Interactions between Calcium acetate and Levothyroxine
1 drug interaction and 15 additional warnings found for the following 2 drugs:
- calcium acetate
- levothyroxine
Drug interactions
Moderate drug interactions
Moderate:
levothyroxine calcium acetate
Applies to: levothyroxine and calcium acetate
Adjust dosing interval
Concurrent administration of calcium-containing products may decrease the oral bioavailability of levothyroxine by one-third in some patients. Pharmacologic effects of levothyroxine may be reduced. The exact mechanism of interaction is unknown but may involve nonspecific adsorption of levothyroxine to calcium at acidic pH levels, resulting in an insoluble complex that is poorly absorbed from the gastrointestinal tract. In one study, 20 patients with hypothyroidism who were taking a stable long-term regimen of levothyroxine demonstrated modest but significant decreases in mean free and total thyroxine (T4) levels as well as a corresponding increase in mean thyrotropin (thyroid-stimulating hormone, or TSH) level following the addition of calcium carbonate (1200 mg/day of elemental calcium) for 3 months. Four patients had serum TSH levels that were higher than the normal range. Both T4 and TSH levels returned to near-baseline 2 months after discontinuation of calcium, which further supported the likelihood of an interaction. In addition, there have been case reports suggesting decreased efficacy of levothyroxine during calcium coadministration. It is not known whether this interaction occurs with other thyroid hormone preparations.
Management
Some experts recommend separating the times of administration of levothyroxine and calcium-containing preparations by at least 4 hours. Monitoring of serum TSH levels is recommended. Patients with gastrointestinal or malabsorption disorders may be at a greater risk of developing clinical or subclinical hypothyroidism due to this interaction.
References (4)
- Schneyer CR (1998) "Calcium carbonate and reduction of levothyroxine efficacy." JAMA, 279, p. 750
- Singh N, Singh PN, Hershman JM (2000) "Effect of calcium carbonate on the absorption of levothyroxine." JAMA, 283, p. 2822-5
- Csako G, McGriff NJ, Rotman-Pikielny P, Sarlis NJ, Pucino F (2001) "Exaggerated levothyroxine malabsorption due to calcium carbonate supplementation in gastrointestinal disorders." Ann Pharmacother, 35, p. 1578-83
- Neafsey PJ (2004) "Levothyroxine and calcium interaction: timing is everything." Home Healthc Nurse, 22, p. 338-9
Food/lifestyle interactions
Moderate food/lifestyle interactions
Moderate:
levothyroxine Food/Lifestyle
Applies to: levothyroxine
Adjust dosing interval
Consumption of certain foods as well as the timing of meals relative to dosing may affect the oral absorption of T4 thyroid hormone (i.e., levothyroxine). T4 oral absorption is increased by fasting and decreased by foods such as soybean flour (e.g., infant formula), cotton seed meal, walnuts, dietary fiber, calcium, and calcium fortified juices. Grapefruit or grapefruit products may delay the absorption of T4 thyroid hormone and reduce its bioavailability. The mechanism of this interaction is not fully understood.
Management
Some manufacturers recommend administering oral T4 as a single daily dose, on an empty stomach, one-half to one hour before breakfast. In general, oral preparations containing T4 thyroid hormone should be administered on a consistent schedule with regard to time of day and relation to meals to avoid large fluctuations in serum levels. Foods that may affect T4 absorption should be avoided within several hours of dosing if possible. Consult local guidelines for the administration of T4 in patients receiving enteral feeding.
References (3)
- (2002) "Product Information. Synthroid (levothyroxine)." Abbott Pharmaceutical
- (2022) "Product Information. Armour Thyroid (thyroid desiccated)." Forest Pharmaceuticals
- Wohlt PD, Zheng L, Gunderson S, Balzar SA, Johnson BD, Fish JT (2009) "Recommendations for the use of medications with continuous enteral nutrition." Am J Health Syst Pharm, 66, p. 1438-67
Moderate:
levothyroxine multivitamins with minerals
Applies to: levothyroxine
Adjust dosing interval
Concurrent administration of calcium-containing products may decrease the oral bioavailability of levothyroxine by one-third in some patients. Pharmacologic effects of levothyroxine may be reduced. The exact mechanism of interaction is unknown but may involve nonspecific adsorption of levothyroxine to calcium at acidic pH levels, resulting in an insoluble complex that is poorly absorbed from the gastrointestinal tract. In one study, 20 patients with hypothyroidism who were taking a stable long-term regimen of levothyroxine demonstrated modest but significant decreases in mean free and total thyroxine (T4) levels as well as a corresponding increase in mean thyrotropin (thyroid-stimulating hormone, or TSH) level following the addition of calcium carbonate (1200 mg/day of elemental calcium) for 3 months. Four patients had serum TSH levels that were higher than the normal range. Both T4 and TSH levels returned to near-baseline 2 months after discontinuation of calcium, which further supported the likelihood of an interaction. In addition, there have been case reports suggesting decreased efficacy of levothyroxine during calcium coadministration. It is not known whether this interaction occurs with other thyroid hormone preparations.
