Terrible reflux on Teva levothyroxine...help!

[EJT82]

Hi, I have just started 50mg of Levothyroxine (teva). I have subclinical hypothyroidism with TPO antibodies. I took the tablets as advised on an empty stomach but they are causing terrible reflux symptoms. I persevered for 2 weeks but have had to stop taking them. The GP told me to try taking lansoprazole at the same time but I decided to stop temporarily to see if the symptoms settle and then maybe try another brand? The only difference o can see from this brand to others is that it contains Mannitol instead of lactose. Just wondered if anyone else has experienced this and could offer any advice?

[helvella Administrator Thyroid UK]

There are scores (or more!) posts and replies here where people have been unable to tolerate Teva levothyroxine.

It is suspected that mannitol could be the issue but we do not have proof.

Switching to another make is likely a very good move.

Taking at same time as lansoprazole is somewhat daft as that affects absorption of levothyroxine!

helvella - Thyroid Hormone Medicines

I have created, and try to maintain, a document containing details of all thyroid hormone medicines in the UK and, in less detail, many others around the world.

helvella.blogspot.com/p/hel...

[EJT82 in reply to helvella]

My thoughts too about the PPI and levo absorption, also don't want to take a second drug to counteract side effects from another! The GP didn't seem particularly interested but I couldnt carry on with the symptoms. I do occasionally get reflux which a wonder if it could be anitbody/thyroid related but not like this!

[SlowDragon Administrator]

suggest you get new prescription from GP to try a different brand of levothyroxine

Teva levothyroxine upsets thousands of patients

Most easily available (and often most easily tolerated) are Mercury Pharma or Accord

Mercury Pharma make 25mcg, 50mcg and 100mcg tablets 

Mercury Pharma also boxed as Eltroxin. Both often listed by company name on pharmacy database - Advanz 

Accord only make 50mcg and 100mcg tablets 

Accord is also boxed as Almus via Boots, and Northstar 50mcg and 100mcg via Lloyds ....but Accord  doesn’t make 25mcg tablets

beware 25mcg Northstar is Teva

 Many patients do NOT get on well with Teva brand of Levothyroxine. Teva is lactose free.

Teva contains mannitol as a filler instead of lactose, which seems to be possible cause of problems.

Mannitol seems to upset many people, it changes gut biome 

Teva is the only brand that makes 75mcg tablet. 

So if avoiding Teva for 75mcg dose ask for 25mcg to add to 50mcg or just extra 50mcg tablets to cut in half

But for some people (usually if lactose intolerant, Teva is by far the best option)

Aristo (currently 100mcg only) is lactose free and mannitol free. 

Wockhardt is very well tolerated, but only available in 25mcg tablets. Some people remain on Wockhardt, taking their daily dose as a number of tablets 

 

List of different brands available in U.K.

thyroiduk.org/if-you-are-hy...

Posts that mention Teva

healthunlocked.com/search/p...

Teva poll

healthunlocked.com/thyroidu...

Once you find a brand that suits you, best to make sure to only get that one at each prescription.

Watch out for brand change when dose is increased or at repeat prescription.

Government guidelines for GP in support of patients if you find it difficult/impossible to change brands 

gov.uk/drug-safety-update/l...

If a patient reports persistent symptoms when switching between different levothyroxine tablet formulations, consider consistently prescribing a specific product known to be well tolerated by the patient. 

academic.oup.com/jcem/artic...

Physicians should: 1) alert patients that preparations may be switched at the pharmacy; 2) encourage patients to ask to remain on the same preparation at every pharmacy refill; and 3) make sure patients understand the need to have their TSH retested and the potential for dosing readjusted every time their LT4 preparation is switched (18).

Levothyroxine is an extremely fussy hormone and should always be taken on an empty stomach and then nothing apart from water for at least an hour after

Many people take Levothyroxine soon after waking, but it may be more convenient and perhaps more effective taken at bedtime

verywellhealth.com/best-tim...

No other medication or supplements at same as Levothyroxine, leave at least 2 hour gap.

