Oral liquid levothyroxine treatment at breakfast: a mistake?

Abstract

Objective: Taking levothyroxine (L-T 4 ) with coffee or with water followed by coffee intake within a few minutes results in poor TSH response in many patients. T 4 is available in tablet form worldwide, but novel formulations in soft gel capsule or liquid form are now available. Design: We fortuitously identified a euthyroid patient who wrongly consumed liquid L-T 4 with coffee at breakfast; after changing the time of consumption to 30 min before breakfast, no change in TSH, free T 4 (fT 4 ), and free tri-iodothyronine (fT 3 ) concentrations was observed. Once the first patient was identified, additional stable euthyroid patients who consumed liquid L-T 4 with coffee were identified. Methods: Patients were recruited by searching our 'thyroid patients' database. All the patients on liquid L-T 4 treatment were contacted by phone to ask them whether they took L-T 4 at breakfast. We identified 54 patients who were submitted to TSH, fT 4 , and fT 3 evaluation, with the indication that the same dosage of L-T 4 be consumed 30 min before breakfast. We determined their TSH, fT 4 , and fT 3 concentrations after 3 and 6 months again.

Oral Liquid Formulation of Levothyroxine Is Stable in Breakfast Beverages and May Improve Thyroid Patient Compliance

“…Prompt bioavailability of T4 is even more expected in case T4 is administered as an oral solution [13,15,16]. Indeed, in a few patients who switched from T4 tablet to T4 oral solution keeping the habit of having coffee concomitantly or within 5 min after T4 ingestion, a decrease in serum TSH was observed [13].…”

“…Switching back to tablets caused TSH levels to worsen. It was also reported that in euthyroid patients who used to take a liquid T4 formulation with coffee at breakfast, TSH, free levothyroxine (fT4), and (free triiodothyronine) fT3 serum levels did not change significantly, after three and six months of treatment, if the T4 solution administration was switched to thirty minutes before breakfast [16]. …”

Hypothyroidism and Nephrotic Syndrome: Why, When and How to Treat

“…Recent data suggested that this formulation could be better absorbed than tablets in cases of malabsorption (e.g. following bariatric surgery) or in patients taking LT 4 during breakfast [66]. Due to its 28% ethanol content, it is not recommended during pregnancy and breastfeeding or in children and high-risk patients [66].…”

Update on the treatment of hypothyroidism

“…A non-randomized study of patients with gastritis who had a stable serum TSH while taking LT4 tablets and who were switched to a lower dose of LT4 gel capsules, showed that two thirds of patients had a similar TSH on the lower dose, again suggesting better absorption of the gel capsule formulation (33). Another non-randomized study suggests that the serum TSH achieved by LT4 gel capsules is not affected by the timing with respect to breakfast (34). If the findings of these studies are bolstered by randomized controlled studies in the future, these LT4 formulations may prove very convenient for hypothyroid patients.…”