Synthroid Administration

[DrWrong]

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So I was at IPPE today when a patient came in to get her first script for synthroid. I ask the patient if she has any questions and she says no, but the pharmacist says over my should to tell the patient to make sure to take it in the morning....

So I say, "Make sure to take this in the morning, because if you take it at night it can cause insomnia."

The pharmacist then tells me that that wasn't the right counseling point that it's because you want to mimic the body's natural rhythm [I guess she means that you want to suppress TSH as much as possible by taking it at night]

This makes no sense to me, though, as the t1/2 of T4 is like 6 days and wouldn't really matter once you got to Css and took the dose at the same time everyday.

So, my question is, why is synthroid taken in the morning?

I've taken the time to bold my actual question to help all you people out who really don't want to read my rant.

 

[All4MyDaughter]

Take it at the same time every day, on an empty stomach. It's easiest for most patients to do that in the morning. Do you know why it should be taken on an empty stomach?

I am not sure about the pharmacists statement about the body's natural rhythm... but the therapeutic goal isn't the "suppression of TSH" but rather normalized levels of thyroid hormone.

Why would you say it causes insomnia? Don't improvise when counseling patients.

 

[FruitFly]

So I was at IPPE today when a patient came in to get her first script for synthroid. I ask the patient if she has any questions and she says no, but the pharmacist says over my should to tell the patient to make sure to take it in the morning....

So I say, "Make sure to take this in the morning, because if you take it at night it can cause insomnia."

The pharmacist then tells me that that wasn't the right counseling point that it's because you want to mimic the body's natural rhythm [I guess she means that you want to suppress TSH as much as possible by taking it at night]

This makes no sense to me, though, as the t1/2 of T4 is like 6 days and wouldn't really matter once you got to Css and took the dose at the same time everyday.

So, my question is, why is synthroid taken in the morning?

I've taken the time to bold my actual question to help all you people out who really don't want to read my rant.

Could be wrong, but I think it may be to emphasize the need to take it on an empty stomach to maximize absorption (the counseling point is to take it first thing in the morning at least a half hour prior to eating breakfast with a full glass of water). Isn't the stomach usually most empty in the morning prior to breakfast?

 

[Aznfarmerboi]

Could be wrong, but I think it may be to emphasize the need to take it on an empty stomach to maximize absorption (the counseling point is to take it first thing in the morning at least a half hour prior to eating breakfast with a full glass of water). Isn't the stomach usually most empty in the morning prior to breakfast?

👍

 

[DrWrong]

Take it at the same time every day, on an empty stomach. It's easiest for most patients to do that in the morning. Do you know why it should be taken on an empty stomach?

I am not sure about the pharmacists statement about the body's natural rhythm... but the therapeutic goal isn't the "suppression of TSH" but rather normalized levels of thyroid hormone.

Why would you say it causes insomnia? Don't improvise when counseling patients.

I wouldn't say I was improvising. I wasn't going based off of what was ont he computer screen, as I didn't have it pulled up. I was taught that throid hormone causes insomnia as it stimulates the bodys metabolic processes, much like cocaine would cause insomnia, just a different neurotransmitter. It should be taken on an empty stomach, from what I read, in order to increase the absorption of the medication to obtain, as you said, normal thyroid levels. I was just guessing that is what she was implying because of the whole circadian rhythm thing.


And yes, I was thinking the same thing that in the morning the stomach is at its most empty state I guess you could say. Maybe that's the deal ;-/.

Either way, I can't really find an answer that is reputable =-(

 

[DrWrong]

I wouldn't say I was improvising. I wasn't going based off of what was ont he computer screen, as I didn't have it pulled up. I was taught that throid hormone causes insomnia as it stimulates the bodys metabolic processes, much like cocaine would cause insomnia, just a different neurotransmitter. It should be taken on an empty stomach, from what I read, in order to increase the absorption of the medication to obtain, as you said, normal thyroid levels. I was just guessing that is what she was implying because of the whole circadian rhythm thing.


And yes, I was thinking the same thing that in the morning the stomach is at its most empty state I guess you could say. Maybe that's the deal ;-/.

Either way, I can't really find an answer that is reputable =-(

I'm not saying that you guys' answers aren't reputable...just so you know 🙂

 

[All4MyDaughter]

It is correct that thyroid hormone can cause insomnia. This is observed in patients who are in a hyperthyroid state. But typically, patients taking Synthroid for hypothyroidism aren't going to experience insomnia. An overdose of thyroid hormone could cause insomnia, as well as other problems.

