DON'T Take Levothyroxine with a Full Glass of Water!

[jimh111]

This study link.springer.com/article/1... finds that taking levothyroxine with a sip of water reduces the amount of levothyroxine needed.

I believe the recommendation to take levothyroxine with a full glass of water is to avoid the tablet becoming stuck in the oesophagus. I don't know of any studies that were carried out prior to this recommendation.

We know that an acid environment in the stomach is needed for good levothyroxine absorption and that an empty stomach is recommended. When empty the stomach is contracted with a small volume. It seems logical that if you introduce a full glass of water it will substantially reduce the acidity of the stomach. This study seems to confirm this hypothesis.

The study has a number of pitfalls. The sujects were on a lowish dose of levothyroxine, averaging 69.1 mcg. Also, it was not placebo controlled, improvements over time may just happen. They could have done a simple crossover trial.

So it does seem that the recommendation to take a full glass of water is silly, we need a better trial to be sure. I take mine with orange juice but I've never had an absorption problem.

Most people are getting on just fine, at least in terms of absorbing their levothyroxine. In which case don't worry, be happy. If you are one of the minority who have absorption problems it might be worthwhile trying a sip of water and see how it goes.

[tattybogle]

seems logical ...

i've always been in the '2 or 3 gulps is plenty' camp

[jimh111 in reply to tattybogle]

Yes, it seems the recommendation to take with a full glass of water comes from cases of the tablet sticking in the throat. It appears that this is a particular problem in the USA as brands such as Levoxyl expand rapidly when wetted. I suspect the clear instructions with these brands get copied into the general advice.

[helvella]

When Levoxyl was reformulated (I think in the first few years of this century), there were reports of gagging.

Choking and Gagging on LEVOXYL Tablets

There have been reports of choking, gagging, tablet stuck in throat, and dysphagia with LEVOXYL tablets, predominately when LEVOXYL tablets were not taken with water

pfizermedicalinformation.co...

Hence this advice was included in the patient information:

Take your dose of LEVOXYL on an empty stomach, at least 30 minutes to 1 hour before breakfast with a full glass of water to avoid choking or gagging.

labeling.pfizer.com/ShowLab...

[jimh111 in reply to helvella]

Our responses have crossed in the post!

[elaar]

Funnily enough I read a couple of studies recently that showed combining Vitamin C with levothyroxine increased the absorption by a reasonable amount.

They suggested putting an effervescent vitamin C tablet 500mg into the water, rather than having it plain. I suppose this would support your statement by making the water midly acidic.

pubmed.ncbi.nlm.nih.gov/246...

[jimh111 in reply to elaar]

I guess the clue's in the name, ascorbic acid. David Halsall who heads the blood testing lab at Addenbrooke's suggests taking it with fruit juice. For most people it doesn't matter as they don't have a problem.

[helvella in reply to elaar]

The principle is fine. But do consider the ingredients of any effervescent vitamin C tablet.

For one example - the first from a very quick search:

Boots High Strength Vitamin C 1000 mg – 20 Orange Flavour Effervescent Tablets

Ingredients

Acid (Citric Acid), Acidity Regulator (Sodium hydrogen Carbonate), Vitamin C, Bulking Agent (Sorbitol), Starch, Natural Flavourings, Sweetener (Sodium Cyclamate, Colour (Beetroot Juice Powder (Maltodextrin, Beetroot Juice concentrate)), Sweetener (Sodium Saccharin), Natural Lemon Flavourings with other Natural Flavourings, Colour (Riboflavin-5’-Phosphate).

boots.com/boots-max-strengt...

[elaar in reply to helvella]

At the time I was thinking along the same lines as you. I looked at a variety of brands, and I couldn't find a single one that didn't contain varying amounts of dodgy sweeteners, so that put me off that idea.

[helvella in reply to elaar]

Maybe get a soda syphon (or soda stream) and put pure (or suitably flavoured) ascorbic acid into it?

(This is, of course, said for humour. I do not know if that approach is safe re metallic components in soda syphons! And it might go flat extremely quickly ending up being pretty pointless.)

I'd also note that while the discussions focus on vitamin C (ascorbic acid), the main acid by weight would be citric acid. Probably also perfectly OK but accuracy is a good idea when we can manage it.

[Arrigo in reply to elaar]

I'd just squeeze some lemon in the water instead.

[Obsdian]

I normally take one sip, only occasionally two, basically what I need to swallow it.

[DippyDame]

Interesting....does the same apply to T3 I wonder.

