4.1. Therapeutic indications

Levothyroxine Oral Solution is indicated for:

i) hypothyroidism (congenital or acquired)

ii) diffuse non toxic goitre

iii) goitre associated with Hashimoto's thyroiditis

iv) Suppression therapy in thyroid carcinoma

4.2. Posology and method of administration

Posology

The treatment of any thyroid disorder should be determined on an individual basis, taking account of clinical response, biochemical tests and regular monitoring.

The individual daily dose should be determined on the basis of laboratory tests and clinical examinations. As a number of patients show elevated concentrations of T4 and fT4, basal serum concentration of thyroid-stimulating hormone provides a more reliable basis for following treatment course.

Patients switching from the oral solution to the tablet form or from the tablet form to the oral solution should be monitored closely.

Levothyroxine is best taken as a single dose on an empty stomach, usually before breakfast.

Hypothyroidism (congenital or acquired)

Adults, children over 12 years

Initial dose:

50 - 100 micrograms daily before breakfast.

Usual maintenance dose:

100 - 200 micrograms daily.

The initial dose is adjusted by 25 to 50 microgram increments at 3 – 4 week intervals until clinical response and measurements of plasma thyroxine and thyroid stimulating hormone indicate that the thyroid deficiency is corrected and a maintenance dose established.

Diffuse non toxic goitre or goitre associated with Hashimoto's thyroiditis

The recommended dose is 50-200 µg/day.

Suppression therapy in thyroid carcinoma

The recommended dose is 150-300 µg/day.

In elderly patients, in patients with coronary heart disease, and in patients with severe or long-existing hypothyroidism, special caution is required when initiating therapy with thyroid hormones, that is, a low initial dose (for example 12.5 microgram/day) should be given which should then be increased slowly and at lengthy intervals (e.g. a gradual increment of 12.5 microgram/day fortnightly) with frequent monitoring of thyroid hormones. A dosage, lower than optimal dosage giving complete replacement therapy, consequentially not resulting in a complete correction of TSH level, might therefore need to be considered.

Paediatric population

The maintenance dose is generally 100 to 150 micrograms per m² body surface area.

For neonates and infants with congenital hypothyroidism, where rapid replacement is important, the initial recommended dosage is 10 to 15 micrograms per kg BW per day for the first 3 months. Thereafter, the dose should be adjusted individually according to the clinical findings and thyroid hormone and TSH values.

For children with acquired hypothyroidism, the initial recommended dosage is 12.5-50 micrograms per day. The dose should be increased gradually every 2 to 4 weeks according to the clinical findings and thyroid hormone and TSH values until the full replacement dose is reached.

Infants should be given the total daily dose at least half an hour before the first meal of the day.

Duration of treatment is usually for life in the case of hypothyroidism, non-toxic goitre and goitre associated with Hashimoto's thyroiditis.

For patients with non-toxic diffuse goitre and normal T4 and TSH levels treatment with levothyroxine can be considered. If no discernible decrease in size of the goitre occurs after 6 to 12 month, thyroxine therapy should be stopped.

Method of administration

Oral

4.3. Contraindications

- Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

- In patients with adrenal insufficiency without adequate corticosteroid cover.

- Treatment with Levothyroxine Oral Solution must not be initiated in acute myocardial infarction, acute myocarditis, and acute pancarditis.

- Combination therapy of levothyroxine and an antithyroid agent for hyperthyroidism is not indicated during pregnancy (see section 4.6).

4.4. Special warnings and precautions for use

Thyroid treatments should be used with caution in patients with cardiovascular disorders, including myocardial insufficiency and hypertension.

To minimise the risk of adverse effects of undetected overtreatment, such as atrial fibrillation and fractures associated with low serum levels of thyroid stimulating hormone (TSH) in older patients, it is important to monitor serum TSH and adjust the dose accordingly during long term use.

Thyroid replacement therapy should be introduced gradually in elderly patients, and those with severe long standing hypothyroidism. Special care is needed when there are symptoms of myocardial insufficiency or ECG evidence of myocardial infarction and for similar reasons the treatment of hypothyroidism in the elderly should be initiated cautiously.

Patients with adrenal insufficiency may react unfavourably to levothyroxine treatment so it is advisable to initiate corticosteroid therapy before giving levothyroxine.

