thyroid and PPIs

[Gettingoldnow]

can anyone advise me I am on thyroxine which I take in the morning ..I have Barrett’s osophagus and hiatus hernia …the hospital put me on 30 mg of lanzaprole to take in the morning but I have to leave 4 hours apart ..I am finding it difficult to leave a 4 hour gap …I can’t take at night as I take a blood pressure pill then a colesteral pill ..lunchtime I take a vit B complex and vit D so all the meds I am finding difficult to take leaving time gaps in between any advice would be helpful thank you

[Bertwills]

I have a hiatus hernia & acid reflux too. There is an alternative treatment which is easier to take with other medications. Famotadine has been prescribed by my GP after I tried it buying from an online chemist. It’s pricey at over £30 but does the trick for me. There are 2 strengths 20 or 40 & I need to 40 at night. You don’t need to leave such a long gap after taking Famotadine. 2 hours ideal but less in desperation will be ok. Excellent reason to ask your GP to change your prescription

I did discover that my reflux is much worse if my T3 dose drops. Taking 10 mcg of T3 stops it. What are your latest test results? Could you have low T3?

There are natural remedies that I’ve liked Aloe Vera, liquorice & marshmallow help sooth. Google for some helpful mixes. Holland & Barrett sell some.

Have you raised the head of your bed so you sleep on a slope?

You mention you take a cholesterol pill. Unless you’re a man & have had a heart attack it won’t be helping you. Hypothyroidism causes higher cholesterol readings but they won’t be harming you. Statins can cause severe muscle aching especially in hypothyroid people. Also they increase the risk of diabetes & therefore, dementia.

[Gettingoldnow in reply to Bertwills]

Thank you for your advice will look into this

[Marz in reply to Gettingoldnow]

Did you manage to research why statins should not be taken when Hypo or undertreated. Its nentioned on the NHS website !

[helvella Administrator in reply to Bertwills]

Famotidine is, I understand, an H2-receptor antagonist.

See references to this here:

bnf.nice.org.uk/drugs/famot...

And H2RA medicines do interfere with absorption of levothyroxine.

Famotidine is expressly mentioned in Table 1 in the paper below:

Medications and Food Interfering with the Bioavailability of Levothyroxine: A Systematic Review

Medications Altering the Gastric pH

A physiological gastric pH is essential for tablet dissolution, which removes the sodium ion and increases its solubility. Elevated pH due to H. pylori infection and autoimmune gastritis ameliorate the subsequent absorption.28,32,125 The phenomenon is explained by ionization status at different environmental pH.126–128 PPIs and H2 antagonists, which reduce the secretion of H+, are used in the treatment of gastric and duodenal ulcers. These drugs can impair the dissolution of LT4 tablets.

Table 1

Cimetidine, Ranitidine, Famotidine

H2 antagonist

Proposed Mechanisms

a) Complexing

b) Delay of the emptying of stomach

c) Alkalization

Recommendations for Clinicians

a) switch to other antacids

b) address concomitant diseases

c) switch to liquid LT4 or capsule

d) dose adjustment of LT4

e) discontinuation of the interfering substance

f) close monitoring

europepmc.org/article/MED/3...

The paper suggests:

Famotidine is usually prescribed as a once-a-day medicine which suggests that its impact on stomach acidity continues all the time. That aspect of interference with levothyroxine cannot be resolved by timing of dose. (Though complexing and delayed stomach emptying might be.)

I note that the observation that reduced stomach acidity is an issue appears to be in direct conflict with suggestion a) of switching to other antacids. Surely, if reduced acidity is achieved, any effects on absorption will occur whatever medicine is used to achieve that?

[Gettingoldnow in reply to helvella]

Thank you

[Bertwills in reply to helvella]

I’ve read that Famotadine is effective for 12 hours, less than a PPI which is 24 hours & why I use it at night to prevent acid reflux when lying down & when I’m unable to use other methods to reduce acidity. I don’t need it during the day so my digestion is nearer normal.

I’ve found it far more effective than the PPIs that were prescribed. Obviously in an ideal world I’d take nothing that interfered with absorption but scoliosis has caused my hiatus hernia & I have no choice but to protect my throat.

Your quotation says that dose adjustment may be necessary. For those of us that have no choice but to use less than ideal medication it’s the answer. Vitamin B12 is severely affected by PPIs too so I supplement.

Giving information about an effective alternative was warranted, I believe.

