Recent surveys show that combination therapy is on the rise, in particular, due to patient demand. The LT4 plus slow-release LT3 preparation has shown promising results in improving serum thyroid hormone concentrations. CONCLUSIONS The beneficial effect of LT4+LT3 combination therapy is not clear, and the safety of long-term therapy is yet under question. More scientific well-designed research projects are required in this field.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ladan Mehran
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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