UNITHROID™ (levothyroxine sodium tablets, USP ) contains synthetic crystalline L-3,3¹,5,5¹-tetraiodothyronine sodium salt [levothyroxine (T₄) sodium]. Synthetic T₄ is identical to that produced in the human thyroid gland. Levothyroxine (T₄) sodium has an empirical formula of C₁₅H₁₀I₄N NaO₄ x H₂O, molecular weight of 798.86 g/mol (anhydrous).

Inactive Ingredients

Colloidal silicon dioxide, lactose, magnesium stearate, microcrystalline cellulose, corn starch, acacia and sodium starch glycolate. The following are the coloring additives per tablet strength:

Strength (mcg)	Color Additive(s)
25	FD&C Yellow No. 6 Aluminum Lake
50	None
75	FD&C Red No. 40 Aluminum Lake, FD&C Blue No. 2 Aluminum Lake
88	D&C Yellow No. 10 Aluminum Lake, FD&C Yellow No. 6 Aluminum Lake, FD&C Blue No. 1 Aluminum Lake
100	D&C Yellow No. 10 Aluminum Lake, FD&C Yellow No. 6 Aluminum Lake
112	D&C Red No. 27 Aluminum Lake
125	FD&C Yellow No. 6 Aluminum Lake, FD&C Red No. 40 Aluminum Lake, FD&C Blue No. 1 Aluminum Lake
150	FD&C Blue No. 2 Aluminum Lake
175	FD&C Blue No. 1 Aluminum Lake, D&C Red No. 27 Aluminum Lake
200	FD&C Red No. 40 Aluminum Lake
300	D&C Yellow No. 10 Aluminum Lake, FD&C Yellow No. 6 Aluminum Lake, FD&C Blue No. 1 Aluminum Lake

Last updated on RxList: 3/10/2008

Levothyroxine sodium is used for the following indications:

Hypothyroidism—As replacement or supplemental therapy in congenital or acquired hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis. Specific indications include: primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) hypothyroidism and subclinical hypothyroidism. Primary hypothyroidism may result from functional deficiency, primary atrophy, partial or total congenital absence of the thyroid gland, or from the effects of surgery, radiation, or drugs, with or without the presence of goiter.

Pituitary TSH Suppression—In the treatment or prevention of various types of euthyroid goiters (see PRECAUTIONS), including thyroid nodules (see PRECAUTIONS), subacute or chronic Iymphocytic thyroiditis (Hashimoto's thyroiditis), multinodular goiter and, as an adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer.

General Principles:

The goal of replacement therapy is to achieve and maintain a clinical and biochemical euthyroid state. The goal of suppressive therapy is to inhibit growth and/or function of abnormal thyroid tissue. The dose of UNITHROID that is adequate to achieve these goals depends on a variety of factors including the patient's age, body weight, cardiovascular status, concomitant medical conditions, including pregnancy, concomitant medications, and the specific nature of the condition being treated (see PRECAUTIONS). Hence, the following recommendations serve only as dosing guidelines. Dosing must be individualized and adjustments made based on periodic assessment of the patient's clinical response and laboratory parameters (see PRECAUTIONS, Laboratory Tests).

UNITHROID is administered as a single daily dose, preferably one-half to one-hour before breakfast. UNITHROID should be taken at least 4 hours apart from drugs that are known to interfere with its absorption (see PRECAUTIONS, Drug Interactions).

Due to the long half-life of levothyroxine, the peak therapeutic effect at a given dose of levothyroxine may not be attained for 4-6 weeks.

Caution should be exercised when administering UNITHROID to patients with underlying cardiovascular disease, to the elderly, and to those with concomitant adrenal insufficiency (see PRECAUTIONS).

Specific Patient Populations:

Hypothyroidism in Adults and in Children in Whom Growth and Puberty are Complete (see PRECAUTIONS, Laboratory Tests).

Therapy may begin at full replacement doses in otherwise healthy individuals less than 50 years old and in those older than 50 years who have been recently treated for hyperthyroidism or who have been hypothyroid for only a short time (such as a few months). The average full replacement dose of levothyroxine is approximately 1.7 mcg/kg/day (e.g., 100-125 mcg/day for a 70 kg adult). Older patients may require less than 1 mcg/kg/day. Levothyroxine doses greater than 200 mcg/day are seldom required. An inadequate response to daily doses ≥ 300 mcg/day is rare and may indicate poor compliance, malabsorption, and/or drug interactions.

For most patients older than 50 years or for patients under 50 years of age with underlying cardiac disease, an initial starting dose of 25-50 mcg/day of levothyroxine is recommended, with gradual increments in dose at 6-8 week intervals. The recommended starting dose of levothyroxine in elderly patients with cardiac disease is 12.5-25 mcg/day, with gradual dose increments at 4-6 week intervals. The levothyroxine dose is generally adjusted in 12.5-25 mcg increments until the patient with primary hypothyroidism is clinically euthyroid and the serum TSH has normalized.

In patients with severe hypothyroidism, the recommended initial levothyroxine dose is 12.5-25 mcg/day with increases of 25 mcg/day every 2-4 weeks, accompanied by clinical and laboratory assessment, until the TSH level is normalized.

In patients with secondary (pituitary) or tertiary (hypothalamic) hypothyroidism, the levothyroxine dose should be titrated until the patient is clinically euthyroid and the serum free-T₄ level is restored to the upper half of the normal range.

Pediatric Dosage—Congenital or Acquired Hypothyroidism (see PRECAUTIONS, Laboratory Tests)

General Principles

In general, levothyroxine therapy should be instituted at full replacement doses as soon as possible. Delays in diagnosis and institution of therapy may have deleterious effects on the child's intellectual and physical growth and development.

Undertreatment and overtreatment should be avoided (see PRECAUTIONS, Pediatric Use). UNITHROID may be administered to infants and children who cannot swallow intact tablets by crushing the tablet and suspending the freshly crushed tablet in a small amount (5-10 mL or 1-2 teaspoons) of water. This suspension can be administered by spoon or dropper.

DO NOT STORE THE SUSPENSION.

Foods that decrease absorption of levothyroxine such as soybean infant formula, should not be used for administering levothyroxine. (see PRECAUTIONS, Drug-Food Interactions).

