Patient 2 A 48yearold woman was diagnosed with primary hypothyroidism during routine workup for angina. At diagnosis, TSH was 75 mu/l and FT4 was 5.6 pmol/l. She was started on thyroxine 75 g daily.Thyroid hormone in health and disease. J Endocrinol.15 PubMed 2. Evans T C. Thyroid disease. Prim Care.640 PubMed 3. Vermeire E, Hearnshaw H, Van Royen P. et al Patient adherence to treatment: three decades of research.
The known physical causes should be excluded before noncompliance is considered most likely, and a trial of weekly supervised thyroxine at the local GP surgery (or pharmacy) may confirm the clinical suspicion.A comprehensive review. J Clin Pharm Ther.342 PubMed 4. Ain K B, Refetoff S, Fein H G. et al Pseudomalabsorption of levothyroxine. JAMA.2120 PubMed 5. Mandel S J, Brent G A, Larsen P R.
A 45-year-old man reports to his primary care physician that his wife has noted. A 28-year-old woman presents to her primary care physician s office with 1 year of. Thyroxine-binding protein has a high affinity for T4; thus despite its low.A 47yearold woman was diagnosed with primary hypothyroidism in 2001 by her. The thyroxine dose was cautiously increased to 200 g daily but the TSH.
This case demonstrates the occurrence of significant hyperprolactinemia in the absence of overt primary hypothyroidism.4 When larger doses of thyroxine are needed, the treating physician needs to investigate the underlying cause. There are many different causes for nonresponse to thyroxine treatment ranging from drugrelated interference with thyroxine absorption to small bowel disease that could also affect thyroxine absorption (table 1).
Clinical examination was unremarkable apart from a weight of 42 kg. Initial investigations, including full blood count, and renal and liver function tests, were within normal limits. Coeliac disease was ruled out by a normal gastroduodenoscopy and undetectable antigliadin and antitissue transglutaminase (antiTTG) antibodies.However, the most common cause of lack of response to thyroxine replacement is poor compliance, 5 although the major disadvantages of hypothyroidism for the patient (such as fatigue, constipation, weight gain) would seem reason enough for treatment compliance.
Copyright 2007 The Fellowship of Postgraduate Medicine. This article has been cited by other articles in PMC. Abstract Hypothyroidism is a common disorder, which is mainly treated in primary rather than secondary care.J Clin Endocrinol Metab.875 PubMed 9. Taylor J, Williams B O, Frater J. et al Twiceweekly dosing for thyroxine replacement in elderly patients with primary hypothyroidism. J Int Med Res.277 PubMed 10.
Further studies including larger number of patients are warranted in order to clarify the efficacy and safety of this method further. Footnotes Conflict of interest: None References 1. Boelaert K, Franklyn J A.Ogawa D, Otsuka F, Mimura U. et al Pseudomalabsorption of levothyroxine: a case report. Endocr J.50 PubMed Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Group.
All patients tolerated the weekly regimen well and the tissue markers of thyroid hormone effect were not different between both groups, with no evidence of toxicity. 8 The main problem with these studies is the small number of patients included.These tests include the thyroid-stimulating hormone test (TSH the thyroxine test (T4. By measuring the level of TSH, doctors can determine even small problems in. T3 levels normally rise when a woman is pregnant or using birth- control pills. mostly follicular adenomas in old-aged dogs, cats and horses; papillary ).
Once daily thyroxine replacement restores euthyroidism in most patients; some patients, however, remain hypothyroid despite adequate thyroxine replacement. Noncompliance is the most common cause of lack of response to thyroxine treatment.The trough and peak serum concentrations of FT4, T3 and TSH were similar. 9 Grebe et al compared daily T4 treatment with once weekly dosing in 12 hypothyroid patients in a randomised crossover trial.
Once weekly thyroxine treatment can be a safe, welltolerated, and effective therapy for patients with noncompliance. Keywords: hypothyroidism, thyroxine, thyroxine replacement, noncompliance Hypothyroidism is common in the general population with an incidence of per year in women and per year in men.Uncorrected thyroid dysfunction in pregnancy has adverse effects on fetal and. area (USA) where a study showed that the IQ scores of 7-9 year old children, born to. Once pregnancy is confirmed the thyroxine dose should be increased by about. Ideally a woman who is known to have hyperthyroidism should seek.
We describe two cases of primary hypothyroidism in which daily thyroxine treatment did not restore biochemical euthyroidism but once weekly thyroxine treatment was successful. In addition we review the evidence and discuss the differential diagnosis of lack of response to thyroxine treatment.Hypothyroidism be treated with l-thyroxine?. A 46 year old woman comes to your office for her. women, women 60, and others at high risk for. pregnancy on thyroxine treatment in hypothyroid women? 45. A. What are the adverse effects.
