Levothyroxine


Article Author:
Bibinaz Eghtedari


Article Editor:
Ricardo Correa


Editors In Chief:
James Beauchamp
Mark Pellegrini
Nicole Hale-Crutch


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Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
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Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/17/2019 9:20:04 AM

Indications

Oral levothyroxine is primarily indicated for the treatment of primary, secondary, and tertiary hypothyroidism.[1] Primary hypothyroidism is when the problem occurs in the thyroid gland with the most common cause been autoimmune condition (Hashimoto thyroiditis) follow up by iatrogenic hypothyroidism (after thyroidectomy). Secondary hypothyroidism is when the problem is in the pituitary gland (from adenomas to post-surgical intervention), and there is a decrease in the production of thyroid stimulating hormone (TSH). Tertiary hypothyroidism is very rare, and the problem is in the hypothalamus with decrease production of thyroid releasing hormone (TRH).

Injectable levothyroxine is indicated for the treatment of myxedema coma or severe hypothyroidism.[2]

Off-label usage includes cadaveric organ recovery.[3]

Mechanism of Action

Levothyroxine (T4) is a synthetic version of one of the body’s natural thyroid hormones: thyroxine (T4). Normally, the hypothalamus secretes thyrotropin-releasing hormone (TRH), which then stimulates the anterior pituitary to secrete thyroid-stimulating hormone (TSH), which subsequently stimulates the thyroid to secrete 80% thyroxine (T4) and 20% L-triiodothyronine (T3). 50% of thyroxine (T4) then gets converted to its active metabolite L-triiodothyronine (T3). The thyroid hormones then work by binding to thyroid receptor proteins contained within the cell nucleus.

Once inside the nucleus, thyroid hormones work by directly influencing DNA transcription to increase body metabolism by increasing gluconeogenesis, protein synthesis, the mobilization of glycogen stores and other more functions.

In scenarios where this process is interrupted (as seen in primary, secondary, or tertiary hypothyroidism), levothyroxine (LT4) can mimic the body’s endogenous T4 production by the thyroid.[4]

Administration

Oral: Administer levothyroxine on an empty stomach (acidity increases absorption), at least 30 to 60 minutes before breakfast or 3 to 4 hours after dinner. Do not administer levothyroxine within 4 hours of administration of products that may contain iron or calcium. Do not administer levothyroxine in conjunction with antacids or proton pump inhibitors.

Capsule: Swallow whole; Do not crush or cut. 

Tablet: May crush into 5 to 10 mL of water and drank immediately. If swallowing tablet whole, administer with a full glass of water to prevent dysphagia.

Solution: Give either undiluted (directly squeeze contents into mouth) or diluted in water only (squeeze contents into water, stir, and drink immediately).

Intravenous levothyroxine is exclusively for use in the hospital setting in which vital signs can undergo close monitoring.[5][6] 

In cases where the patient can not tolerate anything by mouth due to an underlying problem, the levothyroxine capsules are usable as a suppository and are well absorbed. 

Adult Dosing:

For the treatment of hypothyroidism (oral): Adults who are healthy and who have a diagnosis of hypothyroidism for a few months should receive an initial dose of 1.6 mcg/kg/day with a 12.5 to 25 mcg/day dose adjustment every 6 to 8 weeks as needed. Adults with cardiac disease or elderly over 65 years old and hypothyroidism should receive an initial dose of 25 mcg/day with dose adjustment of 12.5 to 25 mcg every 4 to 6 weeks as needed.[5][6] Pregnant patients with newly diagnosed hypothyroidism should receive initial treatment at 1.8 mcg/kg/day. Adjust dose every 4 weeks as needed. If a patient has a diagnosis of hypothyroidism prior to pregnancy, adjust the dose of levothyroxine as needed. After pregnancy, the dose of levothyroxine should decrease to 1.6 mcg/kg/day.[5][6][7]

For the treatment of myxedema coma (IV) or severe hypothyroidism: 200 to 400 mcg initial IV loading dose followed by a daily dose of 1.2 mcg/kg/day with consideration to use lower doses in patients with a history of cardiac disease, arrhythmia, or older patients. Switch to oral therapy (8mcg/kg/day) when symptoms resolve.[6] The equivalence between intravenous to oral is 2 to 1 (for example 200 mcg IV of levothyroxine is equal to 100 mcg of oral levothyroxine )

For organ recovery from a cadaver (IV):20mcg IV bolus to the donor, followed by 10 mcg/hour continuous infusion. Given with methylprednisolone, dextrose, and insulin.[8]

Adverse Effects

Generally, result from incorrect dosing (excessive dosing), often forms a hyperthyroid-like picture or due to an allergic reaction to the excipient of the levothyroxine tablets. Levothyroxine 50 mcg tablets are white and don't contain any die, so there is a decreased risk for an allergic response.