Newborns

The recommended starting dose of levothyroxine in newborn infants is 10-15 mcg/kg/day. A lower starting dose (e.g., 25 mcg/day) should be considered in infants at risk for cardiac failure, and the dose should be increased in 4-6 weeks as needed based on clinical and laboratory response to treatment. In infants with very low (< 5 mcg/dl) or undetectable serum T₄ concentrations, the recommended initial starting dose is 50 mcg/day of levothyroxine.

Infants and Children

Levothyroxine therapy is usually initiated at full replacement doses, with the recommended dose per body weight decreasing with age (see TABLE 3). However, in children with chronic or severe hypothyroidism, an initial dose of 25 mcg/day of levothyroxine is recommended with increments of 25 mcg every 2-4 weeks until the desired effect is achieved.

Hyperactivity in an older child can be minimized if the starting dose is one-fourth of the recommended full replacement dose, and the dose is then increased on a weekly basis by an amount equal to one-fourth the full recommended replacement dose until the full recommended replacement dose is reached.

Table 3: Levothyroxine Dosing Guidelines for Pediatric Hypothyroidism
AGE	Daily Dose Per Kg Body Weighta
0-3 months	10-15 mcg/kg/day
3-6 months	8-10 mcg/kg/day
6-12 months	6-8 mcg/kg/day
1-5 years	5-6 mcg/kg/day
6-12 years	4-5 mcg/kg/day
>12 years	2-3 mcg/kg/day
Growth and puberty complete	1.7 mcg/kg/day
a The dose should be adjusted based on clinical response and laboratory parameters (see PRECAUTlONS, Laboratory Tests and Pediatric Use).

Pregnancy—Pregnancy may increase levothyroxine requirements (see PREGNANCY). Subclinical Hypothyroidism—If this condition is treated, lower levothyroxine doses (e.g. 1 mcg/kg/day) than that used for full replacement may be adequate to normalize the serum TSH level. Patients who are not treated should be monitored yearly for changes in clinical status and thyroid laboratory parameters.

TSH Suppression in Well-differentiated Thyroid Cancer and Thyroid Nodules—

Levothyroxine is used as an adjunct to surgery and radioiodine therapy in the treatment of well-differentiated (papillary and follicular) thyroid cancer. Generally, TSH is suppressed to <0.1 mU/L, and this usually requires a levothyroxine dose of greater than 2 mcg/kg/day. In the treatment of benign nodules and nontoxic multinodular goiter, TSH is generally suppressed to a higher target (0.1-0.3 mU/L) than that used for the treatment of thyroid cancer. Exercise caution when administering levothyroxine to patients with autonomous thyroid tissue (see PRECAUTIONS).

Myxedema Coma—Myxedema coma is a life-threatening emergency characterized by poor circulation and hypometabolism, and may result in unpredictable absorption of levothyroxine sodium from the gastrointestinal tract. Therefore, oral levothyroxine is not recommended to treat this condition. Intravenous levothyroxine sodium should be administered.

UNITHROID™ (levothyroxine sodium tablets, USP ) are round, color coded, partial bisected tablets debossed with JSP and ID Number:

Strength (mcg)	Color	NDC# for bottles of 100	NDC# for bottles of 1000
25	Peach	NDC 52544-902-01	NDC 52544-902-10
50	White	NDC 52544-903-01	NDC 52544-903-10
75	Purple	NDC 52544-904-01	NDC 52544-904-10
88	Olive	NDC 52544-905-01	NDC 52544-905-10
100	Yellow	NDC 52544-906-01	NDC 52544-906-10
112	Rose	NDC 52544-907-01	NDC 52544-907-10
125	Tan	NDC 52544-908-01	NDC 52544-908-10
150	Blue	NDC 52544-909-01	NDC 52544-909-10
175	Lilac	NDC 52544-910-01	NDC 52544-910-10
200	Pink	NDC 52544-911-01	NDC 52544-911-10
300	Green	NDC 52544-912-01	NDC 52544-912-10

STORAGE CONDITIONS

20°C to 25°C (68°F to 77° F) with excursions between 15°C to 30°C (59°F to 86° F)

Manufactured for: Watson Pharma, Inc.,A Subsidiary of Watson Laboratories, Inc.

Corona, CA 92880

Manufactured by: Jerome Stevens Pharmaceuticals, Inc., Bohemia, NY 11716

Rev. 10/00

Last updated on RxList: 3/10/2008

Adverse reactions associated with levothyroxine therapy are primarily those of hyperthyroidism due to therapeutic overdosage. They include the following:

General: fatigue, increased appetite, weight loss, heat intolerance, fever, excessive sweating;

Central nervous system: headache, hyperactivity, nervousness, anxiety, irritability, emotional lability, insomnia;

Musculoskeletal: tremors, muscle weakness;

Cardiac: palpitations, tachycardia, arrhythmias, increased pulse and blood pressure, heart failure, angina, myocardial infarction, cardiac arrest;

Pulmonary: dyspnea;

Gl: diarrhea, vomiting, abdominal cramps;

Dermatologic: hair loss;

Reproductive: menstrual irregularities, infertility.

Pseudotumor cerebri has been reported in children receiving levothyroxine therapy. Seizures have been reported rarely with the institution of levothyroxine therapy. Inadequate levothyroxine dosage will produce or fail to ameliorate the signs and symptoms of hypothyroidism.

Hypersensitivity reactions to inactive ingredients have occurred in patients treated with thyroid hormone products. These include urticaria, pruritus, skin rash, flushing, angioedema, various Gl symptoms (abdominal pain, nausea, vomiting and diarrhea), fever, arthralgia, serum sickness and wheezing. Hypersensitivity to levothyroxine itself is not known to occur.

Many drugs affect thyroid hormone pharmacokinetics and metabolism (e.g., absorption, synthesis, secretion, catabolism, protein binding, and target tissue response) and may alter the therapeutic response to UNITHROID. In addition, thyroid hormones and thyroid status have varied effects on the pharmacokinetics and action of other drugs. A listing of drug-thyroidal axis interactions is contained in Table 2.

The list of drug-thyroidal axis interactions in Table 2 may not be comprehensive due to the introduction of new drugs that interact with the thyroidal axis or the discovery of previously unknown interactions. The prescriber should be aware of this fact and should consult appropriate reference sources (e.g., package inserts of newly approved drugs, medical literature) for additional information if a drug-drug interaction with levothyroxine is suspected.

