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Do not store the crushed tablet/water mixture and do not administer it mixed with foods that decrease absorption of levothyroxine, such as soybean-based infant formula. DAW codes are codes a pharmacy uses when filling your patient’s prescription. DAW-1 indicates that substitution is not allowed, based on the prescriber’s preference, and ensures your patient will receive the treatment you prescribe. It also helps your patient pay the lowest possible price for the product you write if it is billed through insurance. It’s very important to remind the patients, in addition to these factors, that they need to check their pills on a consistent basis. Look to see if the tablets have Synthroid embossed on them to ensure they’re getting the right product.
This is a very important issue on the initial prescription, but even more importantly to make sure that it occurs with every refill or renewal that occurs, as these are often circumstances where the nursing staff or medical assisting staff are involved in sending those prescriptions in via the electronic records system. Careful titration of medication and monitoring is required in that setting. Assess the adequacy of therapy by periodic assessment of laboratory tests and clinical evaluation. Administer SYNTHROID as a single daily dose, on an empty stomach, one-half to one hour before breakfast. Leonidas H. Duntas and Jacqueline Jonklaas have nothing to disclose related to this work.
Therefore, in people over the age of 65 years, levothyroxine should be started at a small dose (25–50 μg/daily) and dose titration should be carried out slowly. Routine use of levothyroxine in subclinical hypothyroidism is controversial. Patients on high dosages of levothyroxine (greater than 200 mcg per day) with persistently elevated TSH levels may be nonadherent or have absorption issues attributed to meal timing or other medications1,5,20 (Table 5 and Table 820). Some patients may experience persistent symptoms despite adequate dosing of levothyroxine to a normal TSH level; therefore, other etiologies should be considered and evaluated accordingly (Table 41,2). If the TSH level is abnormal, the clinician should assess patient adherence, evaluate drug-drug interactions, and adjust the levothyroxine dosage every six to eight weeks until the TSH level normalizes (Figure 22,3,5,7,10,20–25).
There are also certain vitamins and supplements that can interfere with the absorption of SYNTHROID. The FDA has determined that certain levothyroxine products are interchangeable. Administer SYNTHROID at least 4 hours before or after drugs known to interfere with SYNTHROID absorption.
For secondary or tertiary hypothyroidism, serum TSH is not a reliable measure of SYNTHROID dosage adequacy and should not be used to monitor therapy. Use the serum free-T4 level to titrate SYNTHROID dosing until the patient is clinically euthyroid and the serum free-T4 level is restored to the upper half of the normal range. A search of the literature was conducted using the PubMed and CENTRAL (Cochrane) databases. Keywords relating to levothyroxine, hypothyroidism, treatment, levothyroxine dose adjustments, levothyroxine and concomitant conditions, levothyroxine and concomitant medications, and combined treatment with levothyroxine and liothyronine versus levothyroxine were searched. Only reviews and articles providing clinical data, particularly the most recent, were considered.
Hypothyroidism occurs when there is inadequate thyroid hormone production by the thyroid gland or insufficient stimulation by the hypothalamus or pituitary gland. Causes may include primary gland failure or can be iatrogenic, transient, or central (Table 1).1–4 Central causes, such as low levels of thyroid-stimulating hormone (TSH) and free thyroxine (FT4), are synthroid sintomas rare. There are certain populations where we pay closer attention to thyroid medication dosing. Another group is those that have underlying cardiac disease or are at risk for atrial fibrillation.
Dosing here should be individualized based on whether the patients were diagnosed with hypothyroidism prior to pregnancy or during the pregnancy. Persistent clinical and laboratory evidence of hypothyroidism despite an apparent adequate replacement dose of SYNTHROID may be evidence of inadequate absorption, poor compliance, drug interactions, or a combination of these factors. The “optimal dose” was determined for each patient as that dosage of thyroxine being taken when the thyrotropin releasing hormone (TRH) response was normal (ie, an increase in TSH of between 4.7 and 25 mIU/L). Personally, I have had experiences where I have written for brand-name SYNTHROID and the patients have been dispensed generic levothyroxine or even another branded levothyroxine product.
Overtreatment or undertreatment with levothyroxine may have negative effects on different systems throughout the human body. So, my job as a thyroid specialist in these patients is to make sure my patient is treated and gets to a point of consistency, because it is a lifelong course of medication. HypothyroidismSYNTHROID® (levothyroxine sodium) tablets, for oral use is indicated as a replacement therapy in primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) congenital or acquired hypothyroidism. Some patients with a normal TSH level and symptom resolution may become symptomatic again with or without a change in TSH.
When symptoms reappear without a change in TSH level, the physician should consider nonthyroid etiologies. When there is an accompanying change in the TSH level, especially in a patient who has stayed on a stable dosage for some time, other reasons should be explored before adjusting the levothyroxine dosage. If you become pregnant while taking Synthroid, do not stop taking the medicine without your doctor’s advice. Having low thyroid hormone levels during pregnancy could harm both mother and baby. Certain other medicines may also increase or decrease the effects of Synthroid.
Several studies have shown that the levothyroxine dose requirement is decreased in older individuals 8, 48, 49. However, a recent study suggests that this decreased requirement may be mediated by the changes in weight that may accompany ageing 26. Other important considerations regarding levothyroxine doses in older individuals include bearing age-adjusted TSH reference ranges in mind 50 and avoiding over-replacement that might potentially exacerbate other medical conditions 8. Both of these considerations would lead to targeting of higher TSH values in older individuals (Fig. 3).
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