Some like iron, calcium, magnesium, HRT, omeprazole or vitamin D or any PPI like Lansoprazole should be four hours away

(Time gap doesn't apply to Vitamin D mouth spray)

If you normally take levothyroxine at bedtime/in night ...adjust timings as follows prior to blood test

If testing Monday morning, delay Saturday evening dose levothyroxine until Sunday morning. Delay Sunday evening dose levothyroxine until after blood test on Monday morning. Take Monday evening dose levothyroxine as per normal

Similarly if normally splitting your levothyroxine, take whole daily dose 24 hours before test 

Increasing number of members find it smoother/more tolerable to split levothyroxine as two smaller doses, half dose waking, half dose at bedtime. 

[SlowDragon Administrator]

what were your thyroid results and ranges that got you diagnosed as hypothyroid BEFORE starting on levothyroxine

You are legally entitled to printed copies of your blood test results and ranges.

The best way to get access to current and historic blood test results is to register for online access to your medical record and blood test results

UK GP practices are supposed to offer everyone online access for blood test results. Ring and ask if this is available and apply to do so if possible, if it is you may need "enhanced access" to see blood results.

Link re access

healthunlocked.com/thyroidu...

In reality many GP surgeries do not have blood test results online yet

Alternatively ring receptionist and request printed copies of results. Allow couple of days and then go and pick up.

Important to see exactly what has been tested and equally important what hasn’t been tested yet

Bloods should be retested 6-8 weeks after each dose change or brand change in levothyroxine

 

For full Thyroid evaluation you need TSH, FT4 and FT3 plus both TPO and TG thyroid antibodies tested.

Very important to test vitamin D, folate, ferritin and B12 at least once year minimum

About 90% of primary hypothyroidism is autoimmune thyroid disease, usually diagnosed by high thyroid antibodies 

Autoimmune thyroid disease with goitre is Hashimoto’s

Autoimmune thyroid disease without goitre is Ord’s thyroiditis. 

Both are autoimmune and generally called Hashimoto’s.

Have you had thyroid antibodies tested for autoimmune thyroid disease

Low vitamin levels are extremely common when hypothyroid, especially with autoimmune thyroid disease (Hashimoto’s or Ord’s thyroiditis)

Many, many thyroid patients need to improve low vitamin levels

Important vitamins are at good levels so that levothyroxine can work well

[EJT82 in reply to SlowDragon]

Got full access to my results online from the GP, TPO antibodies 740kiu/L (normal range 0-9), TSH 7.46mu/L (normal range 0.2-4.5), T4 13.6pmol/L (normal range 7-17). Vit D lower end of normal but not sure if that's to do with recently finishing chemo-radiation for bowel cancer (turning 40 didn't quite go to plan!!). Got thyroiditis with a benign nodule and some symptoms that correlate with hypothroidism. I've stopped all my supplements as well as the levo. Hoping the reflux settles soon.

[SlowDragon Administrator in reply to EJT82]

Acid Reflux is an extremely common hypothyroid symptom

Thousands of posts on here about low stomach acid 

healthunlocked.com/search/p...

Web links re low stomach acid and reflux and hypothyroidism 

nutritionjersey.com/high-or...

stopthethyroidmadness.com/s...

thyroidpharmacist.com/artic...

 How to test your stomach acid levels 

healthygut.com/articles/3-t...

meraki-nutrition.co.uk/indi...

huffingtonpost.co.uk/laura-...

lispine.com/blog/10-telling...

But never assume you have low stomach acid 

healthygut.com/4-common-bet...

Ppi 

Omeprazole or Lansoprazole will lower vitamin levels even further 

gov.uk/drug-safety-update/p...

webmd.com/heartburn-gerd/ne...

pharmacytimes.com/publicati...

PPI and increased risk T2 diabetes 

gut.bmj.com/content/early/2...

Iron Deficiency and PPI 

medpagetoday.com/resource-c...

futurity.org/anemia-proton-...

onlinelibrary.wiley.com/doi...

sciencedirect.com/science/a...

[EJT82 in reply to SlowDragon]

Fantastic thank you, lots of resources to investigate

[SlowDragon Administrator in reply to EJT82]

50mcg levothyroxine is only the standard starter dose

Eventually you will be in higher dose

Levothyroxine doesn’t “top up” failing thyroid, it replaces it

Typically takes 6-12 months to slowly increase dose up to around full replacement dose

Bloods should be retested 6-8 weeks after each dose change or brand change in levothyroxine

Dose is increased slowly upwards in 25mcg steps

pathlabs.rlbuht.nhs.uk/tft_...

