Mercury Pharma T3 if split dose has to be mixed in water so not just Teva !

[Pascha1]

A post way back saying TEVA T3 had to be mixed with water,

Which Is why I told my friend to avoid Teva brand, anyway she came back and said the other 2 Morningside and Mercury Pharma also had to be split this way, I told her to email it to our Endocrinologist.

She said he didn't know this was how it was supposed to be done, he had always given pill cutters it when he prescribed it.

I went to see him the other day and he asked me how I took my T3 as he had an email from a lady saying it would need to be dissolved in water and why had he given her a cutter when she needed a syringe and that she only had enough tablets for 14 days if she was to follow the PIL.

I said I had sent her that email on Teva and I knew morningside said that but didn't realise Mercury Pharma was like that as well as the PIL was to small for me to read, and because I got pill cutter with it I presumed that cutting in half was they way to do it,

I am wondering if any GP or Endo or any pharmacist actually knows this is the case on them as we are all given a pill cutter with it ?

Are they not supposed to know the way to take pils and advise you on how to take it, has this has been going on years and none of them noticed by all those who are supposed to advise us on this ?

And as Teva had replied the dosage wouldn't be evenly distributed and not advised to cut tablets and to throw half mixture away , Could it be our split doses are over or under medicating at times,?

Maybe everyone should email their GPS and Endocrinologists this info as seems they were unaware of it, maybe they will fight to have the right dosages but I doubt it,

it must of concerned my Endo as he bought it up in my appointment how I was taking my split doses .

[shaws]

I have never heard of dissolving any tablets for thyroid hormones in water. I thought when reading the above of 'how to take it' what a kerfuffle. Why not just take a tablet with one full glass of water. Unless the person is so ill that they have difficulties swallowing.

These tablets are not dispersible as far as I know and there's no need to split doses of T3. Although I know quite a few do so.

Thyroid tablets cannot be taken sublingually as the hormones are too large to be absorbed through the tongue.

The way I have read is to take tablets with one full glass of water so it is absorbed into the stomach .

I take one daily dose of T3 when I get up with a full glass of water. Thyroid hormone tablets are usually taken this way as they can stick in the throat. I have no clinical symptoms and feel well.

[jimh111]

You cannont dissolve liothyronine in water, it is hydrophobic. Swirling the solution (sic) around in water for a few seconds is an attempt to titrate a given volume in the hope the liothyronine particles are evenly distributed, very hit and miss. Note it is not a 'solution' the liothyroine has not dissolved, it is a suspension which may not be very uniform. Teva correctly refer to it as a suspension.

Splitting the tablets is the most accurate way of getting smaller doses. It doesn't matter if the tablets are not split perfectly. If you take your liothyronine in two or three doses a day any minor variations will even out. Split the tablets as you use them so that if one half is slightly smaller you will have the slightly larger half next.

Unfortunately I was given Teva liothyronine for my latest prescription, I find it less potent. Also the Teva leaflet states 'Liothyronine sodium Tablets are a form of thyroxine which is quick acting and long lasting'. It's not thyroxine and not long lasting. Accordingly I will be submitting a 'yellow card' complaint to the MHRA later this week regarding these issues. It seems Teva has simply imported a truck load of liothyronine from Hungary and dashed off a leaflet with the intention of cashing in on the exhorbitant price of liothyronine.

CORRECTION

Liothyronine does dissolve in water pubchem.ncbi.nlm.nih.gov/co... but poorly, 3.96 mg/L (at 37 °C) which equates to 3.96 mcg / ml. At least 5 ml of water is needed to dissolve a 20 mcg tablet. So, 20 ml as advised should be sufficient but it doesn't allow much headroom nor take into consideration whether the excipients interfere with the liothyronine absorption. Another concern is that patients use water at tap temperature which may have a major effect on absorption.

[shaws in reply to jimh111]

Very True. This is a truly disgraceful statement:-

'Liothyronine sodium Tablets are a form of thyroxine

[helvella Administrator in reply to jimh111]

I agree with you jimh111.

