1
|
Seng Yue C, Scarsi C, Bettazzi E, Mautone G, Celi FS, Ducharme M. Proton Pump Inhibitors Do Not Affect the Bioavailability of a Novel Liquid Formulation of Levothyroxine. Endocr Pract 2024; 30:513-520. [PMID: 38554774 DOI: 10.1016/j.eprac.2024.03.388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE This study evaluates the impact of a representative proton pump inhibitor (PPI) (omeprazole), administered simultaneously or staggered, on the pharmacokinetics of levothyroxine (LT4) solution (Tirosint-SOL). METHODS This was a randomized, 3-way crossover, comparative bioavailability study in 36 healthy adults under fasting conditions. Omeprazole 40 mg delayed-release capsule was administered once daily from Day 1 to 6 (mornings, Treatment-A; evenings, Treatment-B; none, Treatment-C) to increase and stabilize gastric pH. In the morning of Day 5, a single dose of LT4 solution 600 mcg was administered. Blood samples were collected 0 to 48 hours post-LT4 administration. Noncompartmental pharmacokinetic parameters were calculated for total serum thyroxine using baseline-corrected data. Maximum concentration (Cmax) and area under the concentration-time curve (AUC0-48) were included in an analysis of variance to obtain geometric mean ratios and 90% confidence intervals. RESULTS For both comparisons (A/C and B/C), geometric mean ratios and 90% confidence intervals for all parameters were within the equivalence boundaries (80%-125%), indicating bioequivalence: for A/C, AUC0-48 98.98% [94%-104%], and Cmax 91.68% [87%-97%]; for B/C, AUC0-48 98.94% [95%-103%], and Cmax 94.90% [90%-100%]. Median Tmax (time associated with Cmax) was similar across treatments. CONCLUSION This study demonstrated that Tirosint-SOL bioavailability is unaffected by coadministration of a representative PPI, given simultaneously or staggered by about 12 hours, compared to administration of LT4 solution alone. For hypothyroid patients on PPI therapy, administration of LT4 solution may reduce variations in thyroid stimulating hormone levels related to intermittent use of acid-reducing drugs and consequently the need for dose adjustments.
Collapse
Affiliation(s)
| | | | | | | | - Francesco S Celi
- Department of Medicine at University of Connecticut Health, Farmington, Connecticut
| | | |
Collapse
|
2
|
Wei BR, Zhao YJ, Cheng YF, Huang C, Zhang F. Helicobacter pylori infection and Parkinson's Disease: etiology, pathogenesis and levodopa bioavailability. Immun Ageing 2024; 21:1. [PMID: 38166953 PMCID: PMC10759355 DOI: 10.1186/s12979-023-00404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
Parkinson's disease (PD), a neurodegenerative disorder with an unknown etiology, is primarily characterized by the degeneration of dopamine (DA) neurons. The prevalence of PD has experienced a significant surge in recent years. The unidentified etiology poses limitations to the development of effective therapeutic interventions for this condition. Helicobacter pylori (H. pylori) infection has affected approximately half of the global population. Mounting evidences suggest that H. pylori infection plays an important role in PD through various mechanisms. The autotoxin produced by H. pylori induces pro-inflammatory cytokines release, thereby facilitating the occurrence of central inflammation that leads to neuronal damage. Simultaneously, H. pylori disrupts the equilibrium of gastrointestinal microbiota with an overgrowth of bacteria in the small intestinal known as small intestinal bacterial overgrowth (SIBO). This dysbiosis of the gut flora influences the central nervous system (CNS) through microbiome-gut-brain axis. Moreover, SIBO hampers levodopa absorption and affects its therapeutic efficacy in the treatment of PD. Also, H. pylori promotes the production of defensins to regulate the permeability of the blood-brain barrier, facilitating the entry of harmful factors into the CNS. In addition, H. pylori has been found to induce gastroparesis, resulting in a prolonged transit time for levodopa to reach the small intestine. H. pylori may exploit levodopa to facilitate its own growth and proliferation, or it can inflict damage to the gastrointestinal mucosa, leading to gastrointestinal ulcers and impeding levodopa absorption. Here, this review focused on the role of H. pylori infection in PD from etiology, pathogenesis to levodopa bioavailability.
Collapse
Affiliation(s)
- Bang-Rong Wei
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education and Key Laboratory of Basic Pharmacology of Guizhou Province and Laboratory Animal Centre, Zunyi Medical University, Zunyi, Guizhou, China
| | - Yu-Jia Zhao
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education and Key Laboratory of Basic Pharmacology of Guizhou Province and Laboratory Animal Centre, Zunyi Medical University, Zunyi, Guizhou, China
| | - Yu-Feng Cheng
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education and Key Laboratory of Basic Pharmacology of Guizhou Province and Laboratory Animal Centre, Zunyi Medical University, Zunyi, Guizhou, China
| | - Chun Huang
- The Fifth People's Hospital of Chongqing, Chongqing, China
| | - Feng Zhang
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education and Key Laboratory of Basic Pharmacology of Guizhou Province and Laboratory Animal Centre, Zunyi Medical University, Zunyi, Guizhou, China.
| |
Collapse
|
3
|
Santos Monteiro S, Santos TS, Lopes AM, Oliveira JC, Freitas C, Couto Carvalho A. Levothyroxine malabsorption or pseudomalabsorption? A question in the management of refractory hypothyroidism. Endocr Connect 2022; 11:EC-22-0355. [PMID: 36318199 PMCID: PMC9716372 DOI: 10.1530/ec-22-0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE The levothyroxine absorption test (LT4AT) is an important tool for distinguishing hypothyroidism due to malabsorption from 'pseudomalabsorption' conditions. Our aim was to review our institution's LT4AT results and assess its role in the management of patients with refractory hypothyroidism. METHODS We performed a retrospective study of all patients evaluated for refractory hypothyroidism who underwent LT4AT in our tertiary center between 2014 and 2020. Its results and the impact on thyroid function management during follow-up were assessed. RESULTS Ten female patients were included with a mean age of 40 years (min-max: 26-62). Mean weight was 72 kg (min-max: 43-88) and baseline LT4 dosage ranged from 2.5 to 5.3 µg/kg/day. The most common causes of hypothyroidism were postsurgical in 50% (n = 5) and autoimmune in 20% (n = 2). During LT4AT, normal LT4 absorption was found in all but one individual (mean FT4 increase of 231%, min-max: 85-668). The only patient with objective LT4 absorption impairment (maximal increase of 48% by hour 5) presented also Helicobacter pylori gastritis and prior history of 'intestinal surgery' during childhood. No adverse events were reported during any of the LT4ATs. During follow-up (median 11.5 months (IQR 23)), three patients obtained euthyroidism and six had improved their hypothyroidism state. CONCLUSIONS The LT4AT is an effective and safe way to assess refractory hypothyroidism and provides valuable information to distinguish LT4 malabsorption from 'pseudomalabsorption'. Our data suggest that most patients with suspicious LT4 malabsorption perform normally during LT4AT. This test provides relevant information for better management of patients with refractory hypothyroidism.
Collapse
Affiliation(s)
- Sílvia Santos Monteiro
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
- Correspondence should be addressed to S Santos Monteiro:
| | - Tiago Silva Santos
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
- Correspondence should be addressed to S Santos Monteiro:
| | - Ana Martins Lopes
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - José Carlos Oliveira
- Department of Clinical Pathology, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - Cláudia Freitas
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| | - André Couto Carvalho
- Division of Endocrinology, Diabetes and Metabolism. Department of Medicine, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar Porto, Portugal
| |
Collapse
|
4
|
Virili C, Bruno G, Santaguida MG, Gargano L, Stramazzo I, De Vito C, Cicenia A, Scalese G, Porowska B, Severi C, Centanni M. Levothyroxine treatment and gastric juice pH in humans: the proof of concept. Endocrine 2022; 77:102-111. [PMID: 35477833 PMCID: PMC9242941 DOI: 10.1007/s12020-022-03056-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/04/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE Despite the absorption of oral thyroxine (T4) occurs in the small bowel, several patients with gastric disorders show an increased need for T4. In vitro evidence suggested that medium pH variations interfere with T4 dissolution. This study was aimed at finding the proof of concept of a direct relationship between the minimal effective dose of T4 and the actual gastric juice pH. PATIENTS AND METHODS Among 311 consecutively thyroxine-treated patients, 61 bearing Hashimoto's thyroiditis (52 F/9 M; median age = 51 years) who complained persistent dyspepsia and/or upper abdominal symptoms following a noninvasive workup for gastrointestinal disorders, underwent EGDS with multiple biopsies and gastric juice pH measurement. All patients accepted to take thyroxine in fasting conditions, abstaining from eating or drinking for one hour. RESULTS Thyroxine requirement increased along with the rising gastric pH (ρ = 0.4229; p = 0.0007). A multivariate analysis revealed that gastric pH was, beside body mass index, the far more important independent variable in determining the effective dose of T4 (p = 0.001). The ROC curve revealed that the pH threshold for an increased thyroxine requirement was at 2.28, being the AUC by 78%. Subdividing patients by the histologic findings, it appeared a significant increase (p = 0.0025) along with the progressive damage of gastric mucosa. CONCLUSION The in vivo measurement of gastric pH highlighted its key role in determining the minimal effective dose of oral T4 and may explain the interference of food, of some drugs and gut disorders on levothyroxine treatment.
Collapse
Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Giovanni Bruno
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | | | | | - Ilaria Stramazzo
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, University of Rome, Rome, Italy
| | - Alessia Cicenia
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Giulia Scalese
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Barbara Porowska
- General and Specialistic Surgery 'Paride Stefanini', University of Rome, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Gastroenterology Unit, 'Sapienza" University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.