[helvella in reply to DippyDame]

Roma Liothyronine capsules Patient Information Leaflet says:

Liothyronine sodium Capsules are taken by mouth. They should be swallowed with a glass of water.

If you have difficulty swallowing a whole capsule, empty the contents of a capsule into a minimum of 20 ml of water. Stir and drink the whole liquid to ensure you take the full dose. It is possible to do this with Liothyronine because this substance is soluble in water.

mhraproducts4853.blob.core....

From that we can take:

Liothyronine is much more soluble in water than levothyroxine. (As is well-known.) Which suggests that acidity is not important.

The water advice is pretty much the same - but we do not know the justification/rationale.

One of the reasons I have tended to be comfortable with the idea of taking water (levothyroxine, liothyronine and most other medicines) is that dispersion avoids the possibility of the entire dose being concentrated in a tiny area of the stomach. But maybe my imagination is allowing this to become a factor which has no reality?

[jimh111 in reply to helvella]

Liothyronine has minimal solubility in water but the amount in a tablet is tiny. Capsules may had different requirements and excipients.

[helvella in reply to jimh111]

Just adding some details from PubChem so that anyone in future can see actual numbers and check whether there is any new information.

Though I am suspicious of the figures as, for example, the levothyroxine details do not mention pH (acidity/alkalinity).

Liothyronine:

3.2.5 Solubility

11.4 [ug/mL] (The mean of the results at pH 7.4)

Very slightly soluble

In water, 3.958 mg/l at 37 °C.

Soluble in dilute alkalis with the formation of a brownish, water-soluble, sodium salt. Insoluble in propylene glycol.

pubchem.ncbi.nlm.nih.gov/co...

Levothyroxine:

3.2.4 Solubility

0.105mg/mL

Slightly soluble in water

Insoluble in ethanol, benzene

pubchem.ncbi.nlm.nih.gov/co...

[DippyDame]

helvella ......thank you!

My T3 is in tablet form.....I tend to take it (4×25mcg) with only 2 or 3 good gulps of water.

I did experiment with roughly chewing the tablets but read that was not advised. I don't think it made any difference....so it's down the hatch, as above, and off to bed!!

I take your point about water/ dispersion though.

[helvella in reply to DippyDame]

I only posted Roma (capsules not tablets) because I knew they had that phrasing on their PILs.

[DippyDame in reply to helvella]

It wasn't a criticism... sorry!

I'm on a 7day hefty abx course so more grumpy etc than normal....2 more days to go!!

[helvella in reply to DippyDame]

No - I didn't take it as criticism! Just wanted to explain/clarify.

[FancyPants54]

I've never done the "full glass of water" thing. It makes no sense to me. All you need is to get the pill into the stomach. So a quick drink out of the bottle by the bed is all I've ever done.

[Sailing14]

Sorry this a late reply but is it better to take lansoprazole than not as it reduces the acid in my stomach, and would this then help absorption when referring to this study on too high an acidic stomach can result in poor absorption.

I don’t know what is causing the acid reflux but I have been put forward for a PH test on the NHS which has a long waiting list.

Sometimes when if I don’t take the anti acid tablet, I start to feel hypothyroid symptoms more than normal so I am unsure if I need to try to continue with them.

Thanks

[jimh111 in reply to Sailing14]

Liw acid results in poor levothyroxine absorption. Reflux is often caused by under treatment of hypothyroidism. Hypothyroidism lowers the tightness of the lower oesophageal sphincter causing acid to reflux up into the oesophagus. Take your levothyroxine away from acid blockers and maje sure you are on an adequate dose of levothyroxine.

[Sailing14 in reply to jimh111]

Thank you for all this advice. I do take the acid medication as far away as I can from the t4 as I know it can affect absorption.

I feel there are absorption problems over the last year due to a long course of antibiotic and antifungal medication. I take t4 at night but sometimes due to hunger, I eat late by bedtime.

Could this be affecting the tablet being absorbed by the time I take it at 6 am?

[jimh111 in reply to Sailing14]

I don't really know, a small meal shouldn't have too much effect. Provided you are reasonably consistent your dose will be adjusted accordingly. Taking levothyroxine with fruit juice helps absorption.

[Sailing14]

Sorry this a late reply but is it better to take lansoprazole than not as it reduces the acid in my stomach, and would this then help absorption when referring to this study on too high an acidic stomach can result in poor absorption.

I don’t know what is causing the acid reflux but I have been put forward for a PH test on the NHS which has a long waiting list.

Sometimes when if I don’t take the anti acid tablet, I start to feel hypothyroid symptoms more than normal so I am unsure if I need to try to continue with them.