I'd like to see the research which shows the dispersing process as being more accurate (that seems to be the only possible justification). If a skilled laboratory technician does it, then it just might be true. I simply cannot see it being so for ordinary patients in uncontrolled environments.

As I see it, a splitter dedicated to liothyronine, and care to avoid crumbs being lost, is likely to be a better approach.

[helvella Administrator in reply to helvella]

Aha! Maybe this:

ncbi.nlm.nih.gov/pubmed/280...

Even if it is, the paper clearly identifies patient skill as a factor. And does not take into account the importance of an exact split versus "slightly more"/"slightly less", the medicine, or pretty much anything else.

[jimh111 in reply to helvella]

How many researchers to change a light bulb! (Answer eight).

I split with my fingers and thumbs along the score line, the halves are then easy to split. But can't be done with the dreaded Teva, no score line and hard as rock, have to use Sabatier.

Usually we take two doses a day and if there is a little more in one portion then the smaller portion will compensate. Although the half life of about 24 hours is a little short the small variations in the portions will have little effect as T3 has to be bound to receptors for several hours. Also, bear in mind that the liothyronine supplies total T3 and our body then regulates free T3 levels. Small differences in portion size don't matter. Making a suspension in water and throwing away half of it (worth £4-61!) is just a profit making scheme.

[Aurealis in reply to jimh111]

Hi jimh111, I also feel Teva is less potent. Have you made a dose adjustment and if so how much please I take 20mcg daily (two doses of 10) with NDT. I’m really tempted to take an extra 10.

[jimh111 in reply to Aurealis]

I needed 20 to 25 mcg and am now on 30 mcg Teva although it might be sligtly too much, perhaps around 27 would be idea. I fnd Teva more irritating giving a sensation of both hypo and hyper. I found Thybon Henning really good but my pharmacist only got hold of it once. I wonder if there are differences in the purity of different brands and also perhaps some are released into the bloodstream more gradually. Wild speculation but it's possible some tissues respond to a short spike in hormone and some don't. In which case a slow release would be beneficial. When I have time to spare I might try splitting the Teva (very difficult to split these rocks) into four or five doses over the day, just as an experiment.

[Aurealis in reply to jimh111]

Thank you. It sounds like an increase of 5mcg might be a safer experiment for me. I have a theory that the T3 has to be in a big enough dose to affect all tissues (and Paul Robinson says this too -uses the waves breaching the sea wall analogy). So I might try one dose of 15 and one of 10. I introduced Teva for the second of each daily dose last week. This week I’m trying two doses of Teva but straight away I feel T3 hunger (if you know what I mean). Have also had itchy skin all week, but seems to be calmed with moisturiser.

[Aurealis in reply to jimh111]

They cut easier at room temperature but you need a cutter.

[jimh111 in reply to Aurealis]

I have one of these screwfix.com/p/evolution-ra... I might give it a try. I think it's the only way to cut Teva successfully.

[greygoose in reply to jimh111]

lol

[amasufindme in reply to jimh111]

Very good jimh111 you have parked a laugh into my evening!

[Aurealis in reply to jimh111]

[Pascha1 in reply to jimh111]

Ha ha are they really that bad ? Made me lol

[Hidden in reply to jimh111]

Yes pull Teva up. They need telling. I'd never take Teva a after the first two times I took it I had two seizures on there 100 mcg thyroxine years ago.

[Pascha1 in reply to Hidden]

Omg , poor you, I won’t accept Teva T3 as was very ill on Teva T4, I had hairs growing out face randomly, that was a nightmare, I had to up my dose from 100 to 200 , my leg turned to jelly I couldn’t stand on it, I wasn’t Ed to sleep 24/7 my hair fell out at an alarming rate, many more things and was on that 9 months before I worked out it was the Teva causing most of my problems that was summer 2017, my leg I can now walk on but is permantly numb knee randomly gives way my hairs on face have nearly stopped I got two on chin but get thinner ever time I pull them out, .. I think Teva T4 is same formula as the french one which was taken off the market..

so who can blame me not trusting their T3.