Table 2: Drug-Thyroidal Axis Interactions
Drug or Drug Class	Effect
Drugs that may reduce TSH secretion - the reduction is not
sustained; therefore, hypothyroidism does not occur
Dopamine/Dopamine Agonists Glucocorticoids Octreotide	Use of these agents may result in a transient reduction in TSH secretion when administered at the following doses: dopamine ( ≥ 1µg/kg/min); Glucocorticoids (hydrocortisone ≥ 100 mg/day or equivalent); Octreotide ( > 100 ug/day).
Drugs that alter thyroid hormone secretion
Drugs that may decrease thyroid hormone secretion, which may result in hypothyroidism
Aminoglutethimide Amiodarone Iodide (including iodine- containing radiographic contrast agents) Lithium Methimazole Propylthioracil (PTU) Sulfonamides Tolbutamide	Long-term lithium therapy can result in goiter in up to 50% of patients, and either subclinical or overt hypothyroidism, each in up to 20% of patients. The fetus, neonate, elderly and euthyroid patients with underlying thyroid disease (e.g., Hashimotos thyroiditis or with Graves disease previously treated with radioiodine or surgery) are among those individuals who are particularly susceptible to iodine- induced hypothyroidism. Oral cholecystographic agents and amiodarone are slowly excreted, producing more prolonged hypothyroidism than parenterally administered iodinated contrast agents. Long-term aminoglutethimide therapy may minimally decrease T4 and T3 levels and increase TSH, although all values remain within normal limits in most patients.
Drugs that may increase thyroid hormone secretion, which may result in hyperthyroidism
Amiodarone Iodide (including iodine-containing radiographic contrast agents)	Iodide and drugs that contain pharmacologic amounts of iodide may cause hypothyroidism in euthyroid patients with Graves disease previously treated with antithyroid drugs or in euthyroid patients with thyroid autonomy (e.g., multinodular goiter or hyperfunctioning thyroid adenoma). Hyperthyroidism may develop over several weeks and may persist for several months after therapy discontinuation. Amiodarone may induce hyperthyroidism by causing thyroiditis.
Drugs that may decrease T4 absorption, which may result in hypothyroidism
Antacids —Aluminum & Magnesium Hydroxides —Simethicone Bile Acid Sequestrants —Cholestyramine —Colestipol Calcium Carbonate Cation Exchange Resins —Kayexalate Ferrous Sulfate Sucralfate	Concurrent use may reduce the efficacy of levothyroxine by binding and delaying or preventing absorption, potentially resulting in hypothyroidism. Calcium carbonate may form an insoluble chelate with levothyroxine, and ferrous sulfate likely forms a ferric-thyroxine complex. Administer levothyroxine at least 4 hours apart from these agents.
Drugs that may alter T4 and T3 serum transport (changes in total T4) - but FT4 concentrations remain normal; and, therefore, hyperthyroidism does not occur
Drugs that may increase serum TBG concentration	Drugs that may decrease serum TBG concentration
Clofibrate Estrogen-containing oral contraceptives Estrogens (oral) Heroin / Methadone 5-Fluorouracil Mitotane Tamoxifen	Androgens / Anabolic Steroids Asparaginase Glucocorticoids Slow-Release Nicotinic Acid
Drugs that may cause protein-binding site displacement
Furosemide ( > 80 mg IV) Heparin Hydantoins Non Steroidal Anti-lnflammatory Drugs —Fenamates —Phenylbutazone Salicylates ( > 2 g/day)	Administration of these agents with levothyroxine results in an initial transient increase in FT4. Continued administration results in a decrease in serum T4 and normal FT4 and TSH concentrations and, therefore, patients are clinically euthyroid. Salicylates inhibit binding of T4 and T3 to TBG and transthyretin. An initial increase in serum FT4, is followed by return of FT4 to normal levels with sustained therapeutic serum salicylate concentrations, although total-T4 levels may decrease by as much as 30%.
Drugs that may alter T4 and T3 metabolism
Drugs that may increase hepatic metabolism, which may result in hypothyroidism
Carbamazepine Hydantoins Phenobarbital Rifampin	Stimulation of hepatic microsomal drug-metabolizing enzyme activity may cause increased hepatic degradation of levothyroxine, resulting in increased Ievothyroxine requirements. Phenytoin and carbamazepine reduce serum protein binding of levothyroxine, and total- and free-T4 may be reduced by 20% to 40%, but most patients have normal serum TSH levels and are clinically euthyroid.
Drugs that may decrease T4 5 - deiodinase activity
Amiodarone Beta-adrenergic antagonists —(e.g., Propranolol > 160 mg/day) Glucocorticoids —(e.g., Dexamethasone ≥ 4 mg/day) Propylthiouracil (PTU)	Administration of these enzyme inhibitors decrease the peripheral conversion of T4 to T3, Ieading to decreased T3 levels. However, serum T4 levels are usually normal but may occasionally be slightly increased. In patients treated with large doses of propranolol ( > 160 mg/day), T3 and T4 levels change slightly, TSH levels remain normal, and patients are clinically euthyroid. It should be noted that actions of particular beta-adrenergic antagonists may be impaired when the hypothyroid patient is converted to the euthyroid state. Short-term administration of large doses of gluco- corticoids may decrease serum T3 concentrations by 30% with minimal change in serum T4 levels. However, long- term glucocorticoid therapy may result in slightly decreased T3 and T4 levels due to decreased TBG production (see above).
Miscellaneous
Anticoagulants (oral) —Coumarin Derivatives —Indandione Derivatives		Thyroid hormones appear to increase the catabolism of vitamin K-dependent clotting factors, thereby increasing the anticoagulant activity of oral anticoagulants. Concomitant use of these agents impairs the compensatory increases in clotting factor synthesis. Prothrombin time should be carefully monitored in patients taking levothyroxine and oral anticoagulants and the dose of anticoagulant therapy adjusted accordingly.
Antidepressants —Tricyclics (e.g., Amitriptyline) —Tetracyclics (e.g., Maprotiline) —Selective Serotonin Reuptake Inhibitors (SSRls; e.g., Sertraline)		Concurrent use of tri/tetracyclic antidepressants and levothyroxine may increase the therapeutic and toxic effects of both drugs, possibly due to increased receptor sensitivity to catecholamines. Toxic effects may include increased risk of cardiac arrhythmias and CNS stimulation; onset of action of tricyclics may be accelerated. Administration of sertraline in patients stabilized on levothyroxine may result in increased levothyroxine requirements.
Antidiabetic Agents —Biguanides —Meglitinides Sulfonylureas Thiazolidediones Insulin		Addition of levothyroxine to antidiabetic or insulin therapy may result in increased antidiabetic agent or insulin requirements. Careful monitoring of diabetic control is recommended, especially when thyroid therapy is started, changed, or discontinued.
Cardiac Glycosides		Serum digitalis glycoside levels may be reduced in hyper-thyroidism or when the hypothyroid patient is converted to the euthyroid state. Therapeutic effect of digitalis glycosides may be reduced.
Cytokines —Interferon- Interleukin-2		Therapy with interferona has been associated with the development of antithyroid microsomal antibodies in 20% of patients and some have transient hypothyroidism, hyperthyroidism, or both. Patients who have antithyroid antibodies before treatment are at higher risk for thyroid dysfunction during treatment. Interleukin-2 has been associated with transient painless thyroiditis in 20% of patients. Interferon- b and g have not been reported to cause thyroid dysfunction.
Growth Hormones —Somatrem —Somatropin		Excessive use of thyroid hormones with growth hormones may accelerate epiphyseal closure. However, untreated hypothyroidism may interfere with growth response to growth hormone.
Ketamine		Concurrent use may produce marked hypertension and tachycardia; cautious administration to patients receiving thyroid hormone therapy is recommended.
Methylxanthine Bronchodilators —(e.g., Theophylline)		Decreased theophylline clearance may occur in hypo-thyroid patients; clearance returns to normal when the euthyroid state is achieved.
Radiographic Agents		Thyroid hormones may reduce the uptake of 123I, 131I, and 99mTc.
Sympathomimetics		Concurrent use may increase the effects of sympatho-Mimetics or thyroid hormone. Thyroid hormones May increase the risk of coronary insufficiency when Sympathomimetic agents are administered to patients With coronary artery disease.
Chloral Hydrate Diazepam Ethionamide Lovastatin Metoclopramide 6-ercaptopurine Nitroprusside Para-aminosalicylate sodium Perphenazine Resorcinol(excessivetopical use) Thiazide Diuretics		These agents have been associated with thyroid hormone and/or TSH level alterations by various mechanisms.

