Lactose Intolerance Revealed by Severe Resistance to Treatment with Levothyroxine

Muñóz-Torres, Manuel; Varsavsky, Mariela; Alonso, Guillermo

doi:10.1089/thy.2006.16.1171

Cited by 43 publications

(26 citation statements)

References 11 publications

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“…Absorption occurs mostly in the jejunum and ileum and is enhanced by a fasting state [2,3,6,[8][9][10][11] . Interference in absorption of thyroid hormones with dietary elements (soja, prunes, nuts, and herbal remedies) or medication, with the most common being cholestyramine, colestipol, aluminium hydroxide-containing antacids, propranolol, laxatives, ferrous salts, calcium carbonate, lovastatin, phenytoin, carbamazepine and rifampicin, should be excluded if euthyroidism cannot be reached using replacement therapy [1, 4-6, 8, 10, 12-16] .…”

Section: Discussion and Reviewmentioning

confidence: 99%

“…Interference in absorption of thyroid hormones with dietary elements (soja, prunes, nuts, and herbal remedies) or medication, with the most common being cholestyramine, colestipol, aluminium hydroxide-containing antacids, propranolol, laxatives, ferrous salts, calcium carbonate, lovastatin, phenytoin, carbamazepine and rifampicin, should be excluded if euthyroidism cannot be reached using replacement therapy [1, 4-6, 8, 10, 12-16] . Other reasons for reduced absorption are high age, high fibre diets, levothyroxine intake with food and hypothyroidism [6,9,17] . Also higher doses of levothyroxine are sometimes needed in rare cases of patients with thyroid hormone resistance.…”

Section: Discussion and Reviewmentioning

confidence: 99%

“…The most common cause of failure of oral replacement therapy is non-compliance [9] . However, pseudomalabsorption due to intentional non-compliance as part of a psychiatric disorder should be considered, as illustrated in the present and other case reports [1,2,8,10,12,13,[18][19][20][21][22][23] .…”

Section: Discussion and Reviewmentioning

confidence: 99%

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Pseudomalabsorption of Levothyroxine: A Challenge for the Endocrinologist in the Treatment of Hypothyroidism

Wilder¹,

Bravenboer²,

Herremans³

et al. 2016

Eur Thyroid J

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Background: Hypothyroidism due to non-compliance with levothyroxine therapy (pseudomalabsorption) is rare. The diagnosis is considered in patients with persistent severe hypothyroidism despite treatment with large doses of levothyroxine. Intestinal malabsorption, drug and dietary interference with levothyroxine absorption and nephrotic syndrome should be excluded. The diagnosis of pseudomalabsorption can be demonstrated by using “an oral 1,000 µg of levothyroxine test” showing a rapid decrease in thyroid-stimulating hormone and increase in thyroxine. There are however few data on the sensitivity and specificity of the test in large cohorts of hypothyroid patients. Treatment of pseudomalabsorption is controversial, with reports using parenteral, intramuscular or single weekly oral dosing of levothyroxine. Cases: We report 3 patients who presented with persistent clinical and biochemical signs of hypothyroidism despite replacement therapy with high doses of levothyroxine. Pseudomalabsorption was diagnosed by a systematic approach, including prior exclusion of digestive, liver and kidney diseases. A peroral challenge test was positive in all cases. Patients denied non-compliance, and a psychiatric approach was elusive. Two of the patients were treated successfully with a single supervised weekly 1,000-µg administration of levothyroxine, while non-supervised weekly administration resulted in hypothyroidism confirming pseudomalabsorption. Conclusions: Non-compliance with medical therapy should be considered in patients with treatment-refractory hypothyroidism. Supervised once weekly levothyroxine treatment is a safe and well-tolerated treatment option, obviating the need for parenteral administration of the drug. Apart from the medical treatment, there is also a need for psychiatric evaluation and care.

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Section: Discussion and Reviewmentioning

confidence: 99%

Section: Discussion and Reviewmentioning

confidence: 99%

See 1 more Smart Citation

Pseudomalabsorption of Levothyroxine: A Challenge for the Endocrinologist in the Treatment of Hypothyroidism

Wilder¹,

Bravenboer²,

Herremans³

et al. 2016

Eur Thyroid J

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“…Absorption of L-T 4 has been shown to be reduced by certain foods such as fiber [6], coffee [7], and soy protein [8,9]. Gastrointestinal disorders such as lactose intolerance [10] and celiac disease [11,12] inflammatory bowel disease and other malabsorptive disorders may result in L-T 4 malabsorption. Medications such as sucralfate [3], ferrous sulfate [13,14], calcium carbonate [15,16], and proton pump inhibitors [17][18][19] are also known to affect absorption of L-T 4 .…”