Caution should also be exercised when administering levothyroxine to diabetics or patients on glycosides.

Sub-clinical hyperthyroidism may be associated with bone loss. To minimise the risk of osteoporosis, dosage of levothyroxine sodium should be titrated to the lowest possible effective level. Parents of children receiving a thyroid agent should be advised that partial loss of hair may occur during the first few months of therapy, but this effect is usually transient and subsequent re-growth usually occurs.

Even slight drug-induced hyperthyroidism must be avoided in patients with coronary failure, cardiac insufficiency or tachycardiac arrhythmias. Hence frequent checks of thyroid hormone parameters must be made in these cases.

In the case of secondary hypothyroidism the cause must be determined before replacement therapy is given and if necessary replacement treatment of a compensated adrenal insufficiency must be commenced.

Where thyroid autonomy is suspected a TRH test should be carried out or a suppression scintigram obtained before treatment.

Levothyroxine should not be given in hyperthyreotic states other than as concomitant supplementation during anti-thyroid drug treatment of hyperthyroidism.

Thyroid hormones are not suitable for weight reduction. Physiological doses do not result in any weight loss in euthyroid patients. Supraphysiological doses may cause severe or even life-threatening undesirable effects (see section 4.9).

In individuals suspected to have cardiovascular disease or to be at high risk, it is important to perform an ECG prior to commencement of levothyroxine treatment in order to detect changes consistent with ischaemia in which case, levothyroxine should be initiated at a low dose, followed by cautious dose escalation to avoid worsening of ischaemia or precipitation of an infarct. If too rapid an increase of metabolism is produced (causing diarrhoea, nervousness, rapid pulse, insomnia, tremors and sometimes anginal pain where there is latent myocardial ischaemia), reduce the dose or withhold for 1-2 days and start again at a lower dose.

This product contains:

• Parahydroxybenzoates. These may cause allergic reactions (possibly delayed).

• Glycerol – This may cause headache, stomach upset and diarrhoea

Information on sodium content:

This medicine contains less than 1 mmol sodium (23 mg) per 5 ml, that is to say essentially 'sodium-free'.

Haemodynamic parameters should be monitored when levothyroxine therapy is initiated in very low birth weight preterm neonates as circulatory collapse may occur due to the immature adrenal function.

Care is required when levothyroxine is administered to patients with known history of epilepsy. Seizures have been reported rarely in association with the initiation of levothyroxine sodium therapy, and may be related to the effect of thyroid hormone on seizure threshold.

Interferences with laboratory test:

Biotin may interfere with thyroid immunoassays that are based on a biotin/streptavidin interaction, leading to either falsely decreased or falsely increased test results. The risk of interference increases with higher doses of biotin.

When interpreting results of laboratory tests, possible biotin interference has to be taken into consideration, especially if a lack of coherence with the clinical presentation is observed.

For patients taking biotin-containing products, laboratory personnel should be informed when a thyroid function test is requested. Alternative tests not susceptible to biotin interference should be used, if available. (see section 4.5)

4.5. Interaction with other medicinal products and other forms of interaction

• The effects of warfarin, dicoumarol, acenocoumarol, phenindione and probably other anticoagulants are increased by the concurrent use of thyroid compounds.

• The antidepressant response to imipramine, amitriptyline and possibly other tricyclic antidepressants can be accelerated by the concurrent use of levothyroxine.

• The absorption of levothyroxine is reduced by sucralfate, sodium polystyrene sulphonate or colestyramine binding within the gut.

• Cimetidine, aluminium hydroxide, calcium carbonate and ferrous sulphate also reduce absorption of levothyroxine from the G.I. tract.

• Dosages should be separated by an interval of several hours.

• The concurrent use of carbamazepine, phenytoin, phenobarbital, products containing St John's Wort (Hypericum perforatum L.), primadone or rifampicin with levothyroxine have been found to increase levothyroxine metabolism, resulting in reduced serum concentrations of thyroid hormone. Therefore, patients on thyroid replacement therapy may require an increase in their dose of thyroid hormone if these products are given concurrently.