I have had Teva codine and I get no pain relief from it, I do not trust Teva at all.

I hope you yellow carded Teva T3 if you haven’t you really need to

[cjrsquared]

I suspect this is a ploy by the pharmaceutical companies to ensure the maximum number of tablets per patient, at greater cost to the nhs to keep profits high. Not that I’m a cynic!

[SeasideSusie Remembering]

I think it should also be asked of the endo and the pharmaceutical company, how is the excess liquid containing the T3 meant to be disposed of? Down the sink or toilet? If so it eventually enters our drinking water supply!

[helvella Administrator in reply to SeasideSusie]

100% endorsed.

[Hidden in reply to SeasideSusie]

Is that a good or bad thing. Lol

[Pascha1]

SeasideSusie The answer to that is also somewhere on this site.

They said something like it should not be thrown into our drainage but to put in a bottle and taken back to the pharmacist to dispose of excess fluid or something to those words.

[SeasideSusie Remembering in reply to Pascha1]

Ah, I missed that then. But what a palaver!

I wonder how the pharmacy will dispose of it.

A while ago (a few years) my friend saw our pharmacy dispose of their returned tablets. The assistant went outside, went to the drain and tipped them down. I'm not saying they do it now, but it happened then. Unbelieveable and irresponsible.

[Pascha1 in reply to SeasideSusie]

OMG thats dreadful and dangerous.

[SlowDragon Ambassador]

As very many patients split their T3 dose, if we did this the number of tablets used per day would double or treble.

Completely and utterly ridiculous.

Morningside Healthcare instructions say exactly the same.

It's a poor plan by pharmaceutical companies to try to increase rate of use

And, as SeasideSusie says....where do they suggest throwing the excess away? Definitely shouldn't dispose of T3 into waste water supply

It's definitely something to raise with NICE

[Pascha1 in reply to SlowDragon]

They all say the same, Teva, Morningside and Mercury Pharma, I never read the label on Mercury Pharma as is too small to see so never bothered and as I got a pill cutter with 1st prescriptionI guessed I should cut it,

My Endo did not know the PIL said this, thats why i bought it up, I still cut mine was hard enough getting T3 with out asking them to double what I get that would another 2 pots I would need per month , ,what a waste of money that would be

They should make smaller doses as they probably know quite a few are on split doses of 20mgs a day .

[Quokka]

Sounds like a way to sell more tablets!

[Pascha1 in reply to Quokka]

I think its was on the PIL on mercury for years but no one has questioned it till Teva had it on there T3 PIL!

I suppose those of us are untrusting in Teva products so checked their PIL.

I for one do not trust Teva meds and wouldnt like to take anything meds by them again..

[Zephyrbear in reply to Pascha1]

Anything from TEVA makes me itch! Probably something to do with whatever fillers they use, but I get that reaction from their meds every time. I now refuse TEVA as a brand completely and, thankfully, my surgery cooperates with me.

[jimh111]

I've never seen it on Mercury / AMCo amd it's not in the current PIL. As an aside they shouldn't suggest splitting tablets as they are not required to guarantee two equal halves will meet specification.

The greatest marketing ploy of all time was adding 'and repeat' to shampoo instructions. Many customers followed the advice and used twice as much.

[helvella Administrator in reply to jimh111]

It is on the version on EMC!

medicines.org.uk/emc/files/...

EMC claims to have history of updates so it should be possible to find out when it was added/changed.

[jimh111 in reply to helvella]

I have some expiring 10/17 and they have a PIL dated 2013. It seems they added this 'advice' in this latest February 2018 PIL. The next PIL will have the advice to take half the dose 'and repeat'.

It's useful to know this as I plan to lobby the CMA again after I've complained about the companies operating a cartel. Changing their advice in unison to include this wastage is further evidence of a cartel.