Guiding Treatment with Thyroxine: 

In the majority of patients 50-100 μg thyroxine can be used as the starting dose. Alterations in dose are achieved by using 25-50 μg increments and adequacy of the new dose can be confirmed by repeat measurement of TSH after 2-3 months. 

The majority of patients will be clinically euthyroid with a ‘normal’ TSH and having thyroxine replacement in the range 75-150 μg/day (1.6ug/Kg on average).

The recommended approach is to titrate thyroxine therapy against the TSH concentration whilst assessing clinical well-being. The target is a serum TSH within the reference range. 

……The primary target of thyroxine replacement therapy is to make the patient feel well and to achieve a serum TSH that is within the reference range. The corresponding FT4 will be within or slightly above its reference range.

The minimum period to achieve stable concentrations after a change in dose of thyroxine is two months and thyroid function tests should not normally be requested before this period has elapsed.

[SlowDragon Administrator in reply to EJT82]

High thyroid antibodies confirms autoimmune thyroid disease also called Hashimoto’s

How low was vitamin D

Links about autoimmune thyroid disease and low vitamin D 

Yet still most Hashimoto's patients struggle to get NHS to test vitamin D 

All Patients with autoimmune thyroid disease should have vitamin D tested annually 

pubmed.ncbi.nlm.nih.gov/286...

Vitamin D deficiency is frequent in Hashimoto's thyroiditis and treatment of patients with this condition with Vitamin D may slow down the course of development of hypothyroidism and also decrease cardiovascular risks in these patients. Vitamin D measurement and replacement may be critical in these patients.

pubmed.ncbi.nlm.nih.gov/273...

Vitamin D insufficiency was associated with AITD and HT, especially overt hypothyroidism. Low serum vitamin D levels were independently associated with high serum TSH levels.

pubmed.ncbi.nlm.nih.gov/300...

The thyroid hormone status would play a role in the maintenance of vitamin D sufficiency, and its immunomodulatory role would influence the presence of autoimmune thyroid disease. The positive correlation between free T4 and vitamin D concentrations suggests that adequate levothyroxine replacement in HT would be an essential factor in maintaining vitamin D at sufficient levels.

ncbi.nlm.nih.gov/pmc/articl...

Our results indicated that patients with hypothyroidism suffered from hypovitaminosis D with hypocalcaemia that is significantly associated with the degree and severity of the hypothyroidism. That encourages the advisability of vit D supplementation and recommends the screening for Vitamin D deficiency and serum calcium levels for all hypothyroid patients.

Essential to maintain good levels of B12, folate and ferritin too

What were most recent vitamin results

[SlowDragon Administrator]

one other thought

If you have had surgery on bowel this may affect absorption of B12

Marz can give more information

[crimple]

EJT82, TEVA levothyroxine contains acacia powder which seriously upset my stomach. I have Actavis/ Almus levo, usually stocked by Boots, never had any more problems. If I needed 25mcgm dose to add to 50 or 100 tablets i always asked for Actavis 50 mcgm tablets that I could then cut in 2. That way I always had same brand and the GP has put on my scrips only Actavis/ Almus. Hope you get over the nasty reaction quickly

[SlowDragon Administrator in reply to crimple]

 crimple

you mean Accord (previously called Activis)

Accord is boxed as Almus via Boots or Northstar via Lloyds

Accord don’t make 25mcg tablets

Advanz is company who makes Mercury Pharma and Eltroxin

List of brands and ingredients

thyroiduk.org/if-you-are-hy...

[EJT82 in reply to crimple]

Did you get acid reflux too?

[crimple in reply to EJT82]

EJT82 I never had acid reflux, thank goodness, so no PPI's, poison in my opinion and too many hypos are given them rather than treating the patient with sufficient T4 and T3!

My stomach sounded like a washing machine churning around and at times was quite painful. That was 10 years ago, won't touch any TEVA on principal, even the T3 which doesn't have acacia powder. At the end of the day it's all about Pharma profits in my opinion!