• A possible interaction occurs with hypoglycaemic agents, hence diabetic patients should be monitored for increased requirements of insulin or oral hypoglycaemic agents.

• If levothyroxine therapy is initiated in digitalised patients, the dose of digoxin may require adjustment, hyperthyroid patients may need their digoxin dosage gradually increased as treatment proceeds, because initially patients are relatively sensitive to digoxin.

• Isolated reports of marked hypertension and tachycardia has been reported with concurrent ketamine administration.

• Lovastatin has been reported to cause one case each of hypothyroidism and hyperthyroidism in two patients taking levothyroxine. False low total plasma concentrations have been observed with concurrent anti-inflammatory treatment such as phenylbutazone or acetylsalicylic acid and levothyroxine therapy.

• Levothyroxine accelerates the metabolism of propranolol.

• Oestrogen, oestrogen containing products and oral contraceptives may increase the requirement of thyroid therapy dosage.

• Conversely, androgens and corticosteroids may decrease serum concentrations of thyroxine-binding globulins.

• Amiodarone may reduce the effects of thyroid hormones used in the treatment of hypothyroidism.

• Effects of levothyroxine may be decreased by concomitant sertraline. Some drugs such as lithium act directly on the thyroid gland and inhibit the release of thyroid hormones leading to clinical hypothyroidism.

• Increased thyroid-stimulating hormone concentration has been noted after the use of chloroquine with proguanil for malaria prophylaxis in a patient stabilised on levothyroxine.

• False low total plasma concentrations have been observed with concurrent anti-inflammatory treatment such as phenylbutazone or acetylsalicylic acid and levothyroxine therapy.

• Thyroid drugs increase metabolic demands and should therefore be used with caution with other drugs known to influence cardiac function, such as the sympathomimetics, as they may enhance this effect. In addition, thyroid hormones may increase receptor sensitivity to catecholamines.

• Anti-obesity drugs such as orlistat may decrease levothyroxine absorption which may result in hypothyroidism (monitor for changes in thyroid function).

• Post-marketing cases have been reported indicating a potential interaction between ritonavir containing products and levothyroxine. Thyroid-stimulating hormone (TSH) should be monitored in patients treated with levothyroxine at least the first month after starting and/or ending ritonavir treatment.

Protease inhibitors

Protease inhibitors (e.g. ritonavir, indinavir, lopinavir) may influence the effect of levothyroxine. Close monitoring of thyroid hormone parameters is recommended. If necessary, the levothyroxine dose has to be adjusted.

Sevelamer

Sevelamer may decrease levothyroxine absorption. Therefore, it is recommended that patients are monitored for changes in thyroid function at the start or end of concomitant treatment. If necessary, the levothyroxine dose has to be adjusted.

Tyrosine kinase inhibitors

Tyrosine kinase inhibitors (e.g. imatinib, sunitinib) may decrease the efficacy of levothyroxine. Therefore, it is recommended that patients are monitored for changes in thyroid function at the start or end of concomitant treatment. If necessary, the levothyroxine dose has to be adjusted.

Propylthiouracil, glucocorticoids, beta-sympatholytics, amiodarone and iodine containing contrast media:

These substances inhibit the peripheral conversion of T4 to T3.

Due to its high iodine content amiodarone can trigger hyperthyroidism as well as hypothyroidism. Particular caution is advised in the case of nodular goitre with possibly unrecognized autonomy.

Enzyme inducing medicinal products:

Enzyme inducing medicinal products such as barbiturates or carbamazepine can increase hepatic clearance of levothyroxine.

Soy-containing compounds:

Soy-containing compounds can decrease the intestinal absorption of levothyroxine. Therefore, a dosage adjustment of Levothyroxine Oral Solution may be necessary, in particular at the beginning or after termination of nutrition with soy supplements.

Proton pump inhibitors (PPIs):

Co-administration with PPIs may cause a decrease in the absorption of the thyroid hormones, due to the increase of the intragastric pH caused by PPIs.

Regular monitoring of thyroid function and clinical monitoring is recommended during concomitant treatment. It may be necessary to increase the dose of thyroid hormones.

Care should also be taken when treatment with PPI ends.

Interferences with laboratory test:

Biotin may interfere with thyroid immunoassays that are based on a biotin/streptavidin interaction, leading to either falsely decreased or falsely increased test results (see section 4.4).