- Endocrine Unit, AUSL Latina, Latina, Italy.
| |
Collapse
|
5
|
Wong S, Krejsa C, Lee D, Harris A, Simard E, Wang X, Allard M, Podoll T, O'Reilly T, Slatter JG. Pharmacokinetics and Macrophage Inhibitory Cytokine-1 Pharmacodynamics of the Murine Double Minute 2 Inhibitor, Navtemadlin (KRT-232) in Fed and Fasted Healthy Subjects. Clin Pharmacol Drug Dev 2022; 11:640-653. [PMID: 35172043 PMCID: PMC9306949 DOI: 10.1002/cpdd.1070] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/12/2021] [Indexed: 12/19/2022]
Abstract
This single 60-mg dose, 4-period crossover study assessed the effect of food and formulation change on navtemadlin (KRT-232) pharmacokinetics (PK) and macrophage inhibitory cytokine-1 (MIC-1) pharmacodynamics. Healthy subjects (N = 30) were randomized to 3 treatment sequences, A: new tablet, fasted (reference, dosed twice); B: new tablet, 30 minutes after a high-fat meal (test 1); C: old tablet, fasted (test 2). PK/pharmacodynamic parameters were measured over 0 to 96 hours. Adverse events were mild without any discontinuations. No serious adverse events or deaths occurred. In treatment A, navtemadlin mean (coefficient of variation) maximum concentration (Cmax ) was 525 (66) ng/mL, at median time to maximum concentration (tmax ) of 2 hours. Mean (coefficient of variation) area under the plasma concentration-time curve from time 0 to time t (AUC0-t ) was 3392 (63.3) ng • h/mL, and arithmetic mean terminal half-life was 18.6 hours. Acyl glucuronide metabolite (M1)/navtemadlin AUC0-t ratio was 0.2, and urine excretion of navtemadlin was negligible. After a meal (B vs A), navtemadlin tmax was delayed by 1 hour. Geometric least squares means ratios (90%CI) for navtemadlin Cmax and AUC0-t were 102.7% (87.4-120.6) and 81.4% (76.2-86.9), respectively. Old vs new tablet fasted formulations (C vs A) had geometric least squares means ratios (90%CI) of 78.4% (72.0-85.3) for Cmax and 85.9% (80.5-91.7) for AUC0-t . MIC-1 Cmax and AUC were comparable across groups; tmax was delayed relative to navtemadlin tmax by ≈8 hours. Navtemadlin AUC0-t and MIC-1 AUC0-t correlated significantly. In conclusion, navtemadlin can be administered safely with or without food; the new formulation does not affect navtemadlin PK. The 60-mg navtemadlin dose elicited a reproducible and robust MIC-1 response that correlated well with navtemadlin exposure, indicating that murine double minute 2 target engagement leads to p53 activation.
Collapse
Affiliation(s)
- Shekman Wong
- Kartos Therapeutics, Inc, Redwood City, CA andBellevueWashingtonUSA
| | - Cecile Krejsa
- Kartos Therapeutics, Inc, Redwood City, CA andBellevueWashingtonUSA
| | - Dana Lee
- Kartos Therapeutics, Inc, Redwood City, CA andBellevueWashingtonUSA
| | - Anna Harris
- Kartos Therapeutics, Inc, Redwood City, CA andBellevueWashingtonUSA
| | | | - Xiaohui Wang
- Certara Strategic ConsultingPrincetonNew JerseyUSA
| | | | | | | | - J. Greg Slatter
- Kartos Therapeutics, Inc, Redwood City, CA andBellevueWashingtonUSA
| |
Collapse
|
6
|
A new approach against Helicobacter pylori using plants and its constituents: A review study. Microb Pathog 2022; 168:105594. [DOI: 10.1016/j.micpath.2022.105594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 02/07/2023]
|
7
|
Mirgoli OJ, Ramjas V, Munugoti S, Silverstein H, Malik F, Salem A, Cassavell F, Atoot A. An Unusual Cause of Refractory Hypothyroidism. Cureus 2022; 14:e23522. [PMID: 35494965 PMCID: PMC9038596 DOI: 10.7759/cureus.23522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
Refractory hypothyroidism has been increasingly identified worldwide. Primary hypothyroidism is considered refractory when there is a persistent elevation of thyroid-stimulating hormone (TSH) above the upper limit of normal despite escalating doses of levothyroxine with or without the persistence of hypothyroid symptoms. Further escalation of levothyroxine to supratherapeutic doses could be associated with potential complications such as iatrogenic hyperthyroidism, cardiac failure, and other conditions. Therefore, physicians should rule out non-compliance and pursue a further evaluation to identify etiologies for increased requirements or decreased absorption of levothyroxine in patients not achieving therapeutic doses. Here, we present a 40-year-old Indian male with worsening refractory hypothyroidism that resolved following eradication of his Helicobacter pylori (H. pylori) infection. Herein, we highlight a unique and reversible cause of refractory hypothyroidism. With this case report, we hope to encourage physicians to include H. pylori testing in the evaluation of primary hypothyroidism refractory to treatment.
Collapse
|
8
|
Jamil MZZ, Salman S, Akhtar M, Iqbal S, Bhalli A, Farooq H. Determining the Association Between Helicobacter pylori Infection and Treatment-Refractory Hypothyroidism. Cureus 2022; 14:e21316. [PMID: 35186575 PMCID: PMC8848460 DOI: 10.7759/cureus.21316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Refractory hypothyroidism, despite weight-based thyroxine dosing, is a common endocrinology consultation in outpatients. Chronic Helicobacter (H.) pylori infection has been reported to be responsible for the poor absorption of thyroxine from the small gut leading to suboptimal response with contradictory evidence. This study was carried out to determine the association of chronic Helicobacter pylori infection with refractory hypothyroidism in outpatients presenting to a tertiary care hospital. Methods One hundred thirty patients with the diagnosis of hypothyroidism, visiting Jinnah Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) Jinnah Hospital Lahore, Pakistan, from January 2020 to February 2021, were included in the study after informed consent following the non-probability consecutive sampling technique. All of these patients were 15-70 years of age, non-pregnant, and receiving thyroxine treatment for at least six weeks. Patients with a history of gastric surgery, malabsorption syndrome, or poor compliance were excluded from the study. Patients’ age, sex, and body mass index (BMI) were recorded in a structured proforma. Patients were categorized into two groups, i.e. controls (biochemically euthyroid on thyroxine treatment with TSH < 4.5mU/L) and cases (refractory hypothyroidism despite 1.6 mcg/kg thyroxine treatment with TSH > 4.5 mU/L). The presence of chronic H. pylori infection was checked with serum immunoglobulin G (IgG) testing by enzyme-linked immunoassay (ELISA) from the hospital laboratory and data analysis was done by SPSS version 21.0 (IBM Corp., Armonk, NY). Results One hundred thirty patients were included in this study, with an age range from 15 to 70 years. Of these, 65/130 (50%) were euthyroid on treatment and 65/130 (50%) had treatment-refractory hypothyroidism. The mean age of patients in our study was 45.81 ± 11 years, with 118 (90.8%) female patients. The prevalence of positive H. pylori IgG antibody was 47/130 (36.2%) overall, with 23 patients (35.4%) in the control (euthyroid) group and 24 patients (36.9%) in the cases (refractory hypothyroidism) group. The difference between the two groups was not statistically significant with an odds ratio of 1.069 (CI 0.523 - 2.187) and a p-value of 0.855. Moreover, age, gender, and BMI had no effect on chronic H. pylori association with refractory hypothyroidism. Conclusion This study does not suggest any significant association between chronic H. pylori infection and treatment-refractory hypothyroidism. Other factors like poor compliance, drug-drug interactions, and malabsorption disorders should be preferably sought in case of refractory hypothyroidism.
Collapse
|
9
|
Shamsdin SA, Khazraei H, Rahimi Jaberi A, Zamani M, Rafiee Monjezi M. Evaluation of Inflammatory Cytokine and Anti Helicobacter Pylori Antibodies in the Pathogenesis of Parkinson's Disease. Middle East J Dig Dis 2022; 14:96-102. [PMID: 36619735 PMCID: PMC9489332 DOI: 10.34172/mejdd.2022.261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/24/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND: Parkinson's disease is a neurodegenerative disorder characterized by degeneration of dopaminergic neurons in the substantia nigari. Previous studies have shown that Helicobacter pylori (H. pylori) infection is associated with treatment and clinical response to Parkinson's disease. In the present study, we aimed to investigate the effect of H. pylori infection in the pathogenesis of Parkinson's disease. METHODS: 75 patients who suffered from Parkinson's disease and H. pylori infection and 91 healthy controls were recruited. All the subjects were evaluated for serum IgM, IgG, and IgA antibodies as well as TNF-α, IL-6, and IL-4 cytokines by Enzyme-Linked ImmunoSorbent Assay (ELISA)methods. RESULTS: The participants included 102 men and 64 women with a mean age of 66±10.2 and 52.6±10.7 years in the patients and control groups, respectively. The level of IgG, TNF-α, IL-6 in the patients with Parkinson's infected with H. pylori was significantly more than that in the control group. In contrast, IgA was significantly lower in patients with Parkinson's disease compared with the control group. CONCLUSION: Probably, persistent infection with H. pylori could be effective in the pathogenesis of Parkinson's disease by dominating the systemic inflammatory profile. It is suggested that pro-inflammatory cytokines followed by H. pylori infection through the promotion of immune response or neurotoxicity might have a role in the pathogenesis of Parkinson's disease.
Collapse
Affiliation(s)
- Seyedeh Azra Shamsdin
- Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hajar Khazraei
- Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abass Rahimi Jaberi
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran,Corresponding Author: Abass Rahimi Jaberi, MD Assistant Professor, Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran Tel:+98 7136121065 Fax:+98 7136121065
| | - Mozhdeh Zamani
- Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | |
Collapse
|
10
|
Ferrari SM, Ragusa F, Elia G, Paparo SR, Mazzi V, Baldini E, Benvenga S, Antonelli A, Fallahi P. Precision Medicine in Autoimmune Thyroiditis and Hypothyroidism. Front Pharmacol 2021; 12:750380. [PMID: 34867359 PMCID: PMC8635786 DOI: 10.3389/fphar.2021.750380] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
Autoimmune thyroid diseases (AITD) are T-cell-mediated organ specific autoimmune disorders, deriving from an altered response of the immune system that leads to the immune attack to the thyroid. Hashimoto’s thyroiditis (HT) and Graves’ disease (GD) are the two principal AITD clinical presentations. Hypothyroidism and thyrotoxicosis are, respectively, the clinical hallmarks of HT and GD. Patients with autoimmune thyroiditis are treated daily with synthetic L-thyroxine (L-T4) at the dose of 1.5–1.7 μg/kg. Various L-T4 formulations are commercially available (tablet, liquid solution, or soft gel capsule). L-T4 in tablets is generally prescribed to treat hypothyroidism, whereas the liquid formulation, or soft gel capsules, can be administered in hypothyroid patients in case of malabsorption or in patients in therapy with drugs interfering with L-T4 absorption. Furthermore, myoinositol has a crucial role in thyroid autoimmunity and function. Clinical studies reported a significant decline in TSH and antithyroid autoantibodies levels after treatment with myoinositol + selenium in patients with subclinical hypothyroidism and autoimmune thyroiditis. Moreover, thyroidectomy can be rarely recommended in patients with autoimmune thyroiditis, with cosmetic reasons for a goiter, or with important signs or symptoms of local compression, or nodular disease with a “suspicious” cytology for malignancy. Furthermore, a recent randomized trial suggested that total thyroidectomy can improve quality of life and fatigue, while medical therapy did not. In this review, we overview currently available evidence in personalized medicine in patients with autoimmune thyroiditis and hypothyroidism. Further research is needed in larger population to investigate the effect of these new treatments on quality of life.