3 The daily lifelong administration of thyroxine can lead to patient noncompliance. The mean treatment dose of oral thyroxine is 1.6 g/kg/day. The results achieved with this dose are adequate and reproducible.In this article we describe two cases of primary hypothyroidism in which daily thyroxine treatment did not restore biochemical euthyroidism but once weekly thyroxine treatment was successful. In addition we discuss the differential diagnosis of lack of response to thyroxine treatment.
In conclusion, poor compliance with oral thyroxine is one of the most common causes of nonresponse to thyroxine treatment. Other causes must be excluded before making the diagnosis of noncompliance. Supervised once weekly oral thyroxine may be a safe, successful and well tolerated treatment regimen, and should be considered as an option in treating these.A 45-year-old woman presenting with carpal tunnel syndrome was found to have a minimally elevated level of thyrotropin with a normal level of thyroxine.
Keck F S, Loos U. Peripheral autoregulation of thyromimetic activity in man. Horm Metab Res.114 PubMed 8. Grebe S K, Cooke R R, Ford H C. et al Treatment of hypothyroidism with once weekly thyroxine.Finally, poor compliance may be due to psychiatric disorders of a depressive nature, which are not uncommon in severe hypothyroidism, although only few patients exhibit true psychopathology. 10 Confronting the patient about issues regarding poor compliance could upset the patient without much improvement in treatment.
Synthroid review by 46 year old female patient. Rating. Over time, synthroid dosage has increased, to 112 mcg per day from the original dose of 50. This is.Discussion. Noncompliance with prescribed medical interventions is an old and well recognised problem in patients with chronic disorders. 3 The frequency of dosing, duration of treatment and number of medications are all implicated in the development of noncompliance, in addition to other factors such as the doctorpatient relationship and the patient's psychiatric history.
The TSH concentration remained persistently elevated despite dose adjustments. The patient denied any noncompliance. There was no evidence of malabsorption and she was not taking any other medications. The thyroxine dose was cautiously increased to 200 g daily but the TSH remained elevated at 15.5 mu/l.Thyroxine dose was increased to 400 g a day. TSH, however, remained elevated. As there was no obvious cause for lack of response, it was felt that the most likely diagnosis was noncompliance.
Adequate precautions need to be taken in patients with ischaemic heart disease. Close liaison between primary and secondary care is essential at the initiation of treatment, but once stabilised, supervision of the patient can be undertaken in the primary care setting in the majority of cases.It was felt that noncompliance was the most likely diagnosis. The patient was started on supervised once weekly thyroxine 750 g. The TSH concentration came down to 1.93 mu/l after 4 weeks of treatment.
The combination of history, examination and primary laboratory investigations is able to exclude most causes. Table 1 Causes of lack of response to thyroxine replacement in hypothyroid patients. The use of once weekly thyroxine is scientifically plausible.Case histories Patient 1 A 47yearold woman was diagnosed with primary hypothyroidism in 2001 by her general practitioner (GP). At diagnosis, the thyroid stimulating hormone (TSH) concentration was 22.90 mu/l ( mu/l). Despite titrating the dose of thyroxine to 375 g once daily, the patient remained hypothyroid with a free T4 (FT4) of 10.9 pmol/l (1025 pmol/l) and a TSH.
A 31-year-old female was diagnosed to have familial elevation of TBG. for almost a year. Thyroxine binding globulin excess causes elevation of total T4 levels.Hyperprolactinemia is common in primary hypothyroidism but, to our knowledge, marked elevation of serum prolactin in subclinical hypothyroidism has not been previously reported. A 45-year-old woman presenting with carpal tunnel syndrome was found to have a minimally elevated level of thyrotropin with a normal level of thyroxine.
The patient was started on supervised once weekly thyroxine 1 mg. Four weeks later, the FT4 improved to 28.5 pmol/l and the TSH fell to 0.05 mu/l. As a result, the weekly dose of thyroxine was reduced to 750 g, which resulted in the TSH concentration returning to normal (1.25 mu/l).Levothyroxine therapy in patients with thyroid disease. Ann Intern Med.502 PubMed 6. Stock J M, Surks M I, Oppenheimer J H. Replacement dosage of Lthyroxine in hypothyroidism. A reevaluation. N Engl J Med.533 PubMed 7.
The TSH concentrations were never well controlled since the diagnosis, with values ranging from mu/l. As a result the patient was referred to our endocrine clinic. The patient denied poor compliance and was not taking any medications that could interfere with thyroxine absorption.7 Studies have shown that a single dose of T4 up to 3 mg is well tolerated. 8 Taylor et al compared once daily versus twice weekly thyroxine treatment in seven female patients.