levothyroxine sodium (L-thyroxine, T4)

(lee voe thye rox' een)

Levothroid, Levoxine, Levoxyl, Synthroid, Unithroid

Pregnancy Category A

Drug class
Thyroid hormone

Therapeutic actions
Increases the metabolic rate of body tissues, thereby increasing oxygen consumption;
respiration and heart rate; rate of fat, protein, and carbohydrate metabolism; and growth
and maturation.

Indications
• Replacement therapy in hypothyroidism
• Pituitary TSH suppression in the treatment and prevention of euthyroid goiters
and in the management of thyroid cancer
• Thyrotoxicosis in conjunction with antithyroid drugs and to prevent goitrogenesis,
hypothyroidism, and thyrotoxicosis during pregnancy
• Treatment of myxedema coma

Contraindications and cautions

• Contraindicated with allergy to active or extraneous constituents of drug,
thyrotoxicosis, and acute MI uncomplicated by hypothyroidism.
• Use cautiously with Addison's disease (treat hypoadrenalism with corticosteroids
before thyroid therapy), lactation, patients with coronary artery disease or angina.

Available forms
Tablets—0.025, 0.05, 0.075, 0.088, 0.1, 0.112, 0.125, 0.137, 0.15, 0.175, 0.2, 0.3 mg;
powder for injection—200, 500 mcg/vial

Dosages
0.05–0.06 mg equals approximately 60 mg (1 grain) thyroid.
ADULTS
• Hypothyroidism: Initial dose: 0.05 mg PO, with increasing increments of
0.025 mg PO q 2–4 wk; maintenance of up to 0.2 mg/day. IV or IM injection can
be substituted for the oral dosage form when oral ingestion is not possible. Usual
IV dose is 50% of oral dose. Start at < 0.025 mg/day in patients with long-
standing hypothyroidism or known cardiac disease.
• Myxedema coma without severe heart disease: 0.4 mg IV as initial dose, then 0.1
to 0.2 mg IV daily; daily maintenance of 0.05 to 0.1 mg once a euthyroid state is
established. Switch to PO once patient is able.
• TSH suppression in thyroid cancer, nodules, and euthyroid goiters: Larger
amounts than used for normal suppression.
• Thyroid suppression therapy: 2.6 mcg/kg/day PO for 7–10 days.
PEDIATRIC PATIENTS
• Congenital hypothyroidism: Infants require replacement therapy from birth.
0–1 yr: 8–10 mcg/kg/day.
1–5 yr: 4–6 mcg/kg/day.
> 5 yr: 3–4 mcg/kg/day.

Pharmacokinetics
Route Onset Peak
Oral Slow 1–3 wk
IV 6–8 hr 24–48 hr

Metabolism: Hepatic; T1/2: 6–7 days

Distribution: Crosses placenta; enters breast milk
Excretion: Bile

IV facts
Preparation: Add 5 mL 0.9% sodium chloride injection, USP or bacteriostatic sodium
chloride injection, USP with benzyl alcohol. Shake the vial to ensure complete mixing.
Use immediately after reconstitution. Discard any unused portion.
Infusion: Inject directly, each 100 mcg over 1 min.
Incompatibilities: Do not mix with any other IV fluids.

Adverse effects
• CNS: Tremors, headache, nervousness, insomnia
• CV: Palpitations, tachycardia, angina, cardiac arrest
• Dermatologic: Allergic skin reactions, partial loss of hair in first few months of
therapy in children
• GI: Diarrhea, nausea, vomiting

Interactions
Drug-drug
• Decreased absorption of oral thyroid preparation with cholestyramine
• Increased risk of bleeding with warfarin—reduce dosage of anticoagulant when T4
is begun
• Decreased effectiveness of digitalis glycosides if taken with thyroid replacement
• Decreased theophylline clearance when patient is in hypothyroid state; monitor
levels and patient response as euthyroid state is achieved

Nursing considerations
Assessment
• History: Allergy to active or extraneous constituents of drug, thyrotoxicosis,
acute MI uncomplicated by hypothyroidism, Addison's disease, lactation
• Physical: Skin lesions, color, temperature, texture; T; muscle tone, orientation,
reflexes; P, auscultation, baseline ECG, BP; R, adventitious sounds; thyroid
function tests
Interventions
• Monitor response carefully at start of therapy, adjust dosage. Full therapeutic
effect may not be seen for several days.
• Do not change brands of T4 products, due to possible bioequivalence problems.
• Do not add IV doses to other IV fluids.
• Use caution in patients with CV disease.
• Administer oral drug as a single daily dose before breakfast.
• Arrange for regular, periodic blood tests of thyroid function.
• For children and other patients who cannot swallow tablets, crush and suspend in
a small amount of water or formula, or sprinkle over soft food. Take immediately.
• Most CV and CNS adverse effects indicate that the dose is too high. Stop drug for
several days and reinstitute at a lower dose.

Teaching points
• Take as a single dose before breakfast.
• This drug replaces an important hormone and will need to be taken for life. Do
not discontinue without consulting your health care provider; serious problems
can occur.
• Wear a medical ID tag to alert emergency medical personnel that you are on this
drug.
• Arrange to have periodic blood tests and medical evaluations. Keep your
scheduled appointments.
• Report headache, chest pain, palpitations, fever, weight loss, sleeplessness,
nervousness, irritability, unusual sweating, intolerance to heat, diarrhea.

Adverse effects in Italic are most common; those in Bold are life-threatening.