Collapse
Affiliation(s)
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giusy Elia
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | | | - Valeria Mazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Enke Baldini
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women’s Endocrine Health, Azienda Ospedaliera Universitaria Policlinico “G. Martino”, I-98125, Messina, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| |
Collapse
|
11
|
Piscione M, Mazzone M, Di Marcantonio MC, Muraro R, Mincione G. Eradication of Helicobacter pylori and Gastric Cancer: A Controversial Relationship. Front Microbiol 2021; 12:630852. [PMID: 33613500 PMCID: PMC7889593 DOI: 10.3389/fmicb.2021.630852] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/14/2021] [Indexed: 12/15/2022] Open
Abstract
Worldwide, gastric cancer (GC) represents the fifth cancer for incidence, and the third as cause of death in developed countries. Indeed, it resulted in more than 780,000 deaths in 2018. Helicobacter pylori appears to be responsible for the majority of these cancers. On the basis of recent studies, and either alone or combined with additional etiological factors, H. pylori is considered a “type I carcinogen.” Over recent decades, new insights have been obtained into the strategies that have been adopted by H. pylori to survive the acidic conditions of the gastric environment, and to result in persistent infection, and dysregulation of host functions. The multistep processes involved in the development of GC are initiated by transition of the mucosa into chronic non-atrophic gastritis, which is primarily triggered by infection with H. pylori. This gastritis then progresses into atrophic gastritis and intestinal metaplasia, and then to dysplasia, and following Correa’s cascade, to adenocarcinoma. The use of antibiotics for eradication of H. pylori can reduce the incidence of precancerous lesions only in the early stages of gastric carcinogenesis. Here, we first survey the etiology and risk factors of GC, and then we analyze the mechanisms underlying tumorigenesis induced by H. pylori, focusing attention on virulence factor CagA, inflammation, oxidative stress, and ErbB2 receptor tyrosine kinase. Moreover, we investigate the relationships between H. pylori eradication therapy and other diseases, considering not only cardia (upper stomach) cancers and Barrett’s esophagus, but also asthma and allergies, through discussion of the “hygiene hypothesis. ” This hypothesis suggests that improved hygiene and antibiotic use in early life reduces microbial exposure, such that the immune response does not become primed, and individuals are not protected against atopic disorders, asthma, and autoimmune diseases. Finally, we overview recent advances to uncover the complex interplay between H. pylori and the gut microbiota during gastric carcinogenesis, as characterized by reduced bacterial diversity and increased microbial dysbiosis. Indeed, it is of particular importance to identify the bacterial taxa of the stomach that might predict the outcome of gastric disease through the stages of Correa’s cascade, to improve prevention and therapy of gastric carcinoma.
Collapse
Affiliation(s)
- Mariagrazia Piscione
- Department of Innovative Technologies in Medicine and Dentistry, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Mariangela Mazzone
- Department of Innovative Technologies in Medicine and Dentistry, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Maria Carmela Di Marcantonio
- Department of Innovative Technologies in Medicine and Dentistry, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Raffaella Muraro
- Department of Innovative Technologies in Medicine and Dentistry, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Gabriella Mincione
- Department of Innovative Technologies in Medicine and Dentistry, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| |
Collapse
|
12
|
Raeder V, Boura I, Leta V, Jenner P, Reichmann H, Trenkwalder C, Klingelhoefer L, Chaudhuri KR. Rotigotine Transdermal Patch for Motor and Non-motor Parkinson's Disease: A Review of 12 Years' Clinical Experience. CNS Drugs 2021; 35:215-231. [PMID: 33559846 PMCID: PMC7871129 DOI: 10.1007/s40263-020-00788-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 12/15/2022]
Abstract
Motor and non-motor symptoms (NMS) have a substantial effect on the health-related quality of life (QoL) of patients with Parkinson's disease (PD). Transdermal therapy has emerged as a time-tested practical treatment option, and the rotigotine patch has been used worldwide as an alternative to conventional oral treatment for PD. The efficacy of rotigotine on motor aspects of PD, as well as its safety and tolerability profile, are well-established, whereas its effects on a wide range of NMS have been described and studied but are not widely appreciated. In this review, we present our overall experience with rotigotine and its tolerability and make recommendations for its use in PD and restless legs syndrome, with a specific focus on NMS, underpinned by level 1-4 evidence. We believe that the effective use of the rotigotine transdermal patch can address motor symptoms and a wide range of NMS, improving health-related QoL for patients with PD. More specifically, the positive effects of rotigotine on non-motor fluctuations are also relevant. We also discuss the additional advantages of the transdermal application of rotigotine when oral therapy cannot be used, for instance in acute medical emergencies or nil-by-mouth or pre/post-surgical scenarios. We highlight evidence to support the use of rotigotine in selected cases (in addition to general use for motor benefit) in the context of personalised medicine.
Collapse
Affiliation(s)
- Vanessa Raeder
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Iro Boura
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
- Department of Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Valentina Leta
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK.
- Department of Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Peter Jenner
- Neurodegenerative Diseases Research Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Heinz Reichmann
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Claudia Trenkwalder
- Department of Neurosurgery, University Medical Centre Göttingen, Göttingen, Germany
- Paracelsus-Elena Klinik, Kassel, Germany
| | | | - K Ray Chaudhuri
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
- Department of Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
13
|
Antonelli A, Elia G, Ragusa F, Paparo SR, Cavallini G, Benvenga S, Ferrari SM, Fallahi P. The Stability of TSH, and Thyroid Hormones, in Patients Treated With Tablet, or Liquid Levo-Thyroxine. Front Endocrinol (Lausanne) 2021; 12:633587. [PMID: 33790863 PMCID: PMC8006411 DOI: 10.3389/fendo.2021.633587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/29/2021] [Indexed: 01/01/2023] Open
Abstract
Approximately, 5% of the population is affected by hypothyroidism, mainly women and persons aged more than 60 years. After the diagnosis of hypothyroidism the usual therapy is tablet levothyroxine (L-T4), with a monitoring of the thyroid-stimulating hormone (TSH) level in primary hypothyroidism every 6-8 weeks and L-T4 is adjusted as necessary to reach an euthyroid state. Once TSH is stabilized in the normal range, it is recommended to conduct annual testing in the treated subjects to warrant suitable replacement. More recently advances regarding L-T4 treatment are the introduction of new oral formulations: the liquid solution, and soft gel capsule. The soft gel capsule permits a quick dissolution in the acid gastric pH. The liquid preparation does not require an acid gastric environment. Many pharmacokinetic studies demonstrated a more rapid absorption for the liquid L-T4, or capsule, than with tablet. Many studies have shown that the liquid, or capsule, formulations can overcome the interaction with foods, drugs or malabsorptive conditions, that are able to impair the tablet L-T4 absorption. Lately studies have suggested that liquid L-T4 can permit to maintain more efficiently normal TSH levels in hypothyroid patients in the long-term follow-up, than tablet L-T4, both in patients with malabsorptive states, and in those without malabsorption. Further large, prospective, longitudinal studies are needed to evaluate the stability of TSH, in hypothyroid patients treated with different L-T4 formulations.
Collapse
Affiliation(s)
- Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Gabriella Cavallini
- Interdepartmental Research Centre on Biology and Pathology of Aging, University of Pisa, Pisa, Italy
| | - Salvatore Benvenga
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program on Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, A.O.U. Policlinico Gaetano Martino, Messina, Italy
| | | | - Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| |
Collapse
|
14
|
Fallahi P, Ferrari SM, Elia G, Ragusa F, Paparo SR, Antonelli A. L-T4 Therapy in Enteric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2021; 12:626371. [PMID: 33708175 PMCID: PMC7940821 DOI: 10.3389/fendo.2021.626371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
Levothyroxine (L-T4) absorption can be impaired by various causes: a) L-T4 ingestion during breakfast, or with food; b) conditions of reduced gastric acidity; c) intestinal procedures and diseases such as bariatric surgery, lactose intolerance (LI), celiac disease (CD), inflammatory bowel disease; d) drugs that alter L-T4 absorption, increasing the gastric pH, or preventing the dissolution of tablets. The development of new oral formulations, i.e. the liquid preparation and the soft gel capsule, represents the most recent advance regarding L-T4 therapy. Treating hypothyroidism with L-T4 tablets can lead to an improper control of thyroid-stimulating hormone (TSH) in ~10%-15% of patients. The improperly elevated TSH is usually managed by increasing the L-T4 daily dose, and revaluating TSH upon 2-6 months. The increase of the L-T4 dosage may cause iatrogenic hyperthyroidism, especially when the underlying disorders are cured. Liquid L-T4 can be administered in patients unable to swallow capsules or tablets, and this is one of its major benefits. Liquid L-T4 can: 1- overcome food and beverages interference; 2- bypass the malabsorption associated with an increased gastric pH; 3- circumvent the issue of malabsorption in patients who underwent bariatric surgery; 4-maintain TSH values under control better than L-T4 tablets in hypothyroid patients with typical or atypical CD, or in patients with LI. Few clinical studies evaluated soft gel L-T4 with encouraging findings in patients with gastric- or coffee-related malabsorption, or hypothyroid patients without malabsorption. Additional research is necessary to investigate liquid L-T4, or soft gel capsule, in other conditions of altered L-T4 absorption.