[Pascha1 in reply to jimh111]

Jimh111

My PIL is dated 2013 and on it the pot has 11/10/ 2018 so they have not updated the PIL from divided doses yet ., but it definitely doesn't say add water on this one, do not know where friend got photo from but obviously not up to date..

[jimh111 in reply to Pascha1]

Pascha1, the 11/10/2108 date is the expiry date. AMCo (Mercury) liothyronine has a 12 month shelf life so your tablets were manufactured on 11/10/2017.

The shelf life was reduced from 36 months to 24 months on 29/04/2014 and

from 24 months to 12 months on 31/03/2016 (I submitted an FOI request).

[helvella Administrator in reply to jimh111]

Have already emailed MHRA:

The PILs and SmPCs for all three UK Liothyronine tablet products contain advice about doses lower than 20 micrograms. From the SmPC for Mercury Pharma Liothyronine, I quote:

Method of Administration: Oral

• For doses lower than 20 micrograms, the tablet should be allowed to dissolve/disperse in 20 mL of water for 10 minutes, in a small measuring cup.

• The patient should gently swirl the solution occasionally to aid the dissolution/dispersion. The patient should then swirl the solution for a few seconds prior to using a suitable oral syringe to withdraw the amount of liquid corresponding to the dose prescribed (5mL for a 5mcg dose; 10 mL for a 10mcg dose).

• The patient can then squirt the liquid directly into their mouth from the suitable oral syringe by gently pressing the plunger.

• Any remaining liquid should be discarded.

(10. Date of revision of the text 02/03/2018)

medicines.org.uk/emc/produc...

There are several issues with this advice.

1) The advice would apply to any dosage other than a multiple of 20 micrograms. For example, 25 or 30 micrograms. Why – seemingly arbitrarily – highlight only doses lower than 20 micrograms?

2) The discarding of remaining liquid is problematical. It should not be put into the drainage system but the advice appears to endorse doing just that - simply by offering no advice to do otherwise. My view is that any remaining liquid should be collected and returned to a pharmacy for safe disposal. However, even that has issues.

3) Was any consideration given to the cost of complying with this advice? Obviously, for a 10 microgram dose, following this advice doubles the cost (compared to splitting tablets). For a low cost medicine, that might be acceptable. At something like £258 for 28 tablets, and the product already being withdrawn from numerous patients on the grounds of cost, it is unconscionable to expect patients to throw half the medicine away!

4) Was any consideration given as to how patients are expected to know they need oral syringes and measuring cups? Where they can be obtained from? (Just checked Boots and they don’t list them.) How much they cost (especially important for those of limited means)? That oral syringes should only be used once?

5) What actual difference does it make to dose as advised rather than splitting tablets? If a tablet splits slightly unevenly does the patient suffer?

6) Where is the research which shows that the advised method is better than splitting for liothyronine? (Given their different ingredients, this research needs to be repeated for each make.)

7) Where did this advice originate in respect to liothyronine? It does rather look as if the biggest beneficiaries of following the advice would be the three manufacturers.

Regards

[helvella Administrator in reply to helvella]

And still waiting for a reply!

Have had two interims with no useful information.

[Pascha1 in reply to helvella]

Thats been a while now, what if we are taking them wrong,, nice to know they care so much about our treatment isn't it ? x

[Pascha1 in reply to helvella]

helvella did you ever get a reply from this, I now see some are getting double the amount of T3 because of this dosing? Just wondered if you had actually heard back as was some time ago,, needs to be addressed to CMA as all doing it now, they have not changed ingredient in the pill is it just another rip off to the NHS,, the CMA have started proceedings and new update on 19th jan 2019 details on Itt , , I’m going to post what you have written to MHRA on if you don’t mind on ITT,, their was another post on this subject but can’t find it, if you find it could you tag me in it please thank you

[helvella Administrator in reply to Pascha1]

Afraid I have not followed it up - yet.

Apologies. Will do soon.

[Pascha1 in reply to helvella]

its just since Mercury Pharma have become Advanz the PIL has changed to mix water and syringe throwing rest away ! , some people who get split doses are now getting syringes instead of pi;; cutters and getting extra meds so they can dose using water to mix......