I also thought some more about the TSH suppression issue... the idea is to get the patient back to a euthyroid state by giving exogenous thyroid hormone. When hormone levels are in balance, TSH levels should normalize too. So it's not totally incorrect to use "TSH suppression" as a therapeutic endpoint. Some doctors only monitor TSH in hypothyroid patients, but others check T4 and T3 levels as well.

Synthroid is also used for TSH suppression in thyroid cancers.

Here is what Lexi Comp lists for oral administration guidelines:

Administer in the morning on an empty stomach, at least 30 minutes before food. Tablets may be crushed and suspended in 1-2 teaspoonfuls of water; suspension should be used immediately. Levoxyl® should be administered with a full glass of water to prevent gagging (due to tablet swelling).

 

[DrWrong]

It is correct that thyroid hormone can cause insomnia. This is observed in patients who are in a hyperthyroid state. But typically, patients taking Synthroid for hypothyroidism aren't going to experience insomnia. An overdose of thyroid hormone could cause insomnia, as well as other problems.

I also thought some more about the TSH suppression issue... the idea is to get the patient back to a euthyroid state by giving exogenous thyroid hormone. When hormone levels are in balance, TSH levels should normalize too. So it's not totally incorrect to use "TSH suppression" as a therapeutic endpoint. Some doctors only monitor TSH in hypothyroid patients, but others check T4 and T3 levels as well.

Synthroid is also used for TSH suppression in thyroid cancers.

Here is what Lexi Comp lists for oral administration guidelines:

Yes, that's what I've been reading. As far as what Lexi Comps has, that's the same generic answer that is found on the package insert of synthroid unfortunately =-(. Although it says it should be taken in the morning, it doesn't imply that it's due to the food effects.

Gastric emptying time is roughly 1-4 hours and SITT is 3-4 hours [under normal thyroid conditions]. So if a patient ate dinner at 6 o clock and then took the synthroid at 10, then there shouldn't be a problem, right?


Oh the enigma! 😕

 

[All4MyDaughter]

Lexi Comp also has this:

Ethanol/Nutrition/Herb Interactions
Food: Taking levothyroxine with enteral nutrition may cause reduced bioavailability and may lower serum thyroxine levels leading to signs or symptoms of hypothyroidism. Soybean flour (infant formula), cottonseed meal, walnuts, and dietary fiber may decrease absorption of levothyroxine from the GI tract.

and also:

Do not take antacids or iron preparations within 4 hours of thyroid medication.

and also:

Absorption: Oral: Erratic (40% to 80%); may be decreased by age and specific foods and drugs

 

[ucrx]

I wouldn't say I was improvising. I wasn't going based off of what was ont he computer screen, as I didn't have it pulled up. I was taught that throid hormone causes insomnia as it stimulates the bodys metabolic processes, much like cocaine would cause insomnia, just a different neurotransmitter. It should be taken on an empty stomach, from what I read, in order to increase the absorption of the medication to obtain, as you said, normal thyroid levels. I was just guessing that is what she was implying because of the whole circadian rhythm thing.


And yes, I was thinking the same thing that in the morning the stomach is at its most empty state I guess you could say. Maybe that's the deal ;-/.

Either way, I can't really find an answer that is reputable =-(

From Dipiro:

"Cholestyramine, calcium carbonate, sucralfate, aluminum hydroxide, ferrous sulfate, soybean formula, and dietary fiber supplements may also impair the absorption of levothyroxine from the gastrointestinal tract."

I think the main reason is the variable absorption caused by food. Because this is a medication with very precise dosing, slight variations in the amount of drug reaching systemic circulation may impact the effects of the drug and ability to reach a stable effective dose.

 

[DrWrong]

From Dipiro:


I think the main reason is the variable absorption caused by food. Because this is a medication with very precise dosing, slight variations in the amount of drug reaching systemic circulation may impact the effects of the drug and ability to reach a stable effective dose.

Well, All4 and you have definitely shown enough evidence that it's because of the fact that food causes the variation in absorption. Thanks guys and gals!

Looks like neither myself or the pharmacist really knew what we were talking about

 

[Sparda29]

👍

 

[rXcmoney]

The pharmacist then tells me that that wasn't the right counseling point that it's because you want to mimic the body's natural rhythm.

The pharmacist was probably getting that confused w/the reason you take prednisone in the am.