Management
Some experts recommend separating the times of administration of levothyroxine and calcium-containing preparations by at least 4 hours. Monitoring of serum TSH levels is recommended. Patients with gastrointestinal or malabsorption disorders may be at a greater risk of developing clinical or subclinical hypothyroidism due to this interaction.
References (4)
- Schneyer CR (1998) "Calcium carbonate and reduction of levothyroxine efficacy." JAMA, 279, p. 750
- Singh N, Singh PN, Hershman JM (2000) "Effect of calcium carbonate on the absorption of levothyroxine." JAMA, 283, p. 2822-5
- Csako G, McGriff NJ, Rotman-Pikielny P, Sarlis NJ, Pucino F (2001) "Exaggerated levothyroxine malabsorption due to calcium carbonate supplementation in gastrointestinal disorders." Ann Pharmacother, 35, p. 1578-83
- Neafsey PJ (2004) "Levothyroxine and calcium interaction: timing is everything." Home Healthc Nurse, 22, p. 338-9
Disease interactions
13 potential interactions Applies to: 13 conditions, including High Blood Pressure, Seizures, Arrhythmia, Hyperthyroidism, and Heart Disease.
Achlorhydria
Major:
calcium acetate
Calcium acetate has a major potential interaction with Achlorhydria.
Calcium is absorbed from the intestinal tract by active transport and passive diffusion. Malabsorption syndromes (celiac disease, GI resection), deficiency of vitamin D, parathyroid hormone, or calcitonin, or an alkaline gastric pH (achlorhydria, carbonate or phosphate salts) can decrease the absorption of oral formulations of calcium. Calcium is available in oral and parenteral formulations.
Adrenal Insufficiency
Major:
levothyroxine
Levothyroxine has a major potential interaction with Adrenal Insufficiency.
The use of thyroid hormones is contraindicated in patients with uncorrected adrenal insufficiency. Thyroid hormones increase tissue demand for adrenocortical hormones and may precipitate acute adrenal crisis. In patients with controlled adrenal insufficiency or other endocrine disorders, therapy for these concomitant disorders may need to be adjusted following thyroid replacement, since hypothyroidism often obscure or diminish the signs and symptoms of these conditions. Clinical monitoring of thyroid and adrenal function as well as any other appropriate endocrine function is recommended during thyroid hormone therapy.
Arrhythmia
Major:
calcium acetate
Calcium acetate has a major potential interaction with Arrhythmia.
Calcium is involved in cardiac muscle contraction and electrical impulse conduction. Therapy with calcium salt formulations (particularly IV) should be administered cautiously to patients with cardiac disease. Patients receiving cardiac glycosides and concomitant IV calcium may experience arrhythmias. Therapy with IV calcium should be administered slowly and at reduced dosages in patients with cardiac disease.
Diabetes Insipidus
Moderate:
levothyroxine
Levothyroxine has a moderate potential interaction with Diabetes Insipidus.
Since hypothyroidism often obscure or diminish the signs and symptoms of endocrine disorders such as diabetes mellitus or diabetes insipidus, thyroid replacement therapy may aggravate the intensity of symptoms associated with these conditions. Patients with endocrine disorders should be monitored more closely during thyroid hormone therapy, and their medication regimen adjusted accordingly. If thyroid medication is later discontinued, a downward readjustment of insulin or oral hypoglycemic agent may be necessary in patients with diabetes mellitus to avoid hypoglycemia.
Diabetes Mellitus
Moderate:
levothyroxine
Levothyroxine has a moderate potential interaction with Diabetes Mellitus.
Since hypothyroidism often obscure or diminish the signs and symptoms of endocrine disorders such as diabetes mellitus or diabetes insipidus, thyroid replacement therapy may aggravate the intensity of symptoms associated with these conditions. Patients with endocrine disorders should be monitored more closely during thyroid hormone therapy, and their medication regimen adjusted accordingly. If thyroid medication is later discontinued, a downward readjustment of insulin or oral hypoglycemic agent may be necessary in patients with diabetes mellitus to avoid hypoglycemia.
Heart Disease
Major:
levothyroxine
Levothyroxine has a major potential interaction with Heart Disease.