Now all uk ones mix with water so this is not good as some are being directed to take this way , but Thybon Henning are clear on PIL to split tablet ..

All pharma UK brands robbing NHS even more now..

A lady takes 3 or 4 x 5mcgs per day she wastes 45- 60 mcg every day....

This will make it even harder for people to get if they have to cough up 2 or 3 or even 4 times the dose, The cost hasn't gone down that much and as the NHS are not allowing some to have T3 re the cost and taking others away with the only 28 tablets pm they will be even less keen if someone has 2-4 smaller doses per day!

[clubby29 in reply to Pascha1]

Hi just read through thread and had a thought,how many endos know about dissolving split dose? Mine is trying hard to make my dose as small as possible so if we point this manufacturer instruction out they would have to supply us with more pills, then do what we do now get the pill cutter out and adjust dose to suit. Not morally correct maybe but needs must.

[Pascha1 in reply to clubby29]

I told my 1st Endo one about a year ago he hadn’t heard of it, I was on MErcury pharma then ,then so could split but as they have changed name to advance the have also changed PIL so not only are they ripping nhs for over pricing they thought that wasn’t enough so made it we have to have double or treble the amount to have to take so if we have to start taking more each month I can see T3 becoming even scarier than it is now, the price really isn’t going back down very quickly.. it’s disgusting as they haven’t changed any ingredients..

I’m getting thybon at moment and you can cut the tablets on them it’s just the UK ones with wate4 dosing it’s a complete scandal !

[clubby29 in reply to Pascha1]

Yes the whole system is shot to bits,lol. This caught my eye because my endo has finally approved me nhs t3. Only took 3 years of me self medding to get it but he’s still reduced my dose, bloody tsh again. Picked up script and in the bag was Teva. Might see if I can have a laugh with the girls in the pharmacy about it, I bet they don’t know either.

[Pascha1 in reply to clubby29]

I’ve said to many pharmacists have you seen the way we are to take uk T3 none of them are awatre if the mixing with water and none of them seem to even care.

[Pascha1]

I'm sorry I have just taken PIL of new MP box and looked at it through a photo you are right it says daily in divided doses, I had taken my friends info as true,

I know morningside and Teva have the dosing with the water , I had advised her to avoid Teva and try and get MP as you didn't have to do all that water and she sent me the pic of MP PIL.

I have corrected her now and will also email the Endo to tell him MP is ok, but it's a good excuse not to get Teva stuff, so either MP dose them more evenly or the other 2 are trying to rip the NHS off even more,

I do apologise I think best get facts right before I post anything like this. I never looked at it as way too small for me to see I had to take photo and expand it before I could see it

SOrry all , my MP pills dated 11/2018

[helvella Administrator in reply to Pascha1]

I suggest always looking at the EMC site:

medicines.org.uk/emc/

For liothyronine:

medicines.org.uk/emc/produc...

Unfortunately, for reasons not at all clear to me, they do not include Teva and Morningside products.

The advantage is that the PIL can be viewed online or downloaded - which then allows you to zoom as required, though this isn't so easy on a phone!

[Pascha1 in reply to helvella]

Thank you

[helvella Administrator in reply to Pascha1]

Another (possible) advantage is that on EMC the PILs are often updated before the paper versions reach us. You also have the opportunity to read the "professional" Summary of Product Characteristics (SmPC) documents which can be helpful.

[Aurealis in reply to helvella]

helvella, AmCo have told my pharmacist that they are in the process of rebranding MP Liothyronine and applying to change the pil for MP Liothyronine to indicate need to put in water to achieve doses less than 20. So the version on EMC is maybe not approved yet?

[helvella Administrator in reply to Aurealis]

Anything is possible!

But I'd point out that last time I looked, Concordia/Mercury Pharma's own website actually links to the documents on the EMC website if you wish to view a PIL or SmPC. That is, they do not host their own PILs but effectively let EMC do it for them.

