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      Oral L‐thyroxine liquid versus tablet in patients submitted to total thyroidectomy for thyroid cancer (without malabsorption): A prospective study

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          Abstract

          Objective

          No consistent data are present in literature about the effectiveness of Levothyroxine (L‐T4) liquid formulation in patients without malabsorption after thyroidectomy. The aim of this study is to compare the effectiveness of L‐T4 liquid formulation, with L‐T4 tablets, in thyroid cancer patients after thyroidectomy (without malabsorption or drug interference).

          Methods

          One hundred five patients were recruited; 52 patients were treated with liquid L‐T4 formulation, while 53 with L‐T4 tablets, at the same dosage (1.5 mcg/kg/day). Patients started to assume the drug the day after surgery, 30 min before breakfast. In both groups circulating levels of thyrotropic hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) were dosed at week 6 (first control), and then at week 12 (second control).

          Results

          We obtained significantly lower TSH values in the liquid L‐T4 group patients, compared to the tablet L‐T4 group, at the first control ( P < .05), and at the second control ( P < .01), while FT4 and FT3 levels were not significantly different. Hypothyroid range (TSH > 3.6 mcU/mL) was significantly more prevalent in the patients treated with L‐T4 tablet.

          Conclusions

          A better control of TSH was observed in thyroidectomized patients (without malabsorption, gastric disorders, or drug interference) with liquid L‐T4 regimen.

          Level of Evidence

          2c–Outcomes Research

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          Most cited references29

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          Thyroxine in goiter, Helicobacter pylori infection, and chronic gastritis.

          Lucilla Gargano, Mark A Franchi, Gianluca Canettieri … (2006)
          Malabsorption of thyroxine has been described in patients treated with drugs that modify an acidic environment. We determined whether there is an increased need for thyroxine in patients with euthyroid multinodular goiter and impaired secretion of gastric acid. We assessed the dose of thyroxine required to obtain a low level of thyrotropin (0.05 to 0.20 mU per liter) in 248 patients with multinodular goiter. Of these 248 patients, 53 also had Helicobacter pylori-related gastritis and 60 had atrophic gastritis of the body of the stomach (31 with evidence of H. pylori infection and 29 without such evidence). The reference group comprised 135 patients with multinodular goiter and no gastric disorders. In addition, variation in the level of serum thyrotropin was prospectively studied in 11 patients treated with thyroxine before and after H. pylori infection and both before and during treatment with omeprazole in 10 patients treated with thyroxine who had gastroesophageal reflux. The daily requirement of thyroxine was higher (by 22 to 34 percent) in patients with H. pylori-related gastritis, atrophic gastritis, or both conditions than in the reference group. In prospective studies, the occurrence of H. pylori infection in the 11 patients treated with thyroxine led to an increase in the level of serum thyrotropin (P=0.002), an effect that was nearly reversed on eradication of H. pylori infection. In a similar way, omeprazole treatment was associated with an increase in the level of serum thyrotropin in all 10 patients treated with thyroxine, an effect that was reversed by an increase in the thyroxine dose by 37 percent. Patients with impaired acid secretion require an increased dose of thyroxine, suggesting that normal gastric acid secretion is necessary for effective absorption of oral thyroxine. Copyright 2006 Massachusetts Medical Society.
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            A systematic review of drug absorption following bariatric surgery and its theoretical implications.