Collapse
Affiliation(s)
- Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- *Correspondence: Poupak Fallahi,
| | | | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| |
Collapse
|
15
|
Stillhart C, Vučićević K, Augustijns P, Basit AW, Batchelor H, Flanagan TR, Gesquiere I, Greupink R, Keszthelyi D, Koskinen M, Madla CM, Matthys C, Miljuš G, Mooij MG, Parrott N, Ungell AL, de Wildt SN, Orlu M, Klein S, Müllertz A. Impact of gastrointestinal physiology on drug absorption in special populations––An UNGAP review. Eur J Pharm Sci 2020; 147:105280. [DOI: 10.1016/j.ejps.2020.105280] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
|
16
|
Wawro N, Amann U, Butt J, Meisinger C, Akmatov MK, Pessler F, Peters A, Rathmann W, Kääb S, Waterboer T, Linseisen J. Helicobacter pylori Seropositivity: Prevalence, Associations, and the Impact on Incident Metabolic Diseases/Risk Factors in the Population-Based KORA Study. Front Public Health 2019; 7:96. [PMID: 31069210 PMCID: PMC6491664 DOI: 10.3389/fpubh.2019.00096] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/04/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction: Helicobacter pylori (H. pylori) is a common infection and known risk factor for gastric cancer. We assessed cross-sectional and longitudinal associations to study the impact of H. pylori seropositivity on metabolic diseases. Methods: Helicobacter pylori seropositivity in serum samples of the KORA study was analyzed by multiplex serology. We calculated sex-specific prevalence of H. pylori seropositivity for the year 2007 based on the first follow-up survey (termed F4) of the KORA study S4. We identified factors associated with H. pylori seropositivity in the F4 survey. Further, we assessed relative risks of incident metabolic diseases/risk factors at the time of the second follow-up survey of S4 (termed FF4) and H. pylori seropositivity at the F4 survey as a determinant. Models were adjusted for age, sex, overweight status, physical activity, smoking status, education level, alcohol intake, and other metabolic diseases. Results: Based on 3,037 persons aged 32 to 82 years, the H. pylori prevalence for 2007 was 30.2% in men (n = 1,465) and 28.1% in women (n = 1,572). Increasing age, current smoking, low education and no alcohol intake were significantly associated with H. pylori seropositivity in the F4 survey. However, no association between H. pylori seropositivity and BMI, metabolic diseases (type 2 diabetes, hypertension and dyslipidemia, gout or increased uric acid) and gastrointestinal diseases (gastritis, inflammatory bowel disease, and gastric or duodenal ulcer) was observed. No significant associations between H. pylori seropositivity and one of the five investigated incident metabolic diseases/risk factors were detected in the longitudinal analysis. Conclusion: We identified associations between age, smoking, education and alcohol intake and H. pylori seropositivity but no impact of H. pylori seropositivity on incident metabolic diseases/risk factors.
Collapse
Affiliation(s)
- Nina Wawro
- German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Munich, Germany.,German Center for Diabetes Research (DZD e.V.), Munich, Germany.,Chair of Epidemiology, Ludwig-Maximilians-Universität München, UNIKA-T, Augsburg, Germany.,German Research Center for Environmental Health (GmbH), Independent Research Group Clinical Epidemiology, Munich, Germany
| | - Ute Amann
- German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Munich, Germany.,Chair of Epidemiology, Ludwig-Maximilians-Universität München, UNIKA-T, Augsburg, Germany
| | - Julia Butt
- Infections and Cancer Epidemiology, Infection, Inflammation and Cancer Program, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christa Meisinger
- German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Munich, Germany.,Chair of Epidemiology, Ludwig-Maximilians-Universität München, UNIKA-T, Augsburg, Germany
| | - Manas K Akmatov
- TWINCORE, Centre for Experimental and Clinical Infection Research, Hanover, Germany.,Helmholtz-Zentrum für Infektionsforschung (HZI), Braunschweig, Germany
| | - Frank Pessler
- TWINCORE, Centre for Experimental and Clinical Infection Research, Hanover, Germany.,Helmholtz-Zentrum für Infektionsforschung (HZI), Braunschweig, Germany
| | - Annette Peters
- German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Munich, Germany.,German Center for Diabetes Research (DZD e.V.), Munich, Germany
| | - Wolfgang Rathmann
- Deutsches Diabeteszentrum, Institute for Biometrics and Epidemiology, Düsseldorf, Germany
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, Campus Grosshadern, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Tim Waterboer
- Infections and Cancer Epidemiology, Infection, Inflammation and Cancer Program, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jakob Linseisen
- German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Munich, Germany.,Chair of Epidemiology, Ludwig-Maximilians-Universität München, UNIKA-T, Augsburg, Germany.,German Research Center for Environmental Health (GmbH), Independent Research Group Clinical Epidemiology, Munich, Germany
| |
Collapse
|
17
|
Yildirim Simsir I, Soyaltin UE, Ozgen AG. Levothyroxine absorption test results in patients with TSH elevation resistant to treatment. Endocrine 2019; 64:118-121. [PMID: 30868414 DOI: 10.1007/s12020-019-01889-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/01/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Persistent elevation of thyroid-stimulating hormone (TSH) is common in endocrinology practice in patients undergoing replacement or suppression therapy with levothyroxine sodium (LT4). After examining the causes of this condition, LT4 absorption test is recommended. In this report, we wanted to share our results of LT4 absorption test in patients with elevated TSH levels. MATERIALS-METHODS The files of patients who presented to our clinic between 2015 and 2018, whose TSH elevation continued despite high-dose LT4 therapy, and who underwent absorption test were reviewed retrospectively. RESULTS Levothyroxine sodium absorption test was applied to five patients. Absorption test revealed LT4 malabsorption in two patients and pseudomalabsorption in the other three patients. DISCUSSION When all published pseudomalabsorption cases were considered, it has been stated that at least 2.5 times increase in basal fT4 level may exclude malabsorption. The formula we used has been implemented by Cleveland Clinic since 2014. CONCLUSION In cases where TSH normalization is not achieved despite high doses of LT4 therapy, LT4 absorption test is an easy test for administration and interpretation and prevents unnecessary medical treatments and examinations.
Collapse
Affiliation(s)
- Ilgin Yildirim Simsir
- Division of Endocrinology and Metabolism Disorders, Ege University Medical Faculty, Izmir, Turkey.
| | - Utku Erdem Soyaltin
- Division of Endocrinology and Metabolism Disorders, Ege University Medical Faculty, Izmir, Turkey
| | - Ahmet Gokhan Ozgen
- Division of Endocrinology and Metabolism Disorders, Ege University Medical Faculty, Izmir, Turkey
| |
Collapse
|
18
|
Tortora A, La Sala D, Vitale M. Switch from tablet levothyroxine to oral solution resolved reduced absorption by intestinal parasitosis. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190026. [PMID: 30897550 PMCID: PMC6432983 DOI: 10.1530/edm-19-0026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/04/2019] [Indexed: 12/23/2022] Open
Abstract
Reduced intestinal absorption of levothyroxine (LT4) is the most common cause of failure to achieve an adequate therapeutic target in hypothyroid patients under replacement therapy. We present the case of a 63-year-old woman with autoimmune hypothyroidism previously well-replaced with tablet LT4 who became unexpectedly no more euthyroid. At presentation, the patient reported the onset of acute gastrointestinal symptoms characterized by nausea, loss of appetite, flatulence, abdominal cramps and diarrhea, associated with increase of thyrotropin levels (TSH: 11 mIU/mL). Suspecting a malabsorption disease, a thyroxine solid-to-liquid formulation switch, at the same daily dose, was adopted to reach an optimal therapeutic target despite the gastrointestinal symptoms persistence. Oral LT4 solution normalized thyroid hormones. Further investigations diagnosed giardiasis, and antibiotic therapy was prescribed. This case report is compatible with a malabsorption syndrome caused by an intestinal parasite (Giardia lamblia). The reduced absorption of levothyroxine was resolved by LT4 oral solution. Learning points: The failure to adequately control hypothyroidism with oral levothyroxine is a common clinical problem. Before increasing levothyroxine dose in a patient with hypothyroidism previously well-controlled with LT4 tablets but no more in appropriate therapeutic target, we suggest to investigate non adhesion to LT4 therapy, drug or food interference with levothyroxine absorption, intestinal infection, inflammatory intestinal disease, celiac disease, lactose intolerance, short bowel syndrome after intestinal or bariatric surgery, hepatic cirrhosis and congestive heart failure. LT4 oral solution has a better absorptive profile than the tablet. In hypothyroid patients affected by malabsorption syndrome, switch of replacement therapy from tablet to liquid LT4 should be tested before increasing the dose of LT4.
Collapse
Affiliation(s)
- Anna Tortora
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Domenico La Sala
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Mario Vitale
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| |
Collapse
|
19
|
Virili C, Antonelli A, Santaguida MG, Benvenga S, Centanni M. Gastrointestinal Malabsorption of Thyroxine. Endocr Rev 2019; 40:118-136. [PMID: 30476027 DOI: 10.1210/er.2018-00168] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/12/2018] [Indexed: 02/07/2023]
Abstract
Levothyroxine, a largely prescribed drug with a narrow therapeutic index, is often a lifelong treatment. The therapeutic efficacy of T4 may be marred by behavioral, pharmacologic, and pathologic issues acting as interfering factors. Despite a continuous search for an optimal T4 treatment, a significant number of patients fail to show a complete chemical and/or clinical response to this reference dose of T4. Gastrointestinal malabsorption of oral T4 represents an emerging cause of refractory hypothyroidism and may be more frequent than previously reputed. In this review, we examine the pharmacologic features of T4 preparations and their linkage with the intestinal absorption of the hormone. We have stressed the major biochemical and pharmacologic characteristics of T4 and its interaction with the putative transporter at the intestinal level. We have examined the interfering role of nutrients, foods, and drugs on T4 absorption at the gastric and intestinal levels. The impact of gastrointestinal disorders on T4 treatment efficacy has been also analyzed, in keeping with the site of action and the interfering mechanisms. Based on the evidence obtained from the literature, we also propose a schematic diagnostic workup for the most frequent and often hidden gastrointestinal diseases impairing T4 absorption.
Collapse
Affiliation(s)
- Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Interdepartmental Program of Molecular and Clinical Endocrinology, and Women's Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
| |
Collapse
|
20
|
Virili C, Stramazzo I, Santaguida MG, Bruno G, Brusca N, Capriello S, Cellini M, Severi C, Gargano L, Centanni M. Ulcerative Colitis as a Novel Cause of Increased Need for Levothyroxine. Front Endocrinol (Lausanne) 2019; 10:233. [PMID: 31040825 PMCID: PMC6476912 DOI: 10.3389/fendo.2019.00233] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Thyroxine absorption takes place at the small intestine level and several disorders affecting this intestinal tract lead to thyroxine malabsorption. An increased need for thyroxine has also been observed in gastric disorders due to variations in drug dissolution and/or in its ionization status. Ulcerative colitis (UC) is an inflammatory bowel disease that has been postulated as a potential cause of the increased need for thyroxine, but there is a lack of evidence on this topic. This study is aimed at measuring the thyroxine requirement in hypothyroid patients with UC. Patients and Methods: Among 8,573 patients with thyroid disorders consecutively seen in our referral center from 2010 to 2017, we identified 34 patients with a definite diagnosis of UC. Thirteen of them were hypothyroid (12 F/1 M; median age = 53 years), bearing UC during the remission phase and in need for thyroxine treatment, thus representing the study group. The dose of T4 required by UC patients has been compared to the one observed in 51 similarly treated age- and weight-matched patients, compliant with treatment and clearly devoid of any gastrointestinal and /or pharmacological interference. Results: To reach the target serum TSH, the dose of thyroxine had to be increased in twelve out of thirteen (92%) hypothyroid patients with ulcerative colitis. The median thyroxine dose required by UC patients was 1.54 μg/kg weight/day, that is 26% higher than the control patients, to reach a similar TSH (1.23 μg/kg weight/day; p = 0.0002). Since half of our study group consisted of patients aged over 60 years old, we analyzed the effect of age on the subdivision in two classes. Six out of seven (86%) adult patients (<60 years) required more T4 than those in the respective control group (1.61 vs. 1.27 μg/kg weight/day; +27%; p < 0.0001). An increased dose (+17%; p = 0.0026) but to a lesser extent, was also observed in all patients over 60 years, as compared to the control group. Conclusions: In almost all hypothyroid patients with UC, the therapeutic dose of thyroxine is increased. Therefore, ulcerative colitis, even during clinical remission, should be included among the gastrointestinal causes of an increased need for oral thyroxine.