Oral anticoagulantsLevothyroxine increases the response to oral anticoagulant therapy. Therefore, a decrease in the dose of anticoagulant may be warranted with correction of the hypothyroid state or when the UNITHROID dose is increased. Prothrombin time should be closely monitored to permit appropriate and timely dosage adjustments (see Table 2). Digitalis glycosides—The therapeutic effects of digitalis glycosides may be reduced by levothyroxine. Serum digitalis glycoside levels may be decreased when a hypothyroid patient becomes euthyroid, necessitating an increase in the dose of digitalis glycosides (see Table 2).

Drug-Food Interactions—Consumption of certain foods may affect levothyroxine absorption thereby necessitating adjustments in dosing. Soybean flour (infant formula), cotton seed meal, walnuts, and dietary fiber may bind and decrease the absorption of levothyroxine sodium from the Gl tract.

Drug-Laboratory Test Interactions—Changes in TBG concentration must be considered when interpreting T₄ and T₃ values, which necessitates measurement and evaluation of unbound (free) hormone and/or determination of the free T₄ index (FT4I). Pregnancy, infectious hepatitis, estrogens, estrogen-containing oral contraceptives, and acute intermittent porphyria increase TBG concentrations. Decreases in TBG concentrations are observed in nephrosis, severe hypoproteinemia, severe liver disease, acromegaly, and after androgen or corticosteroid therapy (see also Table 2). Familial hyper- or hypo-thyroxine binding globulinemias have been described, with the incidence of TBG deficiency approximating 1 in 9000.

Carcinogenesis, Mutagenesis, and Impairment of Fertility—Animal studies have not been performed to evaluate the carcinogenic potential, mutagenic potential or effects on fertility of levothyroxine. The synthetic T₄ in UNITHROID is identical to that produced naturally by the human thyroid gland. Although there has been a reported association between prolonged thyroid hormone therapy and breast cancer, this has not been confirmed. Patients receiving UNITHROID for appropriate clinical indications should be titrated to the lowest effective replacement dose.

PregnancyCategory A—Studies in women taking levothyroxine sodium during pregnancy have not shown an increased risk of congenital abnormalities. Therefore, the possibility of fetal harm appears remote. UNITHROID should not be discontinued during pregnancy and hypothyroidism diagnosed during pregnancy should be promptly treated.

Hypothyroidism during pregnancy is associated with a higher rate of complications, including spontaneous abortion, pre-eclampsia, stillbirth and premature delivery. Maternal hypothyroidism may have an adverse effect on fetal and childhood growth and development.

During pregnancy, serum T₄ levels may decrease and serum TSH levels increase to values outside the normal range. Since elevations in serum TSH may occur as early as 4 weeks gestation, pregnant women taking UNITHROID should have their TSH measured during each trimester. An elevated serum TSH level should be corrected by an increase in the dose of UNITHROID. Since postpartum TSH levels are similar to preconception values, the UNITHROID dosage should return to the pre-pregnancy dose immediately after delivery. A serum TSH level should be obtained 6-8 weeks postpartum.

Thyroid hormones do not readily cross the placental barrier; however, some transfer does occur as evidenced by levels in cord blood of athyroceotic fetuses being approximately one-third maternal levels. Transfer of thyroid hormone from the mother to the fetus; however, may not be adequate to prevent in utero hypothyroidism.

Nursing Mothers—Although thyroid hormones are excreted only minimally in human milk, caution should be exercised when UNITHROID is administered to a nursing woman. However, adequate replacement doses of levothyroxine are generally needed to maintain normal lactation.

Pediatric Use

General

The goal of treatment in pediatric patients with hypothyroidism is to achieve and maintain normal intellectual and physical growth and development.

The initial dose of levothyroxine varies with age and body weight (see DOSAGE AND ADMINISTRATION, Table 3). Dosing adjustments are based on an assessment of the individual patients clinical and laboratory parameters (see PRECAUTIONS, Laboratory Tests).