            D Brocks, R Padwal, Ricky Sharma (2009)
            Demand for bariatric surgery has risen exponentially and bariatric patients often have multiple indications for post-operative pharmacotherapy. The purpose of this study was to systematically review the published literature examining the effect of bariatric surgery on drug absorption. Studies were sought through searches of MEDLINE, EMBASE, the Cochrane Controlled Trials Registry and hand searches of reference lists. Two reviewers independently assessed studies for inclusion. Twenty-six studies (15 case reports/case series evaluating 12 different agents and 11 non-randomized controlled studies examining 15 different agents) were found. Evidence for diminished drug absorption was found in 15/22 studies involving jejunoileal bypass, 1/3 studies of gastric bypass/gastroplasty and 0/1 studies examining biliopancreatic diversion. The effect of bariatric surgery on drug absorption appears drug-specific. Drugs that are intrinsically poorly absorbed, highly lipophilic and/or undergo enterohepatic recirculation exhibited the greatest potential for malabsorption. The most consistent evidence for diminished absorption was found for cyclosporine, thyroxine, phenytoin and rifampin. Reduced drug absorption may occur post-bariatric surgery and this effect appears drug-specific. Individual dose-adjustment and therapeutic monitoring may be required. Rigorously conducted controlled studies are needed to evaluate the effect of modern bariatric procedures on drug absorption.
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              Conditions and drugs interfering with thyroxine absorption.

              Llanyee Liwanpo, Jerome Hershman (2009)
              Food, dietary fibre and espresso coffee interfere with the absorption of levothyroxine. Malabsorptive disorders reported to affect the absorption of levothyroxine include coeliac disease, inflammatory bowel disease, lactose intolerance as well as Helicobacter pylori (H. pylori) infection and atrophic gastritis. Many commonly used drugs, such as bile acid sequestrants, ferrous sulphate, sucralfate, calcium carbonate, aluminium-containing antacids, phosphate binders, raloxifene and proton-pump inhibitors, have also been shown to interfere with the absorption of levothyroxine.
              Article 0 comments Cited 54 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Alessandro Antonelli Prof:
                ORCID: https://orcid.org/0000-0002-5211-6342
                alessandro.antonelli@med.unipi.it
                Journal
                Journal ID (nlm-ta): Laryngoscope Investig Otolaryngol
                Journal ID (iso-abbrev): Laryngoscope Investig Otolaryngol
                Journal ID (doi): 10.1002/(ISSN)2378-8038
                Journal ID (publisher-id): LIO2
                Title: Laryngoscope Investigative Otolaryngology
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Print): 0023-852X
                ISSN (Electronic): 2378-8038
                Publication date (Electronic): 03 October 2018
                Publication date Collection: October 2018
                Volume: 3
                Issue: 5 ( doiID: 10.1002/lio2.v3.5 )
                Pages: 405-408
                Affiliations
                [ 1 ] Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
                [ 2 ] Department of Surgical, Medical, Molecular Pathology and Critical Area University of Pisa Pisa Italy
                Author notes
                [*] [* ]Send correspondence to Alessandro Antonelli, MD, Department of Clinical and Experimental Medicine, University of Pisa, School of Medicine, Via Savi, 10, I‐56126, Pisa, Italy. Email: alessandro.antonelli@ 123456med.unipi.it
                Author information
                https://orcid.org/0000-0002-5211-6342
                Article
                Publisher ID: LIO2186
                DOI: 10.1002/lio2.186
                PMC ID: 6209618
                SO-VID: bf2fdf1a-24a3-456b-b7f4-afb467083518
                Copyright © © 2018 The Authors Laryngoscope Investigative Otolaryngology published by Wiley Periodicals, Inc. on behalf of The Triological Society
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Date received : 14 December 2017
                Date revision received : 07 March 2018
                Date accepted : 25 April 2018
                Page count
                Figures: 1, Tables: 1, Pages: 4, Words: 3423
                Funding
                Funded by: The authors have nothing to declare.
                Categories
                Subject: Thyroid, Parathyroid, and Endocrine
                Subject: Thyroid, Parathyroid, and Endocrine
                Subject: Original Research
                Custom metadata
                source-schema-version-number 2.0
                component-id lio2186
                cover-date October 2018
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.5.1 mode:remove_FC converted:31.10.2018

                Keywords: liquid l‐t4,thyroid cancer,total thyroidectomy,tsh,thyroxine absorption
                Data availability:
                Keywords: liquid l‐t4, thyroid cancer, total thyroidectomy, tsh, thyroxine absorption

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