Collapse
Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- *Correspondence: Camilla Virili
| | - Ilaria Stramazzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | | | - Giovanni Bruno
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Nunzia Brusca
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Silvia Capriello
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Miriam Cellini
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Carola Severi
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Lucilla Gargano
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
| |
Collapse
|
21
|
Skelin M, Lucijanić T, Liberati-Čizmek AM, Klobučar SM, Lucijanić M, Jakupović L, Bakula M, Lončar JV, Marušić S, Matić T, Romić Ž, Dumić J, Rahelić D. Effect of timing of levothyroxine administration on the treatment of hypothyroidism: a three-period crossover randomized study. Endocrine 2018; 62:432-439. [PMID: 30043093 DOI: 10.1007/s12020-018-1686-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/12/2018] [Indexed: 12/22/2022]
Abstract
AIM Hypothyroidism is a common clinical problem that is successfully treated with hormone substitutes in the form of levothyroxine (LT4). LT4 is a drug with a narrow therapeutic index and is usually administered by strict rules, standardly at least half an hour before breakfast. The aim of this study was to investigate a possible effect of different timings of administration on thyroid function status and lipid profile. METHODS The study included patients with the diagnosis of primary hypothyroidism, which were using a stable dose of levothyroxine. They were randomized into three different groups regarding the timing of LT4 administration in a crossover fashion. Each timing regimen lasted for at least 8 weeks; timing regimen A-half an hour before breakfast; timing regimen B-an hour before the main meal of the day; timing regimen C-at bedtime (minimally 2 h after dinner). The hormones (TSH, fT3, fT4) and lipid profile (triglycerides, HDL-, LDL-, and total cholesterol) were measured before the study, at the beginning of every timing regimen and at the end of the study. RESULTS Altogether, 84 patients finished the study. Different timings of LT4 administration were non-inferior in comparison to the standard one and between each other. Median differences in TSH level between baseline and timing regimens were: baseline vs. A = -0.017 95% C.I. (-0.400-0.192); baseline vs. B = -0.325 95% C.I. (-0.562-0.023); baseline vs. C = -0.260 95% C.I. (-0.475-0.000). There were no statistically significant differences in either TSH, fT4, or fT3 when compared between all three timing regimens of LT4 administration and the baseline. There were no statistically significant differences in any of the lipid profile parameters (triglycerides, HDL-, LDL-, and total cholesterol) when compared between all three timing regimens of LT4 administration and the baseline. CONCLUSION The three investigated timing regimens of LT4 administration were equally efficient and offer additional options regarding the treatment individualization.
Collapse
Affiliation(s)
- Marko Skelin
- Pharmacy Department, General Hospital Šibenik, Šibenik, Croatia.
| | - Tomo Lucijanić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dubrava University Hospital, Zagreb, Croatia
| | - Ana-Marija Liberati-Čizmek
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh", Zagreb, Croatia
| | - Sanja Majanović Klobučar
- Rijeka Clinical Hospital Centre, Faculty of Medicine, Department of Endocrinology, Diabetes and Metabolic Diseases, University of Rijeka, Rijeka, Croatia
| | - Marko Lucijanić
- Hematology Department, Dubrava University Hospital, Zagreb, Croatia
| | - Lejsa Jakupović
- Healthcare institution of community pharmacies, Slavonski Brod, Croatia
| | - Miro Bakula
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh", Zagreb, Croatia
| | | | - Srečko Marušić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dubrava University Hospital, Zagreb, Croatia
| | - Tomas Matić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dubrava University Hospital, Zagreb, Croatia
| | - Željko Romić
- Department of Laboratory Diagnostic, Dubrava University Hospital, Zagreb, Croatia
| | - Jerka Dumić
- Faculty of Pharmacy and Biochemistry, Department of Biochemistry and Molecular Biology, University of Zagreb, Zagreb, Croatia
| | - Dario Rahelić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dubrava University Hospital, Zagreb, Croatia
| |
Collapse
|
22
|
El-Serag HB, Kao JY, Kanwal F, Gilger M, LoVecchio F, Moss SF, Crowe S, Elfant A, Haas T, Hapke RJ, Graham DY. Houston Consensus Conference on Testing for Helicobacter pylori Infection in the United States. Clin Gastroenterol Hepatol 2018; 16:992-1002.e6. [PMID: 29559361 PMCID: PMC6913173 DOI: 10.1016/j.cgh.2018.03.013] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/02/2018] [Accepted: 03/09/2018] [Indexed: 02/07/2023]
Abstract
Despite guidelines for detection and treatment of Helicobacter pylori infection, recommendations to test patients before and after therapy are commonly not followed in the United States. At the Houston Consensus Conference, 11 experts on management of adult and pediatric patients with H pylori, from different geographic regions of the United States, met to discuss key factors in diagnosis of H pylori infection, including identification of appropriate patients for testing, effects of antibiotic susceptibility on testing and treatment, appropriate methods for confirmation of infection and eradication, and relevant health system considerations. The experts divided into groups that used a modified Delphi panel approach to assess appropriate patients for testing, testing for antibiotic susceptibility and treatment, and test methods and confirmation of eradication. The quality of evidence and strength of recommendations were evaluated using the GRADE system. The results of the individual workshops were presented for a final consensus vote by all panel members. After the Expert Consensus Development meeting, the conclusions were validated by a separate panel of gastroenterologists, who assessed their level of agreement with each of the 29 statements developed at the Expert Consensus Development. The final recommendations are provided, on the basis of the best available evidence, and provide consensus statements with supporting literature to implement testing for H pylori infection at health care systems across the United States.
Collapse
Affiliation(s)
- Hashem B. El-Serag
- Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - John Y. Kao
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, Michigan
| | - Fasiha Kanwal
- Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas,Center for Innovation in Quality, Effectiveness, and Safety, Houston, Texas
| | - Mark Gilger
- Baylor College of Medicine, Children’s Hospital of San Antonio, San Antonio, Texas,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Frank LoVecchio
- Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - Sheila Crowe
- Department of Medicine, University of California, San Diego, La Jolla, California
| | - Adam Elfant
- Cooper Medical School, Rowan University, Camden, New Jersey
| | - Thomas Haas
- Department of Pathology, Mercy Health System, Janesville, Wisconsin
| | - Ronald J. Hapke
- Northwest Gastroenterology Clinic, Department of Gastroenterology, Legacy Emanuel Medical Center, Portland, Oregon
| | - David Y. Graham
- Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
23
|
Rdzak GM, Whitman LM, Inzucchi SE. Levothyroxine pseudo-malabsorption: testing and treatment in the outpatient setting. Ther Adv Endocrinol Metab 2018; 9:217-222. [PMID: 29977500 PMCID: PMC6022974 DOI: 10.1177/2042018818771433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 03/26/2018] [Indexed: 12/27/2022] Open
Abstract
Persistent elevation of thyroid stimulating hormone (TSH) is a common clinical problem in outpatient clinics treating patients with primary hypothyroidism. One challenge to practitioners involves predicaments where patients have an inadequate response to a seemingly appropriate dose of levothyroxine (L-T4). A patient's self-assessed compliance to hormone replacement therapy or verification refill history at the patient's pharmacy might not be a reliable form of confirmation of non-adherence to the drug by the patient, which has been referred to as "L-T4 pseudo-malabsorption." A fast and inexpensive tool to rule out true LT4 malabsorption and thereby properly diagnosing and ultimately successfully treat LT4 pseudo-malabsorption is available in the outpatient setting. This allows clinicians to identify which patients for individual support in adhering to their prescribed therapy and may also reduce unnecessary referrals for sub-specialty care by endocrinologists.
Collapse
Affiliation(s)
| | - Laura M. Whitman
- Yale Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Silvio E. Inzucchi
- Yale Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
24
|
Hatton GB, Madla CM, Rabbie SC, Basit AW. All disease begins in the gut: Influence of gastrointestinal disorders and surgery on oral drug performance. Int J Pharm 2018; 548:408-422. [PMID: 29969711 DOI: 10.1016/j.ijpharm.2018.06.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 02/07/2023]
Abstract
The term "disease" conjures a plethora of graphic imagery for many, and the use of drugs to combat symptoms and treat underlying pathology is at the core of modern medicine. However, the effects of the various gastrointestinal diseases, infections, co-morbidities and the impact of gastrointestinal surgery on the pharmacokinetic and pharmacodynamic behaviour of drugs have been largely overlooked. The better elucidation of disease pathology and the role of underlying cellular and molecular mechanisms have increased our knowledge as far as diagnoses and prognoses are concerned. In addition, the recent advances in our understanding of the intestinal microbiome have linked the composition and function of gut microbiota to disease predisposition and development. This knowledge, however, applies less so in the context of drug absorption and distribution for orally administered dosage forms. Here, we revisit and re-evaluate the influence of a portfolio of gastrointestinal diseases and surgical effects on the functionality of the gastrointestinal tract, their implications for drug delivery and attempt to uncover significant links for clinical practice.
Collapse
Affiliation(s)
- Grace B Hatton
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Christine M Madla
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Sarit C Rabbie
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Abdul W Basit
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom.
| |
Collapse
|
25
|
Utiyama SRR, De Bem RS, Skare TL, De Carvalho GA, Teixeira LM, Bertolazo M, Ioshii SO, Nisihara R. Anti-parietal cell antibodies in patients with autoimmune thyroid diseases. J Endocrinol Invest 2018; 41:523-529. [PMID: 28929353 DOI: 10.1007/s40618-017-0755-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/26/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autoimmune thyroid disease (ATD) patients may have a higher prevalence of anti-parietal cell antibodies (APCA) than normal population. OBJECTIVE To study the prevalence of APCA in a cohort of ATD patients to know its association with patient's clinical profile and gastrointestinal complaints. METHODS APCA was sought for by indirect immunofluorescence test in 243 ATD patients: 136 (55.9%) with Graves' disease and 107 (44.0%) with Hashimoto's thyroiditis. A structured questionnaire for gastrointestinal symptoms, previous history of thrombosis, arthralgia and other autoimmune diseases in the patients and their families was applied. Positive and negative APCA individuals were compared. Positive patients were invited to perform upper gastrointestinal endoscopy and biopsy of duodenum segments. Sera from 100 healthy individuals from the same geographic area were used as controls. RESULTS APCA was present in 20.1% (49/243) of ATD patients: 21.3% (29/136) in the Graves' sample and 18.6% (20/107) in the Hashimoto's sample (p = 0.61). Patients with positive APCA had more anemia (p = 0.03; OR = 2.89; 95% CI = 1.03-8.07) and less heartburn (p = 0.01; OR = 0.4; 95% CI = 0.20-0.83). Among the group of 49 APCA-positive patients, 24 agreed with upper endoscopy and it was found that 54.1% had atrophic gastritis. CONCLUSIONS There is a high prevalence of positive APCA in ATD patients. APCA are more common in those with anemia and less common in those with complaints of heartburn. Almost half of positive APCA patients had atrophic gastritis.
