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LETTER TO THE EDITOR
Year : 2015  |  Volume : 12  |  Issue : 3  |  Page : 124-125

Phosphate binders bind levothyroxine and affect the control of hypothyroidism


1 Department of Nephrology, Nakatsugawa City Hospital, Gifu Prefecture, Nakagawa-ku, Nagoya, Japan
2 Department of Emergency Medicine, Nagoya Ekisaikai Hospital, Nakagawa-ku, Nagoya, Japan

Date of Web Publication16-Oct-2015

Correspondence Address:
Dr. Akihito Tanaka
Department of Nephrology, Nakatsugawa City Hospital, 1522-1 Komaba, Nakatsugawa City, Gifu Prefecture - 508 8502
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.157924

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How to cite this article:
Tanaka A, Ito Y. Phosphate binders bind levothyroxine and affect the control of hypothyroidism. Thyroid Res Pract 2015;12:124-5

How to cite this URL:
Tanaka A, Ito Y. Phosphate binders bind levothyroxine and affect the control of hypothyroidism. Thyroid Res Pract [serial online] 2015 [cited 2020 Sep 21];12:124-5. Available from: http://www.thetrp.net/text.asp?2015/12/3/124/157924

Sir,

The number of patients who receive regular hemodialysis (HD) is increasing. Among the HD patients, many patients show excessive high levels of phosphate and are administered phosphate binders, such as calcium carbonate (CaCO 3 ), sevelamer hydrochloride (SevHCl), lanthanum carbonate (LaCO 3 ) and so on. On the other hand, hypothyroidism is often seen. Complication of hypothyroidism in HD patients is not rare. Thyroid replacement therapy for HD patients must be performed carefully because phosphate binders bind not only phosphate but also to other medicines, including levothyroxine (LT4).

A female in her twenties had been administered LT4 for hypothyroidism from childhood. She initiated HD for end-stage renal disease (ESRD) due to reflux nephropathy 5 years ago. She started to receive regular HD sessions in our clinic last year. Then, she showed hyperphosphatemia, 8.7 mg/dl, with CaCO 3 4500 mg/day. And her hypothyroidism was well controlled with LT4 150 µg/day, such as thyroid stimulating hormone (TSH) 0.023 µU/ml, free triiodothyronine (FT3) 3.5 pg/ml and free thyroxine (FT4) 1.46 ng/ml. Additional administration of SevHCl 3000 mg/day for hyperphosphatemia was performed which resulted in the control of hypothyroidism getting worse (TSH 9.773 µU/ml). Simultaneously, she complained feeling colder than usual. We diagnosed exacerbation of hypothyroidism. We changed the timing of taking LT4 to at bedtime from morning because the timing was reported to be the best for absorption from intestine [1] and aimed to separate from phosphate binders. After change of timing, her hypothyroidism improved a little (TSH 5.185 µU/ml). We considered that addition of phosphate binders caused the exacerbation of hypothyroidism. Hence, we performed nutritional guidance. Then, hyperphosphatemia improved and withdrawal of SevHCl became possible, following improvement of hypothyroidism (TSH 2.642 µU/ml). However, she had large appetite and often could not control diet. The level of phosphats kept around 6 mg/dl or above. New administration of LaCO 3 (750 mg/day) made the control of hypothyroidism unstable (TSH 5.185 µU/ml). Hence, we performed nutritional guidance repeatedly. Successively, the control of hypothyroidism and hyperphosphatemia is improving (TSH 4.000 µU/ml and phosphorus 5.5 mg/dl with CaCO 3 4500 mg/day and SevHCl 3000 mg/day). Her clinical course is shown in [Figure 1].
Figure 1: Clinical course of phosphate and TSH. The administration of phosphate binders were associated with increasing TSH levels. Sev HCl: sevelamer hydrochloride. CaCO3: calcium carbonate. LaCO3: Lanthanum carbonate. TSH: Thyroid stimulating hormone. LT4: Levothyroxine. P: Phosphate

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This report confirms that phosphate binders, such as CaCO 3 , SevHCl and LaCO 3 , bind LT4 and make the control of hypothyroidism unstable. CaCO 3 is famous for this fact, [2] however, SevHCl [3] and LaCO3 [4] also bind and affect absorption of LT4. For the HD patients with LT4 and phosphate binders, adjustment of phosphate binders must be careful. Increasing dose of phosphate binders may cause malabsorption of LT4 and make the control of hypothyroidism worse. Then, more dose of LT4 may be necessary. Or the timing of taking LT4 must be separated from phosphate binders at least 4 hours and is favorable at bedtime. Needless to say, the control of hyperphosphatemia is also important.

It is important to know that phosphate binders, not only CaCO 3 but also SevHCl and LaCO 3 bind LT4 and affect its absorption. Health care providers must know this fact and control hypothyroidism and hyperphosphatemia carefully.

 
  References Top

1.
Bolk N, Visser TJ, Nijman J, Jongste IJ, Tijssen JG, Berghout A. Effects of evening vs morning levothyroxine intake: A randomized double-blind crossover trial. Arch Intern Med 2010;170:1996-2003.  Back to cited text no. 1
    
2.
Schneyer CR. Calcium carbonate and reduction of levothyroxine efficacy. JAMA 1998;279:750.  Back to cited text no. 2
[PUBMED]    
3.
John-Kalarickal J, Pearlman G, Carlson HE. New medications which decrease levothyroxine absorption. Thyroid 2007;17:763-5.  Back to cited text no. 3
    
4.
Weitzman SP, Ginsburg KC, Carlson HE. Colesevelam hydrochloride and lanthanum carbonate interfere with the absorption of levothyroxine. Thyroid 2009;19:77-9.  Back to cited text no. 4
[PUBMED]    


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