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Reversible normalisation of TSH in patients with autoimmune atrophic gastritis who received L-T4 tablet form after switching to oral liquid

Absorption of levothyroxine is clearly an issue which has not yet been fully addressed. With absorption of tablets potentially varying between 50 and 80% depending on make and the person taking them (e.g. gut issues), there is plenty of room for people to vary greatly in requirements.

Liquid products are, unfortunately, very much more expensive than tablets, so a wholesale changeover to them seems unlikely. But for some they might be very helpful.

BMC Gastroenterol. 2016; 16: 22.

Published online 2016 Feb 24. doi: 10.1186/s12876-016-0439-y

PMCID: PMC4787146

Reversible normalisation of serum TSH levels in patients with autoimmune atrophic gastritis who received L-T4 in tablet form after switching to an oral liquid formulation: a case series

Poupak Fallahi, Silvia Martina Ferrari, Ilaria Ruffilli, and Alessando Antonelli



L-thyroxine (L-T4) malabsorption is a potential concern in patients with autoimmune atrophic gastritis.


We evaluated five patients with autoimmune gastritis, who showed high serum thyrotropin (TSH) levels (in the hypothyroid range) while in therapy with L-T4 in tablet. All patients were switched to receive an oral L-T4 liquid formulation maintaining the same dosage.


In all patients who received L-T4 in tablet form after switching to an oral liquid formulation with the same L-T4 dosage, TSH circulating levels were normalized. In four patients who were switched back again to receive L-T4 in tablets, maintaining the dosage, TSH levels worsened again reaching levels in the hypothyroid range.


The fact that the change from tablets to liquid oral formulation normalised serum TSH levels, and that switching back to tablets caused thyrotropin levels to worsen, leads us to believe that absorption of L-T4 is greater with oral liquid formulations in these patients. These results suggest that the L-T4 oral liquid formulation could circumvent the pH alteration resulting from atrophic gastritis.

Keywords: L-thyroxine, Liquid L-thyroxine, Hypothyroidism, Gastritis


2 Replies

I used to crunch my T4 but on my current tablets, I feel them start to disintegrate even before I have managed to get my glass of water to my lips. (Actavis and Uni-Pharma.) So I no longer do.

Failure to disintegrate and deliver the claimed dose was an issue for Levoxyl ten or fifteen years ago - they reformulated with things like croscarmellose. The upshot was having to put warnings on that they must be swallowed with a glass of water otherwise they could puff up in your throat!


That might be a very good move. But we always have to realise that levothyroxine tends to disperse rather than dissolve.

I do seriously keep wondering if there might be a sensible, practical DIY approach. But I don't what that could be.

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