Collapse
Affiliation(s)
- S R R Utiyama
- Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Rua Padre Camargo, 280, 80060-240, Curitiba, Brazil
- Department of Clinical Analysis, Federal University of Paraná, Curitiba, Brazil
| | - R S De Bem
- Gastroenterology and Endoscopy Service, Clinical Hospital, Federal University of Paraná, Curitiba, Brazil
| | - T L Skare
- Evangelic University Hospital of Curitiba, Curitiba, Brazil
| | - G A De Carvalho
- Endocrinology Service, Clinical Hospital, Federal University of Paraná, Curitiba, Brazil
| | - L M Teixeira
- Endocrinology Service, Clinical Hospital, Federal University of Paraná, Curitiba, Brazil
| | - M Bertolazo
- Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Rua Padre Camargo, 280, 80060-240, Curitiba, Brazil
| | - S O Ioshii
- Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Rua Padre Camargo, 280, 80060-240, Curitiba, Brazil
- Graduate Program in Health Technology, Pontifical Catholic University of Paraná, Curitiba, Brazil
| | - R Nisihara
- Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Rua Padre Camargo, 280, 80060-240, Curitiba, Brazil.
- Department of Medicine, Positivo University, Curitiba, Brazil.
| |
Collapse
|
26
|
Benvenga S, Capodicasa G, Perelli S, Ferrari SM, Fallahi P, Antonelli A. Increased Requirement of Replacement Doses of Levothyroxine Caused by Liver Cirrhosis. Front Endocrinol (Lausanne) 2018; 9:150. [PMID: 29720960 PMCID: PMC5915540 DOI: 10.3389/fendo.2018.00150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/20/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Since hypothyroidism is a fairly common dysfunction, levothyroxine (L-T4) is one of the most prescribed medications. Approximately 70% of the administered L-T4 dose is absorbed. The absorption process takes place in the small intestine. Some disorders of the digestive system and some medicines, supplements, and drinks cause L-T4 malabsorption, resulting in failure of serum TSH to be normal. Only rarely liver cirrhosis is mentioned as causing L-T4 malabsorption. CASE REPORT In this study, we report increased requirement of daily doses of l-thyroxine in two patients with the atrophic variant of Hashimoto's thyroiditis and liver cirrhosis. In one patient, this increased requirement could have been contributed by the increased serum levels of the estrogen-dependent thyroxine-binding globulin (TBG), which is the major plasma carrier of thyroid hormones. In the other patient, we switched from tablet L-T4 to liquid L-T4 at the same daily dose. Normalization of TSH levels was achieved, but TSH increased again when she returned to tablet L-T4. CONCLUSION Liver cirrhosis can cause increased L-T4 requirements. In addition to impaired bile secretion, the mechanism could be increased serum TBG. A similar increased requirement of L-T4 is observed in other situations characterized by elevation of serum TBG. Because of better intestinal absorption, L-T4 oral liquid formulation is able to circumvent the increased need of L-T4 in these patients.
Collapse
Affiliation(s)
- Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Giovanni Capodicasa
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
- *Correspondence: Giovanni Capodicasa,
| | - Sarah Perelli
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy
| | | | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
27
|
Trimboli P, Virili C, Centanni M, Giovanella L. Thyroxine Treatment With Softgel Capsule Formulation: Usefulness in Hypothyroid Patients Without Malabsorption. Front Endocrinol (Lausanne) 2018; 9:118. [PMID: 29619010 PMCID: PMC5871661 DOI: 10.3389/fendo.2018.00118] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 03/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Levothyroxine sodium (LT4) is the therapy of choice for hypothyroidism. In the last decade, new LT4 formulations, such as liquid and softgel capsules, became available. Even if some evidence has been reached in the efficacy of liquid LT4 in patients with suboptimal TSH on tablet LT4, the usefulness of softgel LT4 has been rarely studied. This study aimed at evaluating the effect of switching from tablet to softgel LT4 patients without increased need for LT4. TSH was used as proxy of LT4 bioavailability and effectiveness. METHODS During the period from April to August 2017, 19 patients on tablet LT4 treatment for hypothyroidism, mostly due to autoimmune thyroiditis, were enrolled. Subjects with causes of malabsorption or increased requirement of LT4 were previously excluded. Patients finally included were asked to switch from tablet to softgel LT4 formulation at unchanged dose and ingestion fashion (30 min before breakfast). TSH was measured with chemiluminescence immunoassays. RESULTS According to exclusion and inclusion criteria, 19 patients were finally selected. One of these had headache 4 days later and come back to tablet LT4, and 18 of them (16W/2M; mean age = 55 years; BMI 22.7 kg/m2) completed the study. They were treated with a median LT4 dose of 88 μg/day and showed a median TSH value of 3.33 mIU/L. The rate of cases with TSH ≤ 4.0 mIU/L was 61.1% (11/18 cases). When patients were re-evaluated after 3 months of softgel LT4, we observed that TSH reached levels under 4.0 mIU/L in 16/18 (88.9%) patients, TSH was lower in 11 cases, and in 6 out of 7 patients with pre-switch TSH values over the normal range. Overall, TSH values on softgel LT4 (median 1.90 mIU/L) was significantly lower from that observed during tablet LT4 (p = 0.0039). CONCLUSION These data show that hypothyroid patients with no proven malabsorption may have an improved TSH following 3 months from the switch from tablet to softgel LT4 preparation at unchanged dose.
Collapse
Affiliation(s)
- Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- *Correspondence: Pierpaolo Trimboli,
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Luca Giovanella
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| |
Collapse
|
28
|
Virili C, Giovanella L, Fallahi P, Antonelli A, Santaguida MG, Centanni M, Trimboli P. Levothyroxine Therapy: Changes of TSH Levels by Switching Patients from Tablet to Liquid Formulation. A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2018; 9:10. [PMID: 29434573 PMCID: PMC5790785 DOI: 10.3389/fendo.2018.00010] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/09/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In the last years, levothyroxine (LT4) has been commercialized also in liquid formulation, which is less sensitive to the factors known to reduce the absorption of tablet LT4. To date, there is no robust information that liquid LT4 can improve pharmacologic thyroid homeostasis of patients with reduced efficacy of tablet LT4. This analysis aimed at achieving solid evidence that switching thyroxine treatment from tablet to liquid preparation improves patients' TSH levels. METHODS The search was performed in PubMed/MEDLINE and Scopus database based on the terms "thyroid," "levothyroxine," and "liquid," and updated until September 25, 2017. Studies were included only if they described patients with suboptimal TSH on tablet LT4, subsequently switched to liquid LT4. RESULTS The literature search retrieved 462 articles and six were finally included. The pooled mean difference of TSH value between tablet and liquid LT4 was 4.23 mIU/L (95% CI from 3.69 to 4.77). Mild heterogeneity was found (I2 60%). Overall mean difference of TSH was significant (p < 0.0001). CONCLUSION The present meta-analysis showed that patients with suboptimal TSH on tablet LT4 can have a significantly improved TSH by switching to liquid LT4 formulation at unchanged dose.
Collapse
Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- *Correspondence: Camilla Virili,
| | - Luca Giovanella
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Santaguida
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| |
Collapse
|
29
|
Virili C, Centanni M. "With a little help from my friends" - The role of microbiota in thyroid hormone metabolism and enterohepatic recycling. Mol Cell Endocrinol 2017; 458:39-43. [PMID: 28167127 DOI: 10.1016/j.mce.2017.01.053] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/28/2017] [Accepted: 01/31/2017] [Indexed: 02/07/2023]
Abstract
The gut microbiota is composed of over 1200 species of anaerobes and aerobes bacteria along with bacteriophages, viruses and fungal species. Increasing evidence indicates that the intestinal microbiota, beside digestive equilibrium, is also crucial for immunologic, hormonal and metabolic homeostasis. The intestinal microbiota interacts with distant organs by signals which may be part of the bacteria themselves or their metabolites. Dysbiosis has been observed in inflammatory or autoimmune disorders such as multiple sclerosis or type 1 diabetes as well as in obesity and type 2 diabetes. Functional thyroid disorders were associated with bacterial overgrowth and a different microbial composition. Although thyroid metabolism was apparently disregarded, the interference of microbiota on peripheral iodothyronine homeostasis is an intriguing issue. In this review we focused on the interactions of intestinal microbiota with thyroid-related micronutrients and with the metabolic steps of endogenous and exogenous iodothyronines.
Collapse
Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Corso Della Repubblica 79, 04100 Latina, Italy; Endocrinology Unit, AUSL Latina, Corso Della Repubblica 79, 04100 Latina, Italy.
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Corso Della Repubblica 79, 04100 Latina, Italy; Endocrinology Unit, AUSL Latina, Corso Della Repubblica 79, 04100 Latina, Italy.
| |
Collapse
|
30
|
Centanni M, Benvenga S, Sachmechi I. Diagnosis and management of treatment-refractory hypothyroidism: an expert consensus report. J Endocrinol Invest 2017; 40:1289-1301. [PMID: 28695483 PMCID: PMC5680379 DOI: 10.1007/s40618-017-0706-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/01/2017] [Indexed: 12/17/2022]
Abstract
There is a frequently encountered subset of hypothyroid patients who are refractory to standard thyroid hormone replacement treatment and require unexpectedly high doses of levothyroxine. In addition to clinical situations where hypothyroid patients are non-compliant, or where there is the possibility of excipient-induced disease exacerbation (gluten/celiac disease), therapeutic failure may be due to impaired absorption of the administered drug. The common approach to managing patients with unusual thyroxine needs is to escalate the dose of levothyroxine until targeted TSH levels are achieved. This approach can increase the risk for prolonged exposure to supratherapeutic doses of levothyroxine, which increase the chances of adverse outcomes. Repeated adjustments of levothyroxine can also escalate the costs of treatment, as frequent office visits and laboratory tests are required to determine and maintain the desired dose. Clinicians should take a systematic approach to managing patients whom they suspect of having treatment-refractory hypothyroidism. This may include searching for, and adjusting, occult medical conditions and/or other factors that may affect the absorption of levothyroxine, before up-titrating the dose of traditional levothyroxine therapy. Depending on the underlying pathology, another approach that may be considered is to try alternative formulations of levothyroxine that are less susceptible to intolerance issues related to excipients, or, in some cases, to malabsorption. The early discovery of these factors via a thoughtful patient work-up may avoid unnecessary thyroid medication adjustments and their consequences for both patients and clinicians.