[Gettingoldnow in reply to Bertwills]

Thanks for that input .lucky for me I do take. B12 complex

[helvella Administrator in reply to Bertwills]

I wasn't disagreeing with the suggestion as such - just (hopefully) providing some more information.

Clearly, oral solutions and/or increased dosing seem likely to be necessary.

One of the major problems is when anything changes, it is necessary to consider more testing and dose adjustments. Which is ridiculously hard to achieve.

And the British National Formulary doesn't mention any possible interaction between Famotidine and levothyroxine. Which shows how appallingly information about medicines is maintained and distributed.

[Gettingoldnow in reply to helvella]

All Infomation is very helpful in understanding g these medications as even the docs and chemists don’t know the answers sometimes .my chemist just said take at night ..I looked up the info on google and that is where I got the 4 hours from .but I would rather have the correct info than googling …even my doc says to google things ..I am amazed

[Hidden in reply to Gettingoldnow]

Haven’t you ever sat in the surgery and watched your Doctor ‘Google’ search for information?

When used properly, with appropriate websites used, the internet is an excellent source of information for everyone. I can recall my GP picking up the MIMS book of drug reference tables when prescribing many years ago. Like BNF, it’s now available online.

The pity of it is that ‘Google’ has become a synonym for ‘Internet’. Even worse, it’s become a verb. I cringe when I hear people say they’re going to ‘Google’ something.

I wouldn’t touch Google with a barge pole but I use the internet on a daily basis. Used properly, it’s no less reliable than books - and often is more reliable than medics

[Hidden]

You don’t need to leave four hours between PPIs and thyroid meds.

No matter when you take them, there will be constant serum levels 24 hours a day. That’s the point of PPIs.

[Gettingoldnow in reply to Hidden]

Ah thank you it’s just that I was reading the leaflet and looking at thyroxine with PPI and it said leave 4 hours …I take my thyroxine on waking and leave an hour before eating .when would you advise the timing between the two ?

[Hidden in reply to Gettingoldnow]

Not necessary.

Treat it as just another medication. We are advised to leave an hour between other meds and Levo (unless it’s calcium, iron etc)

I think this myth has arisen because indigestion remedies need a four hour gap. PPI is not an indigestion remedy as such. It works by suppressing stomach acid and PPIs create an alkaline environment 24/7 if taken correctly.

[greygoose in reply to Hidden]

Two hours between levo and other meds and supplements, surely? Four hours for calcium etc.

[Hidden in reply to greygoose]

Apologies. Two hours between any other med / supplement and four or more for those which have specific recommendations

[Gettingoldnow in reply to greygoose]

Thank you ..yes I think the confusion is the calcium which I don’t have ..I think I have mastered the answer for me much appreciated

[Batty1 in reply to Gettingoldnow]

Ive been taking my PPI and Levo 3 hours apart without issues … if your really wanting to wait 4 hours then I suggest getting up much earlier taking Levo and go back to bed for few hours then take stomach pill and then you only have a 1/2 hour to wait for food .

[Gettingoldnow in reply to Hidden]

Thank you for your advice much appreciated

[Batty1]

What time do you take your Levo? I take mine at 5am take my PPI at 8am … never had issues.

[Gettingoldnow in reply to Batty1]

Wel I have been getting up at 3 the last few days taking my thyroxine then going back to bed until 7

[Gettingoldnow in reply to Batty1]

After looking at the replies will adjust meds to fir in with me not the other way round lol.thanks for advice

[Hidden]

I hope this doesn’t sound too cavalier but I’ve been taking PPIs long term an hour after NDT.

My thyroid blood results haven’t changed at all.

[Gettingoldnow in reply to Hidden]

That is what I wanted to know .i think I will get my thyroid bloods checked in 6 months privately thanks much appreciated

[Hidden in reply to Gettingoldnow]

You’re welcome

[Hidden]

Many of the conventions about how and when to take thyroid meds are rather inflexible. Of course we know that calcium, iron etc must not be taken too close to Levo but good old common sense must prevail.

Nothing would get me up in the middle of the night to comply with some of these ‘rules’. The best rule to follow is your blood results 😉

[Gettingoldnow in reply to Hidden]

Yes that’s what it looks like

[Dryski]

I take my levo in the morning and my omeprazole 20 mg a half hour before my evening meal. This helps from having reflux at night. Hasn't affected my levels. This is how I was instructed to do it.

[Gettingoldnow in reply to Dryski]

Thank you