In children in whom a diagnosis of permanent hypothyroidism has not been established, it is recommended that levothyroxine administration be discontinued for a 30-day trial period, but only after the child is at least 3 years of age. Serum T₄ and TSH levels should then be obtained. If the T₄ is low and the TSH high, the diagnosis of permanent hypothyroidism is established, and levothyroxine therapy should be reinstituted. If the T₄

and TSH are normal, euthyroidism may be assumed and, therefore, the hypothyroidism can be considered to have been transient. In this instance, however, the physician should carefully monitor the child and repeat the thyroid function tests if any signs or symptoms of hypothyroidism develop. In this setting, the clinician should have a high index of suspicion of relapse. If the results of the levothyroxine withdrawal test are inconclusive, careful follow-up and subsequent testing will be necessary.

Since some more severely affected children may become clinically hypothyroid when treatment is discontinued for 30 days, an alternate approach is reduce the replacement dose of levothyroxine by half during the 30-day trial period. If, after 30 days, the serum TSH is elevated above 20 mU/L, the diagnosis permanent hypothyroidism is confirmed and full replacement therapy should be resumed. However, if the serum TSH has not risen to greater than 20 mU/L, levothyroxine treatment should be discontinued for another 30-day trial period followed by repeat serum T₄ and TSH.

The presence of concomitant medical conditions should be considered in certain clinical circumstances and, if present, appropriately treated (see PRECAUTIONS).

Congenital Hypothyroidism (see PRECAUTIONS, Laboratory Tests and DOSAGE AND ADMINISTRATION)

Rapid restoration of normal serum T₄ concentrations is essential for preventing the adverse effects of congenital hypothyroidism on intellectual development as well as on overall physical growth and maturation. Therefore, UNITHROID therapy should be initiated immediately upon diagnosis and is generally continued for life.

During the first 2 weeks of UNITHROID therapy, infants should be closely monitored for cardiac overload, arrhythmias, and aspiration from avid suckling.

The patient should be monitored closely to avoid undertreatment or overtreatment. Undertreatment may have deleterious effects on intellectual development and linear growth. Overtreatment has been associated with craniosynostosis in infants, and may adversely affect the tempo of brain maturation and accelerate the bone age with resultant premature closure of the epiphyses and compromised adult stature.

Acquired Hypothyroidism in Pediatric Patients

The patient should be monitored closely to avoid undertreatment and overtreament. Undertreatment may result in poor school performance due to impaired concentration and slowed mentation and in reduced adult height. Overtreatment may accelerate the bone age and result in premature epiphyseal closure and compromised adult stature.

Treated children may manifest a period of catch-up growth, which may be adequate in some cases to normalize adult height. In children with severe or prolonged hypothyroidism, catch-up growth may not be adequate to normalize adult height.

Geriatric Use

Because of the increased prevalence of cardiovascular disease among the elderly, levothyroxine therapy should not be initiated at the full replacement dose (see PRECAUTIONS and DOSAGE AND ADMINISTRATION).

Last updated on RxList: 3/10/2008

Levothyroxine sodium should not be used in the treatment of male or female infertility unless this condition is associated with hypothyroidism.

General

Levothyroxine has a narrow therapeutic index. Regardless of the indication for use, careful dosage titration is necessary to avoid the consequences of over- or under-treatment. These consequences include, among others, effects on growth and development, cardiovascular function, bone metabolism, reproductive function, cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism.

Effects on bone mineral densityIn women, long-term levothyroxine sodium therapy has been associated with decreased bone mineral density, especially in postmenopausal women on greater than replacement doses or in women who are receiving suppressive doses of levothyroxine sodium. Therefore, it is recommended that patients receiving levothyroxine sodium be given the minimum dose necessary to achieve the desired clinical and biochemical response.

Patients with underlying cardiovascular diseaseExercise caution when administering levothyroxine to patients with cardiovascular disorders and to the elderly in whom there is an increased risk of occult cardiac disease. In these patients, levothyroxine therapy should be initiated at lower doses than those recommended in younger individuals or in patients without cardiac disease (see PRECAUTIONS, Geriatric Use and DOSAGE AND ADMINISTRATION). If cardiac symptoms develop or worsen, the levothyroxine dose should be reduced or withheld for one week and then cautiously restated at a lower dose. Overtreatment with levothyroxine sodium may have adverse cardiovascular effects such as an increase in heart rate, cardiac wall thickness, and cardiac contractility and may precipitate angina or arrhythmias. Patients with coronary artery disease who are receiving levothyroxine therapy should be monitored closely during surgical procedures, since the possibility of precipitating cardiac arrhythmias may be greater in those treated with levothyroxine. Concomitant administration of levothyroxine and sympathomimetic agents to patients with coronary artery disease may precipitate coronary insufficiency.

Patients with autonomous thyroid tissueExercise caution when administering levothyroxine to patients with autonomous thyroid tissue in order to prevent precipitation of thyrotoxicosis.

Associated endocrine disorders

Hypothalamic/pituitary hormone deficienciesIn patients with secondary or tertiary hypothyroidism, additional hypothalamic/pituitary hormone deficiencies should be considered, and, if diagnosed, treated (see PRECAUTIONS, Autoimmune polyglandular syndrome for adrenal insufficiency).

Autoimmune polyglandular syndromeOccasionally, chronic autoimmune thyroiditis may occur in association with other autoimmune disorders such as adrenal insufficiency, pernicious anemia, and insulin-dependent diabetes mellitus. Patients with concomitant adrenal insufficiency should be treated with replacement glucocorticoids prior to initiation of treatment with levothyroxine sodium. Failure to do so may precipitate an acute adrenal crisis when thyroid hormone therapy is initiated, due to increased metabolic clearance of glucocorticoids by thyroid hormone. Patients with diabetes mellitus may require upward adjustments of their antidiabetic therapeutic regimens when treated with levothyroxine (see PRECAUTIONS, Drug Interactions).

Other associated medical conditions

Infants with congenital hypothyroidism appear to be at increased risk for other congenital anomalies, with cardiovascular anomalies (pulmonary stenosis, atrial septal defect, and ventricular septal defect,) being the most common association.