Collapse
Affiliation(s)
- M. Centanni
- Section of Endocrinology, Department of Medico-surgical Services and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - S. Benvenga
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women’s Endocrine Health, A.O.U. Policlinico G Martino, Messina, Italy
| | - I. Sachmechi
- Division of Endocrinology, Queens Hospital Center, Icahn School of Medicine, Jamaica, NY USA
| |
Collapse
|
31
|
Vita R, Santaguida MG, Virili C, Segni M, Galletti M, Mandolfino M, Di Bari F, Centanni M, Benvenga S. Serum Thyroid Hormone Antibodies Are Frequent in Patients with Polyglandular Autoimmune Syndrome Type 3, Particularly in Those Who Require Thyroxine Treatment. Front Endocrinol (Lausanne) 2017; 8:212. [PMID: 28894436 PMCID: PMC5581384 DOI: 10.3389/fendo.2017.00212] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/09/2017] [Indexed: 11/30/2022] Open
Abstract
Polyglandular autoimmune syndrome (PAS) type 3 consists of autoimmune thyroid disease (AITD) coexisting with ≥1 non-thyroidal autoimmune disease (NTAID) other than Addison's disease and hypoparathyroidism. We evaluated the prevalence and repertoire of thyroid hormones antibodies (THAb) in PAS-3 patients. Using a radioimmunoprecipation technique, we measured THAb (T3IgM, T3IgG, T4IgM, and T4IgG) in 107 PAS-3 patients and 88 controls (patients with AITD without any NTAID). Based on the selective coexistence of AITD with one NTAID (chronic autoimmune gastritis, non-segmental vitiligo or celiac disease), patients were divided into group 1 (chronic autoimmune gastritis positive, n = 64), group 2 (non-segmental vitiligo positive, n = 24), and group 3 (celiac disease positive, n = 15). At least one of the four THAb was detected in 45 PAS-3 patients (42.1%) and 28 controls (31.8%, P = 0.14), with similar rates in the three PAS-3 groups. The rates of T3Ab, T4Ab, and T3 + T4Ab were similar in groups 1 and 2, while in group 3, T3Ab was undetected (P = 0.02). In PAS-3 patients, the rate of levothyroxine treatment was greater in THAb-positive patients compared to THAb-negative patients (76.7 vs. 56.1%, P = 0.03, RR = 1.4, 95% CI 1.03-1.81). Not unexpectedly, levothyroxine daily dose was significantly higher in group 1 and group 3, namely in patients with gastrointestinal disorders, compared to group 2 (1.9 ± 0.4 and 1.8 ± 0.3 vs. 1.5 ± 0.2 μg/kg body weight, P = 0.0005 and P = 0.004). Almost half of PAS-3 patients have THAb, whose repertoire is similar if chronic autoimmune gastritis or celiac disease is present. A prospective study would confirm whether THAb positivity predicts greater likelihood of requiring levothyroxine treatment.
Collapse
Affiliation(s)
- Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Maria Giulia Santaguida
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Maria Segni
- Department of Pediatrics and Child Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Marina Galletti
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Mattia Mandolfino
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Flavia Di Bari
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Endocrinology Unit, AUSL Latina, Latina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital Policlinico Universitario G. Martino, Messina, Italy
| |
Collapse
|
32
|
Ernst FR, Barr P, Elmor R, Sandulli W, Thevathasan L, Sterman AB, Goldenberg J, Vora K. The Economic Impact of Levothyroxine Dose Adjustments: the CONTROL HE Study. Clin Drug Investig 2017; 37:71-83. [PMID: 27798756 PMCID: PMC5209418 DOI: 10.1007/s40261-016-0462-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background In general, hypothyroidism can be adequately treated with a consistent daily dose of levothyroxine. However, the need for levothyroxine dose adjustments is frequent in clinical practice. The extent to which levothyroxine dose adjustments increase the utilization of healthcare resources has not previously been described in the clinical literature. Objective The primary objective of our study was to measure the effect of levothyroxine dose adjustments in terms of their utilization of healthcare resources including direct and indirect costs. A secondary goal was to identify any differences in patient characteristics that may be responsible for levothyroxine dose adjustments. Methods A retrospective medical chart review was conducted among patients of selected healthcare providers in the USA. Patients who were recently started on levothyroxine therapy (<6 months) were excluded to avoid situations that were more likely attributable to treatment initiation than inadequate therapeutic effect. Trained nurses extracted data from patient charts and electronic medical record systems for review. We analyzed the cost of resources consumed by the frequency of levothyroxine dose changes over 24 months: 0 dose changes (no dose adjustment group); one dose change, two dose changes, three or more dose changes (≥1 dose adjustment group). Results The study included 454 patients. Overall estimated resource utilization was higher per patient in the ≥1 dose adjustment group (US$5824) vs. the no dose adjustment group (US$3166) during the 24-month study period. When direct and indirect costs were combined, overall costs of care were greatest in patients requiring three or more dose adjustments (US$8220/patient). Patients in this cohort incurred 2.5-fold greater total costs compared with patients requiring no dose adjustments (US$8220 vs. US$3166). Among the 58 patients in the group requiring three or more dose adjustments, mean direct medical costs were significantly higher than in the patients requiring no dose adjustments (US$6387 vs. US$2182). Patients with at least one dose adjustment experienced a 40.3% increase in lost productivity vs. patients who had no dose adjustments (US$1381 vs. US$984). Loss of productivity was highest among patients with three or more levothyroxine dose adjustments. Among this cohort, there was an 86.4% increase in lost productivity vs. patients who had no levothyroxine dose adjustments (US$1833 vs. US$984). Conclusions Patients experiencing multiple levothyroxine dose adjustments were shown to consume more healthcare resources, resulting in higher costs than those who required no dose adjustments. Each care episode contributed to lost time and wages with total estimated lost productivity escalating with increasing levothyroxine dose adjustments over a 24-month period. Electronic supplementary material The online version of this article (doi:10.1007/s40261-016-0462-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Frank R Ernst
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA.
| | - Peri Barr
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA
| | - Riad Elmor
- Health Economics and Outcomes Research, Indegene, Inc., 222 Chastain Meadows Court, Suite 300, Kennesaw, GA, 30144, USA
| | | | - Lionel Thevathasan
- LT Associates Ltd, Paris, France
- Department of Neuroscience, University of Oxford, Oxford, UK
| | | | | | - Kevin Vora
- Akrimax Pharmaceuticals, LLC, Cranford, NJ, USA
| |
Collapse
|
33
|
Skelin M, Lucijanić T, Amidžić Klarić D, Rešić A, Bakula M, Liberati-Čizmek AM, Gharib H, Rahelić D. Factors Affecting Gastrointestinal Absorption of Levothyroxine: A Review. Clin Ther 2017; 39:378-403. [PMID: 28153426 DOI: 10.1016/j.clinthera.2017.01.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/23/2016] [Accepted: 01/03/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Levothyroxine (LT4) is a drug with a narrow therapeutic index, applied in small amounts (micrograms), which makes interactions in the absorption phase clinically significant. The main aim of this article was to review and present the latest information on factors that affect the gastrointestinal absorption of this drug. METHODS Relevant data were collected by using the MEDLINE, PubMed, EMBASE, Web of Science, Science Direct, and Scopus databases with the key words levothyroxine and absorption. Searches were not limited to specific publication types, study designs, dates, or languages. The reports were highly variable in the amount of information provided regarding study design and methods. Because of the heterogeneity of studies, no statistical analysis was performed. FINDINGS Many gastrointestinal disorders, such as celiac disease, atrophic gastritis, lactose intolerance, and Helicobacter pylori infection, may impede the absorption of levothyroxine. During treatment of these disorders, it is necessary to monitor serum thyroid-stimulating hormone and free T4 values to reduce the risk of developing iatrogenic hyperthyroidism. Soybeans and coffee have the greatest impact on the reduction of absorption, whereas vitamin C has the ability to increase it. Conversely, the effect of dietary fiber on the absorption of LT4 is not yet fully understood; further research is needed on this topic. A decrease in the absorption of LT4 is established and clinically significant when administered concomitantly with cholestyramine, colesevelam, lanthanum, calcium carbonate, calcium citrate, calcium acetate, iron sulfate, ciprofloxacin, aluminum hydroxide, sevelamer, or proton pump inhibitors. This effect should be taken into consideration when prescribing these drugs concomitantly with LT4. The effects of Giardia lamblia infection and the influence of orlistat, polystyrene sulfonate, raloxifene, and simethicone on absorption of LT4 have been poorly documented. For bariatric surgery, sucralfate and H2-antagonist interactions are not well founded or contradictory evidence is available regarding their existence; additional research should be conducted. IMPLICATIONS The majority of the interactions are clinically significant. They are based on the LT4 adsorption on interfering substances in the digestive tract, as well as a consequently reduced amount of the drug available for absorption. These interactions can be avoided by separating the administration of LT4 and the interfering substance.
Collapse
Affiliation(s)
- Marko Skelin
- Pharmacy Department, General Hospital Šibenik, Šibenik, Croatia
| | - Tomo Lucijanić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Clinical Hospital Dubrava, Zagreb, Croatia
| | | | - Arnes Rešić
- Department of Paediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Miro Bakula
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh," Zagreb, Croatia
| | - Ana-Marija Liberati-Čizmek
- Department of Endocrinology, Diabetes and Metabolic Disorders, General Hospital "Sv. Duh," Zagreb, Croatia
| | - Hossein Gharib
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Dario Rahelić
- Department of Endocrinology, Diabetes and Metabolic Disorders, Clinical Hospital Dubrava, Zagreb, Croatia
| |
Collapse
|
34
|
Cellini M, Santaguida MG, Virili C, Capriello S, Brusca N, Gargano L, Centanni M. Hashimoto's Thyroiditis and Autoimmune Gastritis. Front Endocrinol (Lausanne) 2017; 8:92. [PMID: 28491051 PMCID: PMC5405068 DOI: 10.3389/fendo.2017.00092] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/07/2017] [Indexed: 12/16/2022] Open
Abstract
The term "thyrogastric syndrome" defines the association between autoimmune thyroid disease and chronic autoimmune gastritis (CAG), and it was first described in the early 1960s. More recently, this association has been included in polyglandular autoimmune syndrome type IIIb, in which autoimmune thyroiditis represents the pivotal disorder. Hashimoto's thyroiditis (HT) is the most frequent autoimmune disease, and it has been reported to be associated with gastric disorders in 10-40% of patients while about 40% of patients with autoimmune gastritis also present HT. Some intriguing similarities have been described about the pathogenic mechanism of these two disorders, involving a complex interaction among genetic, embryological, immunologic, and environmental factors. CAG is characterized by a partial or total disappearance of parietal cells implying the impairment of both hydrochloric acid and intrinsic factor production. The clinical outcome of this gastric damage is the occurrence of a hypochlorhydric-dependent iron-deficient anemia, followed by pernicious anemia concomitant with the progression to a severe gastric atrophy. Malabsorption of levothyroxine may occur as well. We have briefly summarized in this minireview the most recent achievements on this peculiar association of diseases that, in the last years, have been increasingly diagnosed.
