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MANAGEMENT: Some experts recommend separating the times of administration of levothyroxine and calcium-containing preparations by at least 4 hours. In these patients, levothyroxine therapy should be initiated at lower doses than those recommended in younger individuals or in patients without cardiac disease (see WARNINGS ; PRECAUTIONS , Geriatric Use ; and DOSAGE AND ADMINISTRATION ). If cardiac symptoms develop or worsen, the levothyroxine dose should be reduced or withheld for one week and then cautiously restarted at a lower dose. The frequency of TSH monitoring during levothyroxine dose titration depends on the clinical situation but it is generally recommended at 6—8 week intervals until normalization. Patients with diabetes mellitus may require upward adjustments of their antidiabetic therapeutic regimens when treated with levothyroxine (see PRECAUTIONS , Drug Interactions ). Patients with concomitant adrenal insufficiency should be treated with replacement glucocorticoids prior to initiation of treatment with levothyroxine sodium. Taking levothyroxine over long periods of time may cause bone loss, which can lead to osteoporosis. The relative bioavailability of Levoxyl® tablets, compared to an equal nominal dose of oral levothyroxine sodium solution, is approximately 98%. Concomitant administration of levothyroxine and sympathomimetic agents to patients with coronary artery disease may precipitate coronary insufficiency. Many drugs interact with levothyroxine sodium necessitating adjustments in dosing to maintain therapeutic response (see Drug Interactions ). , package inserts of newly approved drugs, medical literature) for additional information if a drug-drug interaction with levothyroxine is suspected. The levothyroxine tablet can dissolve very quickly and swell in the throat, possibly causing choking or gagging. In isolated case reports, patients stabilized on levothyroxine developed symptoms of hypothyroidism and/or elevated thyroid-stimulating hormone (TSH) levels following the addition of lovastatin or simvastatin. In addition, there have been case reports suggesting decreased efficacy of levothyroxine during calcium coadministration. The exact mechanism of interaction is unknown but may involve nonspecific adsorption of levothyroxine to calcium at acidic pH levels, resulting in an insoluble complex that is poorly absorbed from the gastrointestinal tract. Levothyroxine is contraindicated in patients with uncorrected adrenal insufficiency since thyroid hormones may precipitate an acute adrenal crisis by increasing the metabolic clearance of glucocorticoids (see PRECAUTIONS ). The majority of the levothyroxine dose is absorbed from the jejunum and upper ileum. In one study, 20 patients with hypothyroidism who were taking a stable long-term regimen of levothyroxine demonstrated modest but significant decreases in mean free and total thyroxine (T4) levels as well as a corresponding increase in mean thyrotropin (thyroid-stimulating hormone, or TSH) level following the addition of calcium carbonate (1200 mg/day of elemental calcium) for 3 months. Do not take levothyroxine for longer than your doctor has prescribed. Levothyroxine is given when the thyroid does not produce enough of this hormone on its own. Calcium carbonate may form an insoluble chelate with levothyroxine, and ferrous sulfate likely forms a ferric-thyroxine complex. Administer levothyroxine at least 4 hours apart from these agents. Patients with coronary artery disease who are receiving levothyroxine therapy should be monitored closely during surgical procedures, since the possibility of precipitating cardiac arrhythmias may be greater in those treated with levothyroxine. Hypothyroidism, After Thyroid Removallevothyroxine, Levoxyl, Armour Thyroid, Cytomel, Levothroid, liothyronine, More. Levothyroxine (T4) sodium has an empirical formula of C15H10I4N NaO4 • H2O, molecular weight of 798. Patients treated concomitantly with orlistat and levothyroxine should be monitored for changes in thyroid function. Overtreatment with levothyroxine sodium may have adverse cardiovascular effects such as an increase in heart rate, cardiac wall thickness, and cardiac contractility and may precipitate angina or arrhythmias. For patients who have recently initiated levothyroxine therapy and whose serum TSH has normalized or in patients who have had their dosage or brand of levothyroxine changed, the serum TSH concentration should be measured after 8—12 weeks. Levothyroxine is also used to treat or prevent goiter (enlarged thyroid gland), which can be caused by hormone imbalances, radiation treatment, surgery, or cancer. Therefore, it is recommended that patients receiving levothyroxine sodium be given the minimum dose necessary to achieve the desired clinical and biochemical response.

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