Last updated on RxList: 3/10/2008

The signs and symptoms of overdosage are those of hyperthyroidism (see PRECAUTIONS and ADVERSE REACTIONS). In addition, confusion and disorientation may occur. Cerebral embolism, shock, coma, and death have been reported. Seizures have occurred in a child ingesting approximately 20 mg of levothyroxine. Symptoms may not necessarily be evident or may not appear until several days after ingestion of levothyroxine sodium.

Acute Massive Overdosage—This may be a life-threatening emergency, therefore, symptomatic and supportive therapy should be instituted immediately. If not contraindicated (e.g., by seizures, coma, or loss of the gag reflex), the stomach should be emptied by emesis or gastric lavage to decrease gastrointestinal absorption. Activated charcoal or cholestyramine may also be used to decrease absorption. Central and peripheral increased sympathetic activity may be treated by administering -receptor antagonists, e.g., propranolol (1 to 3 mg intravenously over a 10 minute period, or orally, 80 to 160 mg/day). Provide respiratory support as needed; control congestive heart failure; control fever, hypoglycemia, and fluid loss as necessary. Glucocorticoids may be given to inhibit the conversion of T₄ to T₃. Because T₄ is highly protein bound, very little drug will be removed by dialysis.

 

Levothyroxine is contraindicated in patients with untreated thyrotoxicosis of any etiology and in patients with acute myocardial infarction. Levothyroxine is contraindicated in patients with uncorrected adrenal insufficiency since thyroid hormones may precipitate an acute adrenal crisis by increasing the metabolic clearance of glucocorticoids (see PRECAUTIONS). UNITHROID is contraindicated in patients with hypersensitivity to any of the inactive ingredients in UNITHROID tablets. (See DESCRIPTION, Inactive Ingredients).

Last updated on RxList: 12/8/2004

Thyroid hormone synthesis and secretion is regulated by the hypothalamic-pituitary-thyroid axis. Thyrotropin-releasing hormone (TRH) released from the hypothalamus stimulates secretion of thyrotropin-stimulating hormone, TSH, from the anterior pituitary. TSH, in turn, is the physiologic stimulus for the synthesis and secretion of thyroid hormones, L-thyroxine (T₄) and L-triiodothyronine (T₃), by the thyroid gland. Circulating serum T₃ and T₄ levels exert a feedback effect on both TRH and TSH secretion. When serum T₃ and T₄ levels increase, TRH and TSH secretion decrease. When thyroid hormone levels decrease, TRH and TSH secretion increase.

The mechanisms by which thyroid hormones exert their physiologic actions are not completely understood, but it is thought that their principal effects are exerted through control of DNA transcription and protein synthesis. T₃ and T₄ diffuse into the cell nucleus and bind to thyroid receptor proteins attached to DNA. This hormone nuclear receptor complex activates gene transcription and synthesis of messenger RNA and cytoplasmic proteins. Thyroid hormones regulate multiple metabolic processes and play an essential role in normal growth and development, and normal maturation of the central nervous system and bone. The metabolic actions of thyroid hormones include augmentation of cellular respiration and thermogenesis, as well as metabolism of proteins, carbohydrates and lipids. The protein anabolic effects of thyroid hormones are essential to normal growth and development.

The physiologic actions of thyroid hormones are produced predominately by T₃, the majority of which (approximately 80%) is derived from T₄ by deiodination in peripheral tissues.

Levothyroxine, at doses individualized according to patient response, is effective as replacement or supplemental therapy in hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis.

Levothyroxine is also effective in the suppression of pituitary TSH secretion in the treatment or prevention of various types of euthyroid goiters, including thyroid nodules, Hashimotos thyroiditis, multinodular goiter and, as adjunctive therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer (see INDICATIONS AND USAGE, PRECAUTIONS, DOSAGE AND ADMINISTRATION).

PHARMACOKINETICS

AbsorptionAbsorption of orally administered T₄ from the gastrointestinal (GI) tract ranges from 40% to 80%. The majority of the levothyroxine dose is absorbed from the jejunum and upper ileum. The relative bioavailability of UNITHROID tablets, compared to an equal nominal dose of oral levothyroxine sodium solution, is approximately 99%. T₄ absorption is increased by fasting, and decreased in malabsorption syndromes and by certain foods such as soybean infant formula. Dietary fiber decreases bioavailability of T₄. Absorption may also decrease with age. In addition, many drugs and foods affect T₄ absorption (see PRECAUTIONS, Drug Interactions and Drug-Food Interactions).

DistributionCirculating thyroid hormones are greater than 99% bound to plasma proteins, including thyroxine-binding globulin (TBG), thyroxine-binding prealbumin (TBPA), and albumin (TBA), whose capacities and affinities vary for each hormone. The higher affinity of both TBG and TBPA for T₄ partially explains the higher serum levels, slower metabolic clearance, and longer half-life of T₄ compared to T₃. Protein-bound thyroid hormones exist in reverse equilibrium with small amounts of free hormone. Only unbound hormone is metabolically active. Many drugs and physiologic conditions affect the binding of thyroid hormones to serum proteins (see PRECAUTIONS, Drug Interactions and Drug-Laboratory Test Interactions). Thyroid hormones do not readily cross the placental barrier (see PRECAUTIONS, Pregnancy).

Metabolism—T₄ is slowly eliminated (see TABLE 1). The major pathway of thyroid hormone metabolism is through sequential deiodination. Approximately eighty-percent of circulating T₃ is derived from peripheral T₄ by monodeiodination. The liver is the major site of degradation for both T₄ and T₃; with T₄ deiodination also occurring at a number of additional sites, including the kidney and other tissues. Approximately 80% of the daily dose of T₄ is deiodinated to yield equal amounts of T₃ and reverse T₃ (rT₃). T₃ and rT₃ are further deiodinated to diiodothyronine. Thyroid hormones are also metabolized via conjugation with glucuronides and sulfates and excreted directly into the bile and gut where they undergo enterohepatic recirculation.

EliminationThyroid hormones are primarily eliminated by the kidneys. A portion of the conjugated hormone reaches the colon unchanged and is eliminated in the feces.

Approximately 20% of T₄ is eliminated in the stool. Urinary excretion of T₄ decreases with age.