Collapse
Affiliation(s)
- Miriam Cellini
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Silvia Capriello
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Nunzia Brusca
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Lucilla Gargano
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- *Correspondence: Marco Centanni,
| |
Collapse
|
35
|
McMillan M, Rotenberg KS, Vora K, Sterman AB, Thevathasan L, Ryan MF, Mehra M, Sandulli W. Comorbidities, Concomitant Medications, and Diet as Factors Affecting Levothyroxine Therapy: Results of the CONTROL Surveillance Project. Drugs R D 2016; 16:53-68. [PMID: 26689565 PMCID: PMC4767717 DOI: 10.1007/s40268-015-0116-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background The CONTROL Surveillance Project was a comprehensive patient-based survey conducted among hypothyroid patients undergoing treatment. The primary objective of the study was to specifically quantify the prevalence of factors adversely affecting levothyroxine therapy. Methods Participants were selected from a large proprietary database. Those eligible for the study completed a 21-question survey. Results Of the eligible hypothyroid patients, 925 (92.5 %) were being treated with levothyroxine monotherapy. The mean age was 60.4 years; 755 (81.6 %) were female and 168 (18.2 %) were male. Almost half of those receiving levothyroxine (435, 47.0 %) had at least one comorbid condition that could adversely affect its absorption: gastroesophageal reflux disease (33.8 % of patients), irritable bowel syndrome (9.7 %), lactose intolerance (7.8 %), or a history of gastric bypass surgery or bowel resection (3.0 %). Other factors reported by many patients that could adversely affect levothyroxine absorption included use of prescription medications (20.6 %) and over-the-counter medications (34.3 %) used to treat comorbid gastrointestinal (GI) conditions; use of dietary supplements (51.8 %, primarily calcium and iron); and intake of foods/beverages high in fiber, iodine, or soy (68.0 %). Of the 13.4 % who reported difficulty controlling their hypothyroid symptoms, significantly more patients with comorbid GI conditions reported such difficulty (7.8 versus 5.6 %, P < 0.01). Frequent changes in levothyroxine dosing (two or more dose changes in the past year) were reported by 8.0 % of survey participants. Those with GI comorbidities were nearly twice as likely to have such changes (5.0 versus 3.0 %, P < 0.01). Conclusion Better initial workup of patients, including identification of relevant GI comorbidities and allergies, may help in the early detection of factors that may affect the performance of levothyroxine.
Collapse
Affiliation(s)
- Marjorie McMillan
- McMillan Survey Research and Statistical Consulting, 8428 Arendal Cove, Memphis, TN, USA.
| | | | - Kevin Vora
- Akrimax Pharmaceuticals, LLC, Cranford, NJ, USA
| | | | - Lionel Thevathasan
- LT Associates Ltd, Paris, France.,Department of Neuroscience, University of Oxford, Oxford, UK
| | | | - Munish Mehra
- Quantum Change Group, LLC, Gaithersburg, MD, USA
| | | |
Collapse
|
36
|
Virili C, Trimboli P, Romanelli F, Centanni M. Liquid and softgel levothyroxine use in clinical practice: state of the art. Endocrine 2016; 54:3-14. [PMID: 27473098 DOI: 10.1007/s12020-016-1035-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/22/2016] [Indexed: 12/23/2022]
Abstract
Levothyroxine is recognized as the treatment of choice for hypothyroidism. So far, the tablet levothyroxine has been the formulation almost exclusively used, even though an optimal daily dose of levothyroxine has been unsuccessfully sought and a consensus not achieved. Due to progressive use of a more individually tailored levothyroxine dose, increasing evidence has instead displayed that many gastrointestinal disorders, polypharmacy, and food interference may raise the daily levothyroxine requirement. In recent years, alternative levothyroxine formulations have become available and have rapidly gained attention because of their pharmacokinetic properties. This study aims to provide an overview regarding the use of softgel capsule and/or liquid levothyroxine solution while performing a review of published studies about such topic. A comprehensive computer literature search of the PubMed/MEDLINE, Scopus, and Google Scholar databases has been conducted to find published articles on this topic. The search algorithm was based on the combinations of the following terms: "oral solution" or "soft gel" or "liquid", and "levothyroxine". The computer search resulted in 75 articles; through a critical review of such titles and abstracts and a screening of their references lists, the review included 18 original articles relating to 800 patients treated with alternative formulations. Despite some limits, the results obtained using softgel and liquid levothyroxine were consistent with each other. In selected categories of levothyroxine-treated patients (pediatric, suffering from hypo-achlorhydria, polypharmacy, undergone bariatric surgery, fed through enteric tube) these new formulations have shown promising attributes in improving a treatment that needs to be individually tailored.
Collapse
Affiliation(s)
- Camilla Virili
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Pierpaolo Trimboli
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Francesco Romanelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Centanni
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.
- Endocrinology Unit, AUSL Latina, Latina, Italy.
| |
Collapse
|
37
|
Morelli S, Reboldi G, Moretti S, Menicali E, Avenia N, Puxeddu E. Timing of breakfast does not influence therapeutic efficacy of liquid levothyroxine formulation. Endocrine 2016; 52:571-8. [PMID: 26537478 DOI: 10.1007/s12020-015-0788-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/23/2015] [Indexed: 02/07/2023]
Abstract
Oral levothyroxine (L-T4) is the mainstay of hypothyroidism treatment. Many factors may influence its absorption, including the timing of administration. Objective of the study is to demonstrate the therapeutic equivalence of administering liquid L-T4 with breakfast or 10 min before breakfast. This was a pilot study conducted with a crossover design AB/BA where A stays for L-T4 with breakfast and B for L-T4 10 min before breakfast. A post hoc analysis was conducted to compare L-T4 administered at breakfast or 10 min before breakfast with L-T4 administered 30 min before breakfast. Sixty-one hypothyroid patients were enrolled and assigned to one of the two treatment sequences. All patients were evaluated for TSH levels at the end of each period. Fifty-nine patients completed the study. The mean thyrotropin concentration was 1.52 ± 0.73 µU/ml when L-T4 was administered with breakfast and 1.46 ± 0.81 µU/ml when it was taken 10 min before breakfast, without clinically and statistically significant differences (P = 0.59), regardless of treatment sequence and period. The mean thyrotropin concentration was 1.54 ± 0.9 µU/ml when L-T4 was administered at 0-10 min intervals before breakfast and 1.25 ± 0.7 µU/ml when it was taken 30 min before breakfast (ratio = 1.23, within our definition of equivalence set at 0.8-1.25). There is therapeutic equivalence between liquid L-T4 administration at breakfast or 10 min before breakfast. We can also hypothesize that there are no clinically relevant differences between liquid L-T4 administration 30 min before breakfast or at shorter intervals.
Collapse
Affiliation(s)
- Silvia Morelli
- Department of Medicine, University of Perugia, Perugia, Italy
- Research Centre of Thyroid Proteomics and Genomics (CRiProGeT), University of Perugia, Terni, Italy
| | | | - Sonia Moretti
- Department of Medicine, University of Perugia, Perugia, Italy
- Research Centre of Thyroid Proteomics and Genomics (CRiProGeT), University of Perugia, Terni, Italy
| | - Elisa Menicali
- Department of Medicine, University of Perugia, Perugia, Italy
- Research Centre of Thyroid Proteomics and Genomics (CRiProGeT), University of Perugia, Terni, Italy
| | - Nicola Avenia
- Research Centre of Thyroid Proteomics and Genomics (CRiProGeT), University of Perugia, Terni, Italy
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Efisio Puxeddu
- Department of Medicine, University of Perugia, Perugia, Italy.
- Research Centre of Thyroid Proteomics and Genomics (CRiProGeT), University of Perugia, Terni, Italy.
| |
Collapse
|
38
|
Qi TN, Pan K, Wang F, Wei G, Jiang Y, Zhang RH, Zheng J, Zhang DD, Chen ZH. Clarithromycin resistance and 23S rRNA gene mutation characteristics of Helicobacter pylori isolates from patients in Qiannan Autonomous Prefecture. Shijie Huaren Xiaohua Zazhi 2015; 23:2901-2906. [DOI: 10.11569/wcjd.v23.i18.2901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the antibiotic sensitivity of Helicobacter pylori (H. pylori) isolates from patients in the People's Hospital of Qiannan Autonomous Prefecture and to analyze mutations in the domain V of 23S rRNA gene that are related with clarithromycin resistance.
METHODS: Clarithromycin susceptibility tests of 74 H. pylori isolates were performed by the modified agar dilution method (breakpoint susceptibility testing). Domain V of 23S rRNA gene of 22 clarithromycin resistant strains, 10 clarithromycin susceptible strains and a control stain (NCTC11637) were amplified and sequenced. Nucleotide homology of these sequences were compared to H. pylori U27270 (GenBank accession number: U27270) which is a susceptible strain.
RESULTS: Clarithromycin resistance rate of 74 H. pylori isolates was 29.7% (22/74). Ten types of mutations in domain V of 23S rRNA gene were found in this study. T2183C, T2245C and T2321C mutations were found in both clarithromycin resistant strains and susceptible strains. Mutations only found in resistant strains included A2144G(4/22), A2224G(4/22), C2196T(1/22), C2289T(1/22), A2435G(1/22), C2695A(1/22) and T2712C(1/22).
CONCLUSION: Clarithromycin resistance rate of H. pylori isolates from the People's Hospital of Qiannan Autonomous Prefecture was high. A2144G and A2224G mutations were the most prevalent mutation types related with clarithromycin resistance and there were three novel mutation types (A2435G, C2695 and T2712C).
Collapse
|