4.6. Fertility, pregnancy and lactation

Pregnancy

Women on a maintenance dose for hypothyroidism who become pregnant, must be monitored closely. Levothyroxine sodium does not readily cross the placenta in the second and third trimester, but may do so in the first. Levothyroxine sodium is not known to have either carcinogenic or tetragenic effects.

Treatment with levothyroxine should be given consistently during pregnancy and breast-feeding in particular. Dosage requirements may even increase during pregnancy.

Experience has shown that there is no evidence of drug-induced teratogenicity and/or foeto-toxicity in humans at the recommended therapeutic dose level. Excessively high dose levels of levothyroxine during pregnancy may have a negative effect on foetal and postnatal development.

Combination therapy of hyperthyroidism with levothyroxine and anti-thyroid agents is not indicated in pregnancy. Such combination would require higher doses of anti-thyroid agents, which are known to pass the placenta and to induce hypothyroidism in the infant.

Thyroid suppression diagnostic tests should not be carried out during pregnancy, as the application of radioactive substances in pregnant women is contraindicated.

Breast-feeding

Levothyroxine is secreted into breast milk during lactation but the concentrations achieved at the recommended therapeutic dose level are not sufficient to cause development of hyperthyroidism or suppression of TSH secretion in the infant. Levothyroxine can be used during breast-feeding.

Fertility

No data available

4.7. Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed. However, since Levothyroxine is identical to the naturally occurring thyroid hormone, it is not expected that Levothyroxine Oral Solution has any influence on the ability to drive and use machines.

4.8. Undesirable effects

The following side effects are usually due to excessive dosage, and correspond to symptoms of hyperthyroidism. Adverse reactions listed below have been observed during clinical studies and/or during marketed use and are based on clinical trial data and classified according to MedDRA System Organ Class. These reactions usually disappear after dose reduction or withdrawal of treatment.

Frequency categories are defined according to the following convention:

Not known (cannot be estimated from the available data):

System organ class

Undesirable effects

Immune system disorders

Hypersensitivity reaction

Endocrine disorders

Thyrotoxic crisis1

Psychiatric disorders

Restlessness, agitation, insomnia

Nervous system disorders

Tremor, headache

Cardiac disorders

Angina pectoris, arrhythmia, palpitations, tachycardia

Vascular disorders

Flushing

Respiratory, thoracic and mediastinal disorders

Dyspnoea

Gastrointestinal disorders

Diarrhoea, vomiting

Skin and subcutaneous tissue disorders

Hyperhidrosis, alopecia, rash, pruritus

Musculoskeletal and connective tissue disorder

Arthralgia, muscle spasm, muscular weakness

Reproductive system disorders

Menstruation irregular

General disorders and administration site conditions

Pyrexia, malaise, oedema

Investigations

Weight decreased

1 Thyroid crisis have occasionally been reported following massive or chronic intoxication and cardiac arrhythmias, heart failure, coma and death have occurred.

Paediatric population

Heat intolerance, transient hair loss, benign intracranial hypertension, craniostenosis in infants and premature closure of epiphysis in children.

Reporting of suspected adverse reactions:

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Symptoms

An elevated T3 value is a more reliable indicator of overdose than elevated T4 or fT4 values.

In the event of an overdose, symptoms displaying a marked increase in metabolic activity occur (see section 4.8). Depending on the extent of the overdose, it is recommended that the patient stops taking the product and undergoes a check-up.

Symptoms may manifest themselves as marked beta-adrenergic effects, such as tachycardia, anxiety states, agitation and hyperkinesis. The symptoms may be reduced by beta-receptor blockers. At extreme doses, plasmapheresis may be useful.

Following overdose in humans (with suicidal intent) doses of 10 mg levothyroxine were tolerated without complications.

There are some reports of sudden cardiac death in patients who have misused levothyroxine over many years.

Management

Overdosage following recent ingestion can be treated using gastric lavage/emesis. Propranolol and other supportive measures are used to maintain the circulation. Antithyroid drugs such as propylthiouracil and lithium are unlikely to be of benefit to prevent thyrotoxic crisis due to delayed absorption/onset of action.