Table 1: Pharmacokinetic Parameters of Thyroid Hormones in Euthyroid Patients
Hormone	Ratio Released from Thyroid Gland	Biologic Potency	T1/2 (days)	Protein Binding (%)2
Levothyroxine (T4)	20	1	6-71	99.96
Liothyronine (T3)	1	4	≤2	99.5
1 3 to 4 days in hyperthyroidism, 9 to 10 days in hypothyroidism;
2 Includes TBG, TBPA, and TBA

 

Last updated on RxList: 12/8/2004

Patients should be informed of the following information to aid in the safe and effective use of UNITHROID:

1. Notify your physician if you are allergic to any foods or medicines, are pregnant or intend to become pregnant, are breast-feeding or are taking any other medications, including prescription and over-the-counter preparations.

2. Notify your physician of any other medical conditions you may have, particularly heart disease, diabetes, clotting disorders, and adrenal or pituitary gland problems. Your dose of medications used to control these other conditions may need to be adjusted while you are taking UNITHROID. If you have diabetes, monitor your blood and/or urinary glucose levels as directed by your physician and immediately report any changes to your physician. If you are taking anticoagulants (blood thinners), your clotting status should be checked frequently.

3. Use UNITHROID only as prescribed by your physician. Do not discontinue or change the amount you take or how often you take it, unless directed to do so by your physician. 4. The levothyroxine in UNITHROID is intended to replace a hormone that is normally produced by your thyroid gland. Generally, replacement therapy is to be taken for life, except in cases of transient hypothyroidism, which is usually associated with an inflammation of the thyroid gland (thyroiditis).

5. Take UNITHROID as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. Levothyroxine absorption is increased on an empty stomach.

6. It may take several weeks before you notice an improvement in your symptoms.

7. Notify your physician if you experience any of the following symptoms: rapid or irregular heartbeat, chest pain, shortness of breath, leg cramps, headache, nervousness, irritability, sleeplessness, tremors, change in appetite, weight gain or loss, vomiting, diarrhea, excessive sweating, heat intolerance, fever, changes in menstrual periods, hives or skin rash, or any other unusual medical event.

8. Notify your physician if you become pregnant while taking UNITHROID. It is likely that your dose of UNITHROID will need to be increased while you are pregnant.

9. Notify your physician or dentist that you are taking UNITHROID prior to any surgery. 10. Partial hair loss may occur rarely during the first few months of UNITHROID therapy, but this is usually temporary.

11. UNITHROID should not be used as a primary or adjunctive therapy in a weight control program.

12. Keep UNITHROID out of the reach of children. Store UNITHROID away from heat, moisture, and light.

Laboratory Tests General

The diagnosis of hypothyroidism is confirmed by measuring TSH levels using a sensitive assay (second generation assay sensitivity ≤0.1 mlU/L or third generation assay sensitivity ≤0.01 mlU/L) and measurement of free-T₄.

The adequacy of therapy is determined by periodic assessment of appropriate laboratory tests and clinical evaluation. The choice of laboratory tests depends on various factors including the etiology of the underlying thyroid disease, the presence of concomitant medical conditions, including pregnancy, and the use of concomitant medications (see PRECAUTIONS, Drug Interactions and Drug-Laboratory Test Interactions). Persistent clinical and laboratory evidence of hypothyroidism despite an apparent adequate replacement dose of UNITHROID may be evidence of inadequate absorption, poor compliance, drug interactions, or decreased T₄ potency of the drug product.

Adults

In adult patients with primary (thyroidal) hypothyroidism, serum TSH levels (using a sensitive assay) alone may be used to monitor therapy. The frequency of TSH monitoring during levothyroxine dose titration depends on the clinical situation but it is generally recommended at 6-8 week intervals until normalization. For patients who have recently initiated levothyroxine therapy and whose serum TSH has normalized or in patients who have had their dosage or brand of levothyroxine changed, the serum TSH concentration should be measured after 8-12 weeks. When the optimum replacement dose has been attained, clinical (physical examination) and biochemical monitoring may be performed every 6-12 months, depending on the clinical situation, and whenever there is a change in the patient's status. It is recommended that a physical examination and a serum TSH measurement be performed at least annually in patients receiving UNITHROID. (see PRECAUTIONS and DOSAGE AND ADMINISTRATION). Pediatrics

In patients with congenital hypothyroidism, the adequacy of replacement therapy should be assessed by measuring both serum TSH (using a sensitive assay) and total- or free-T₄. During the first three years of life, the serum total- or free-T₄ should be maintained at all times in the upper half of the normal range. While the aim of therapy is to also normalize the serum TSH level, this is not always possible in a small percentage of patients, particularly in the first few months of therapy. TSH may not normalize due to a resetting of the pituitary-thyroid feedback threshold as a result of in utero hypothyroidism. Failure of the serum T₄ to increase into the upper half of the normal range within 2 weeks of initiation of UNITHROID therapy and/or of the serum TSH to decrease below 20 mU/L within 4 weeks should alert the physician to the possibility that the child is not receiving adequate therapy. Careful inquiry should then be made regarding compliance, dose of medication administered, and method of administration prior to raising the dose of UNlTHROID.

The recommended frequency of monitoring of TSH and total or free T₄ in children is as follows: at 2 and 4 weeks after the initiation of treatment; every 1-2 months during the first year of life; every 2-3 months between 1 and 3 years of age; and every 3 to 12 months thereafter until growth is completed. More frequent intervals of monitoring may be necessary if poor compliance is suspected or abnormal values are obtained. It is recommended that TSH and T₄ levels, and a physical examination, if indicated, be performed 2 weeks after any change in UNITHROID dosage. Routine clinical examination, including assessment of mental and physical growth and development, and bone maturation should be performed at regular intervals (see PRECAUTIONS, Pediatric Use and DOSAGE AND ADMINISTRATION).

Secondary (pituitary) and tertiary (hypothalamic) hypothyroidism

Adequacy of therapy should be assessed by measuring serum free-T₄ levels, which should be maintained in the upper half of the normal range in these patients.

Last updated on RxList: 12/8/2004

IMPORTANT NOTE: This is a summary and does not contain all possible information about this product. For complete information about this product or your specific health needs, ask your health care professional. Always seek the advice of your health care professional if you have any questions about this product or your medical condition. This information is not intended as individual medical advice and does not substitute for the knowledge and judgment of your health care professional. This information does not contain any assurances that this product is safe, effective, or appropriate for you.