Thyroid hormones cause increases in myocardial contractility and heart rate as a result of increased metabolic demands and oxygen consumption. Therapy with thyroid hormones should be administered cautiously and initiated at reduced dosages in patients with cardiovascular disorders such as angina, coronary artery disease, and hypertension. Clinical monitoring of cardiovascular function is recommended. If chest pain or exacerbation of cardiovascular disease occurs, the dosage of thyroid hormone should be reduced, even at the expense of achieving euthyroid state. Thyroid hormones should not be administered to patients with an acute myocardial infarction that is not complicated by hypothyroidism.
High Blood Pressure
Major:
levothyroxine
Levothyroxine has a major potential interaction with High Blood Pressure.
Thyroid hormones cause increases in myocardial contractility and heart rate as a result of increased metabolic demands and oxygen consumption. Therapy with thyroid hormones should be administered cautiously and initiated at reduced dosages in patients with cardiovascular disorders such as angina, coronary artery disease, and hypertension. Clinical monitoring of cardiovascular function is recommended. If chest pain or exacerbation of cardiovascular disease occurs, the dosage of thyroid hormone should be reduced, even at the expense of achieving euthyroid state. Thyroid hormones should not be administered to patients with an acute myocardial infarction that is not complicated by hypothyroidism.
Hyperthyroidism
Major:
levothyroxine
Levothyroxine has a major potential interaction with Hyperthyroidism.
The use of thyroid hormones is contraindicated in patients with untreated thyrotoxicosis of any etiology, since thyroid hormones may exacerbate the condition.
Malabsorption Syndrome
Major:
calcium acetate
Calcium acetate has a major potential interaction with Malabsorption Syndrome.
Calcium is absorbed from the intestinal tract by active transport and passive diffusion. Malabsorption syndromes (celiac disease, GI resection), deficiency of vitamin D, parathyroid hormone, or calcitonin, or an alkaline gastric pH (achlorhydria, carbonate or phosphate salts) can decrease the absorption of oral formulations of calcium. Calcium is available in oral and parenteral formulations.
Phosphate Imbalance
Major:
calcium acetate
Calcium acetate has a major potential interaction with Phosphate Imbalance.
Elevated serum concentrations of calcium and phosphate can exceed the solubility level and result in calcium- phosphate precipitates that deposit in vascular and renal systems as well as other soft tissues of the body. Therapy with calcium should be administered with extreme caution in patients with hyperphosphatemia (hypoparathyroidism or severe renal impairment). Administration of oral calcium acetate or calcium carbonate, in addition to providing calcium, complexes phosphates within the GI tract. These complexes are eliminated in the feces. Clinical monitoring of serum calcium and phosphate concentrations is necessary.
Renal Dysfunction
Major:
calcium acetate
Calcium acetate has a major potential interaction with Renal Dysfunction.
Absorption of oral calcium formulations may be altered and elimination of calcium by the kidney decreased with renal impairment. Hyperphosphatemia occurs during renal failure. Calcium acetate or calcium carbonate, in addition to providing calcium, complexes phosphates within the GI tract. Calcium carbonate can partially correct metabolic acidosis associated with chronic renal failure. Clinical monitoring of renal function and serum calcium and phosphate concentrations is necessary.
Sarcoidosis
Major:
calcium acetate
Calcium acetate has a major potential interaction with Sarcoidosis.
Hypercalciuria, with or without hypercalcemia, may occasionally occur in patients with sarcoidosis. Elevated calcium levels may result from increased intestinal absorption of calcium, which is related to the extrarenal production of vitamin D by mononuclear phagocytes present within the sarcoid granuloma. Therapy with calcium salts should be administered cautiously and only if necessary in patients with sarcoidosis.
Seizures
Moderate:
levothyroxine
Levothyroxine has a moderate potential interaction with Seizures.
Thyroid hormones may alter the seizure threshold. Seizures have been reported rarely following the initiation of levothyroxine therapy. Therapy with thyroid hormones should be administered cautiously in patients predisposed to seizures.
More resources
calcium acetate
A total of 90 drugs are known to interact with calcium acetate.
- Calcium acetate is in the following drug classes: minerals and electrolytes, phosphate binders.
- Calcium acetate is used to treat Hyperphosphatemia.
levothyroxine
A total of 254 drugs are known to interact with levothyroxine.
- Levothyroxine is in the drug class thyroid drugs.
- Levothyroxine is used to treat the following conditions:
Drug Interaction Classification
| Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit. | |
| Moderately clinically significant. Usually avoid combinations; use it only under special circumstances. | |
| Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan. | |
| No interaction information available. |
Further information
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