In my book, looks rather more as if this update is live but the person who spoke to your pharmacist was not aware that it had actually been made live. However, that is just a guess.

[SlowDragon Ambassador]

As many patients take 5mcg doses it would be far more sensible to manufacture UK 5mcg dose

I know there is a non Uk 5mcg T3 (perrigo? Even more expensive I believe)

I currently take 3 x 5mcg so often have to juggle unequal 1/4's cut with a scalpel.

The whole thing is beyond a joke

[helvella Administrator in reply to SlowDragon]

Perrigo no longer make liothyronine - the formulation has been acquired by Mayne Pharma. I have not yet heard of anyone actually managing to get hold of Mayne Pharma liothyronine.

There are also 5 microgram tablets from Pfizer Cytomel, SigmaPharm and Mylan from the USA.

[coneflower in reply to helvella]

I have mayne t3 but i felt very unwell with an irregular heart beat after one dose and the second time i tried it same thing...i did so well on perrigo...i react to gluten and starch is a cross reactor. My consultant has recommended teva, im hypersensitive and the reports about it are not good on here. What do you think, what would you advise Di

[lolajone in reply to coneflower]

Have there been adverse reports for Teva t3. I know there are plenty for Teva t4. Personally I was ok on perrigo so am now having a bit of a nightmare trying alternatives. Can’t tolerate sigmapharm. I had a bad reaction to Teva t4 a couple of years ago, felt as if I was being poisoned so really don’t want to try any other Teva product? Any help or advice would be gratefully received

[Pascha1 in reply to lolajone]

You could ask for Thybon Henning German brand by Sanoffi , problem is not licensed in uk so up to go if they are willing to put on prescription,, or you could phone round independent pharmacies to see if they can supply it,

It’s lactose free and tablets are slightly bigger and says in the PIL ok for splitting doses, with cutter, I take this and sometimes have a quarter 5mcg dose, I take sublingual under tongue and as it breaks down am left with hard bit, which could be the active part of drug, if it it’s its very evenly distributed throughout the tablet.. so maybe ask for these,, cheaper than uk brNds, but you may have to be ask if you can have it named patient basis as not licences.. not sure how pharmacy can dispense unlicenced drug as where drs can’t precribe it !

[Afaghieh]

I use pharma mercury . I found recently that I can split the tablets by finger nails washed hands of course. Before this wasn't possible. At the same time I gained weight gradually. This made me to Q whether formula has been changed due to cost!

[SlowDragon Ambassador in reply to Afaghieh]

I found it very weak (and always very near use by date)

Hence changed to Morningside Healthcare

[serenfach]

I do what we used to do as nurses. Crush the tablet between two spoons - place the tablet on one spoon and using the back of the other spoon, gently crush and rotate - it works a treat. We used to then mix the results with jam (for young children and elderly) and if you need half, just eat half the jam and leave the rest for later. It was thought that the sugar content in the jam helped the absorbtion of the drug. I do drink a glass of water afterwards though as I dont like jam that much!

[Hidden]

Thank you for these helpful comments. I always had MP lio for many years and split the tablets into quarters as I take 5mcg twice a day along with my thyroxine. Then I was allowed the 5mcg tablets (Perrigo) but when they were discontinued I was given Sigmapharm after a hunt around pharmacies to even supply 5mcg tablets. Boy oh boy did I suffer with these cheap (quality) and nasty expensive tablets. Long story short I went back onto cutting 20mcg (Morningside) in quarters again. I have never dissolved in water (for goodness sake I take the first dose early morning an hour before getting up) and my T4/T3 blood levels were always nicely stable (until recently) and I hope they soon will be again.

Thank you for the warnings about TEVA, I will ask my GP to put Morningside as my named brand onto my prescription as he does with my Thyroxine (same problems when Eltroxin was withdrawn).

[coneflower]

Im hypersensitive after perrigo...im still hunting fir a replacement...sigma made me ill and now been offered teva??? What would you advise to take if i can get it?? Di