LEVOTHYROXINE - ORAL

(lee-voe-thye-ROX-een)

COMMON BRAND NAME(S): Levothroid, Levoxyl, Synthroid, Unithroid

WARNING: This medication should not be used either alone or in combination with diet pills to treat obesity or for weight loss because serious, even life-threatening, effects could occur. Large doses of this medication, especially with diet pills, may cause symptoms of toxicity. See the Side Effects and Overdose sections for more information.

USES: Levothyroxine is used to treat an underactive thyroid (hypothyroidism). It replaces the hormone that is normally produced by the thyroid gland. Low thyroid levels can occur naturally or when the thyroid gland is injured by radiation/medications or removed by surgery. It is important to have adequate levels of thyroid hormone in your bloodstream to maintain normal mental and physical activity. In children, adequate levels of thyroid hormone are important for normal mental and physical growth and development.

This medication is used to treat other types of thyroid disorders as well (e.g., certain types of goiters, thyroid nodules, thyroiditis, thyroid cancer).

HOW TO USE: Take this medication by mouth usually once a day on an empty stomach, 1/2 to 1 hour before breakfast, or as directed by your doctor. To prevent difficulty swallowing the tablet, take it with a full glass of water unless otherwise directed by your doctor.

For children who cannot swallow whole tablets, crush the tablet and mix in 1 or 2 teaspoons (5 or 10 milliliters) of water, and give using a spoon or dropper as soon as possible after preparation. Do not store the mixture for later use. Do not mix crushed tablets in soybean infant formula. Consult your pharmacist for more information.

Use this medication regularly in order to get the most benefit from it. Remember to use it at the same time each day. Your doctor may need to adjust your dosage based on your medical condition, your response to therapy, and your laboratory test results.

Do not stop taking this medication without consulting with your doctor. Replacement therapy is usually taken for life.

It may take up to 4-6 weeks before the full benefits of this medication take effect. Inform your doctor if your condition persists or worsens.

SIDE EFFECTS: Symptoms of low thyroid levels include fatigue, muscle aches, constipation, dry skin, weight gain, slow heart rate, sensitivity to cold, or dry brittle hair that tends to fall out easily. These symptoms should disappear as your body adjusts to the medication. If they persist or become bothersome, notify your doctor promptly.

Headache, nervousness, trembling, sweating, increased appetite, diarrhea, weight loss or insomnia may occur. If any of these effects persist or worsen, notify your doctor promptly.

In rare instances, some hair loss may occur during the first few months of starting this drug. This effect is usually temporary as your body adjusts to this medication. If this effect persists or worsens, notify your doctor promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Seek immediate medical attention if you have any of these very unlikely but serious side effects: chest pain, rapid or irregular heartbeat, shortness of breath, seizures.

An allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of an allergic reaction include: rash, itching, swelling, dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Contact your doctor for medical advice about side effects. The following numbers do not provide medical advice, but in the US you may report side effects to the Food and Drug Administration (FDA) at 1-800-FDA-1088. In Canada, you may call Health Canada at 1-866-234-2345.

PRECAUTIONS: Before taking levothyroxine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.

This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have: overactive thyroid conditions (e.g., thyrotoxicosis), a heart attack (acute myocardial infarction), adrenal gland problems (e.g., uncorrected adrenal insufficiency).

Do not use thyroid drugs for weight control.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: heart problems (e.g., hypertension, congestive heart failure, arrhythmias, coronary artery disease), diabetes, male or female infertility problems (unless caused by underactive thyroid disease), bone loss disease (e.g., osteoporosis), other hormone disorders (e.g., hypothalamic/pituitary hormone deficiencies, autoimmune polyglandular syndrome), certain thyroid problems (e.g., nontoxic diffuse goiter, nodular thyroid disease), blood clotting disorders.

Notify your doctor or dentist that you are taking this medication prior to any surgery.

Caution is advised when using this drug in children because overuse may reduce the child's future adult height. Consult your doctor for details.

Caution is advised when using this drug in the elderly because they may be more sensitive to the effects of the drug.

Current information shows that this drug may be used during pregnancy. Tell your doctor if you are pregnant because your dose will have to be adjusted.

Small amounts of this drug pass into breast milk. Consult your doctor before breast-feeding.

DRUG INTERACTIONS: Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription drugs you may use, especially of: warfarin, digoxin, estrogen products (including estrogen-containing birth control pills), diabetes medicines (e.g., insulin, glipizide, rosiglitazone), amiodarone, iodide (including radiographic contrast agents containing iodine), lithium, anti-thyroid agents (e.g., methimazole, propylthiouracil), androgens/anabolic steroids, glucocorticoids (e.g., dexamethasone, prednisone), high dose salicylates (e.g., aspirin), phenobarbital, rifamycins (e.g., rifampin), beta blockers (e.g., propranolol), antidepressants (e.g., amitriptyline, maprotiline, sertraline), cytokines (e.g., interferon-alpha, interleukin-2), growth hormones, ketamine, theophylline.

Check the labels on all your medicines (e.g., cough-and-cold products, diet aids) because they may contain ingredients such as decongestants or caffeine that could increase your heart rate or blood pressure. Ask your pharmacist about the safe use of these products.

Certain medicines may decrease absorption of this drug into your bloodstream. Therefore, take levothyroxine 4 hours apart from: calcium supplements, iron supplements, antacids, simethicone, orlistat, cholestyramine, colesevelam, colestipol, sucralfate, sodium polystyrene sulfonate.

Certain foods may decrease absorption of this medication when taken at the same time. Take levothyroxine separately from: soybean flour (soybean infant formula), walnuts, dietary fiber.

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include: excessive sweating, extreme nervousness, fast/irregular heartbeat, chest pain, seizures.

NOTES: Laboratory and/or medical tests (e.g., thyroid function tests) should be done periodically to monitor the effectiveness of this medication. Inform your doctor if you change to a different brand of thyroid hormone.

MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. Call your doctor if you miss 2 or more doses in a row.

STORAGE: Store at room temperature (77 degrees F or 25 degrees C) away from light and moisture. Brief storage between 59 and 86 degrees F (15 and 30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

Information last revised September 2008 Copyright(c) 2008 First DataBank, Inc.