Adverse effects (frequency undefined) include: angina pectoris, tachycardia, palpitations, arrhythmias, myocardial infarction, dyspnea, anxiety, fatigue, headache, heat intolerance, insomnia, irritability, diaphoresis, skin rash, alopecia, goiter, weight loss, menstrual irregularities, abdominal cramps, diarrhea, emesis, reduced fertility, and decreased bone mineral density (a result of TSH suppression).[5][6]

Contraindications

Levothyroxine is contraindicated in individuals with uncorrected adrenal insufficiency, individuals with acute myocardial infarction, acute myocarditis, pancarditis, active heart arrhythmias and individuals with thyrotoxicosis or hyperthyroidism.[5][6]

Monitoring

In adults, monitor TSH levels approximately 6 to 8 weeks after initiating treatment with levothyroxine. Upon achieving the correct dosing of levothyroxine, monitor TSH levels 4 to 6 months after, and then every 12 months after that.  Patients should receive education about the symptoms of hyperthyroidism,  and to contact their physician for medication dose decrease if those symptoms were to appear.[5][6] Important to mention that patient with secondary or tertiary hypothyroidism the TSH is not reliable (will remain low) and the best indicator to adjust dosing will be the free or total T4.

Toxicity

Levothyroxine toxicity is rare; however, it is most likely to occur in the setting of accidental ingestion by children or older adults 

Thyroxine (T4) and Triiodothyronine (T3) levels rise within 1 to 2 hours of ingestion. In the initial stage of overdose (6 to 12 hours post-ingestion), the common signs of toxicity would be tremulousness, tachycardia, hypertension, anxiety, and diarrhea. Rarely, convulsions, thyroid storm, acute psychosis, arrhythmias, and acute myocardial infarction may occur. 

The onset of signs and symptoms may be delayed up to 3 to 10 days, and as such, close monitoring should continue in such patients. 

There is no antidote for the treatment of levothyroxine overdose. Treatment options include gastric lavage, activated charcoal, cholestyramine, glucocorticoids, beta-blockers, propylthiouracil, and supportive measures.[9]

Enhancing Healthcare Team Outcomes

An interprofessional team of healthcare professionals is necessary for the management of levothyroxine overdose. This team would include a nurse, laboratory technician, pharmacist, and physicians (both primary care and endocrinologist).  

Upon first prescribing levothyroxine, adjustment of the medication should take place every 6 to 8 weeks until the patient reaches a steady state. If the patient has symptoms of hyperthyroidism, advise the patient to contact the physician to determine if these are side effects of the medication. A physician or nurse should then order TSH and free T4 levels immediately. If the free T4 comes back elevated, the physician should decrease the dose of the levothyroxine to prevent cardiac complications and other symptoms of hyperthyroidism.


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Levothyroxine - Questions

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Which of the following medications can reduce the bioavailability of levothyroxine?



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What complications can develop in a geriatric patient from long-term administration of levothyroxine?



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Which of the following statements is appropriate counselling for a patient that is supposed to start taking levothyroxine?



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T4 is the primary active compound for which of the following?



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Which drug causes weight loss and tachycardia?



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Which of the following is a pharmacist’s counseling point for a patient who has been started on 50 micrograms of levothyroxine (Levoxyl) for hypothyroidism?



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A patient shows up in your pharmacy with a new prescription for Synthroid (levothyroxine) 50 mcg daily. Since he has not been on this medication previously, you counsel him. Which of the following is a valid counseling point?



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As you begin to process an inpatient order for generic levothyroxine, you scan the patient's most recent vital signs and see a heart rate of 134 beats/min. What is the proper course of action?



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A patient is rushed to the emergency department with an apparent drug overdose. His presentation includes tachycardia, palpitations, and chest pain. An IV beta-blocker is ordered to stabilize the cardiac activity. Which of the following drugs is the most likely culprit for this overdose?



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Which of the following is an indication is levothyroxine use?



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Levothyroxine - References

References

Cooper DS,Halpern R,Wood LC,Levin AA,Ridgway EC, L-Thyroxine therapy in subclinical hypothyroidism. A double-blind, placebo-controlled trial. Annals of internal medicine. 1984 Jul;     [PubMed]
Ono Y,Ono S,Yasunaga H,Matsui H,Fushimi K,Tanaka Y, Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. Journal of epidemiology. 2017 Mar;     [PubMed]
Salim A,Vassiliu P,Velmahos GC,Sava J,Murray JA,Belzberg H,Asensio JA,Demetriades D, The role of thyroid hormone administration in potential organ donors. Archives of surgery (Chicago, Ill. : 1960). 2001 Dec;     [PubMed]
Fish LH,Schwartz HL,Cavanaugh J,Steffes MW,Bantle JP,Oppenheimer JH, Replacement dose, metabolism, and bioavailability of levothyroxine in the treatment of hypothyroidism. Role of triiodothyronine in pituitary feedback in humans. The New England journal of medicine. 1987 Mar 26;     [PubMed]
Garber JR,Cobin RH,Gharib H,Hennessey JV,Klein I,Mechanick JI,Pessah-Pollack R,Singer PA,Woeber KA, Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2012 Nov-Dec;     [PubMed]
Jonklaas J,Bianco AC,Bauer AJ,Burman KD,Cappola AR,Celi FS,Cooper DS,Kim BW,Peeters RP,Rosenthal MS,Sawka AM, Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid : official journal of the American Thyroid Association. 2014 Dec;     [PubMed]
Alexander EK,Marqusee E,Lawrence J,Jarolim P,Fischer GA,Larsen PR, Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. The New England journal of medicine. 2004 Jul 15;     [PubMed]
Nath DS,Ilias Basha H,Liu MH,Moazami N,Ewald GA, Increased recovery of thoracic organs after hormonal resuscitation therapy. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2010 May;     [PubMed]
Medeiros-Neto G, Thyroxine Poisoning 2000;     [PubMed]

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