Tea and juice as a causes of levothyroxine malabsorption and intermittent hypothyreoidism: a case report

Dragan Tesic; Edita Stokic; Milica Medic/Stojanoska; Milena Mitrovic; Dragana Tomic-Naglic; Tijana Icin; Ivana Bajkin; Bozidar Dejanovic; Mirjana Tomic

doi:10.1530/endoabs.56.P996

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Endocrine Abstracts (2018) 56 P996 | DOI: 10.1530/endoabs.56.P996

ECE2018 Poster Presentations: Thyroid Clinical case reports - Thyroid/Others (21 abstracts)

Tea and juice as a causes of levothyroxine malabsorption and intermittent hypothyreoidism: a case report

Dragan Tesic ¹ , Edita Stokic ¹ , Milica Medic/Stojanoska ¹ , Milena Mitrovic ¹ , Dragana Tomic-Naglic ¹ , Tijana Icin ¹ , Ivana Bajkin ¹ , Bozidar Dejanovic ¹ & Mirjana Tomic ²

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¹Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Vojvodina, Novi Sad, Serbia; ²Emergency Center, Clinical Centre of Vojvodina, Novi Sad, Serbia.

Introduction: Biological casuses of levothyroxine (LT4) malabsorption are well known. Congestive heart failure, gastrointestinal diseases, pregnancy, medication or dietary interference are the most commonly known causes of poor oral absorption of LT4. However, when substitution therapy with LT4 fails we need to be more exploratory.

Case description: Female, born in 1987, BH 164 cm, BW 73kg, in 2010 she was presented as M. Basedowi and in october 2011 near thyreodectomy was done. In 2012 despate 200 mgr LT4 her TSH had been always elevatred. She was admitted to hospital in december 2017 with levothyroxine dosage of 700 mgr. In the last few months she was treated with Novothyral preparation 100, 3 tablets per day (combination of levothyroxyn 100 mgr and liothyronin 20 mgr) but without success. During 6 years period patient did have 24 controls (four per year) by secondary ot tertiary level endocrinologists). Most of the time she has been felt, briefly described, not healthy’’. In 2014.y. and 2016.y. she had two birds. During pregnancy levothyroxine dosage was 300-400 mgr. During all these years transient hypothyreoidism has been presented. Values of hormones were as follows:

On 8.day of hospitalisation we performed:

After the test we obtained the data that she was taking levothyroxin on empty stomac but frequently with juice or tea. After a few days of hospital stay she started using the drug with water. Her latest dosage of levothyroxine is 100 mgr and latest control of hormones in referente range.


	Admittance to Clinic	7.day in Clinic	Average±SD	Median	MIN-MAX.	Reference values
TSH mIU/L	>100	9.4	55.7±61.97	23.8	0.01-201	0.35-4.94
fT4 pmol/L	5.9	10.8	12.8±7.8	11.4	1.98-31.8	9-19
fT3 pmol/L	-	7.4	3.8±2.2	3.57	0.2-8.8	2.6-5.7

Table: Levothyroxyne Absorption Test (LAT) with 1000mgr levothyroxine
	0.h	1.h	2.h	3.h	4.h	5.h	Reference values
TSH mIU/L	4.15	3.77	3.52	3.36	2.65	3.05	0.35-4.94
-relation to 0.h	1	0,91	0,85	0,81	0,54	0,73
fT4 pmol/L	12.1	16.86	23.91	24.26	26.76	22.48	9-19
-relation to 0.h	1	1,39	1,96	2,00	2,21	1,86
fT3 pmol/L	7.4	7.35	7.67	7.43	7.6	6.97	2.6-5.7
-relation to 0.h		0,99	1,03	1.00	1.03	0.94

Discussion: LAT in our testing excluded malabsorpition of levothyroxine. Pseudomalabsorption was not caused because of nonadherence. Our patient did have actually dietary interference of juice and/or tea of mint with levothyroxine absorption.