Section: Discussionmentioning

confidence: 99%

Treatment of Thyroxine Malabsorption

et al. 2015

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The aim of the case study was to report the successful use of intramuscular levothyroxine (L-T 4 ) in two patients with profound oral L-T 4 malabsorption. We present two cases of patients who remained hypothyroid despite very high oral doses of L-T 4 . In both cases, poor L-T 4 absorption was documented with an absorption study. Intramuscular L-T 4 injections were initiated in both cases and doses were titrated to achieve normalization of thyroid stimulating hormone (TSH) and free thyroxine (free T 4 ). Additionally, after achieving euthyroidism for a period of time, each patient was able to successfully transit back to oral administration of L-T 4 . Synthetic oral L-T 4 is the drug of choice for replacement therapy in patients with hypothyroidism. Whenever euthyroidism cannot be achieved despite escalating L-T 4 doses, the presence of interfering factors must be considered. These factors include low patient compliance or reduced L-T 4 absorption due to other dietary factors, concomitant medication use or gastrointestinal disease. Furthermore, severe hypothyroidism itself may impair absorption, presumably due to edema of the small bowel mucosa. Parenteral L-T 4 has been shown to be an effective method of replacing thyroid hormone in those patients with apparent thyroid hormone malabsorption. However, there is no consensus or guidelines available to aid physicians in the use of parenteral L-T 4 . In patients with hypothyroidism despite large doses of levothyroxine, physicians should consider thyroid malabsorption once compliance and interfering medicines have been ruled out. In these patients, if no correctable interfering factor is identified, intramuscular replacement appears to be an effective alternative.

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“…There is a report of a severe case of hypothyroidism reputed to have been caused by an intestinal giardiasis (39). Other causes of malabsorption may include lactose intolerance (40).…”

Section: Drug Interaction and Concomitant Diseasesmentioning

confidence: 99%

The difficult patient: drug interaction and the influence of concomitant diseases on the treatment of hypothyroidism

Ward

2010

Arq Bras Endocrinol Metab

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summaRyAlthough most hypothyroid patients do well with one single tablet of thyroxine daily, approximately 10% are dissatisfied and another important group of patients is difficult to control. We reviewed the most common causes for frequent-dose adjustment or high-dose requirement, including poor compliance with therapy and inadequate medication. Since these two causes have been ruled out, drug interaction and other concomitant diseases need to be investigated. Requirements of thyroxine increase in all conditions characterized by impaired gastric acid secretion. Proton-pump inhibitors, antacids and a long list of drugs may decrease thyroxine absorption. In addition, a series of diseases including celiac disease and chronic inflammatory intestinal diseases, as well as nutritional habits may be important in patient control. Finally, we mention the effects of a growing list of drugs and thyroid disruptors that may also affect thyroid hormone metabolism at many levels. Arq Bras Endocrinol Metab. 2010;54(5):435-42 Keywords Medication-taking behavior; compliance; bioequivalence; absorption; nutritional habits sumáRio Embora a maior parte dos pacientes com hipotiroidismo fique bem com um único comprimido diário de tiroxina, aproximadamente 10% não ficam satisfeitos e outro importante grupo de pacientes apresenta controle difícil. Foram revistas as causas mais comuns para necessidades frequentes de ajuste de dose ou uso de dose elevadas, incluindo falta de adesão à terapia e medicação inadequada. Descartando-se essas duas causas, é necessário investigar o uso de drogas e a presença de doenças concomitantes. Existe necessidade maior de tiroxina quando diminui a secreção ácida do estômago. Inibidores de bomba de prótons, antiácidos e uma longa lista de drogas podem dificultar a absorção da tiroxina. Várias doenças, incluindo a doença celíaca e as doenças intestinais inflamatórias crônicas, além dos hábitos alimentares, são importantes no controle do paciente hipotiroideo. Finalmente, foram mencionados os efeitos de uma lista crescente de drogas e disruptores que podem afetar o metabolismo tiroidiano em diferentes níveis. Arq Bras Endocrinol Metab. 2010;54(5):435-42 Descritores

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Lactose Intolerance Revealed by Severe Resistance to Treatment with Levothyroxine

Cited by 43 publications

References 11 publications

Pseudomalabsorption of Levothyroxine: A Challenge for the Endocrinologist in the Treatment of Hypothyroidism

Pseudomalabsorption of Levothyroxine: A Challenge for the Endocrinologist in the Treatment of Hypothyroidism

Treatment of Thyroxine Malabsorption

The difficult patient: drug interaction and the influence of concomitant diseases on the treatment of hypothyroidism

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