[THYROTOXICOSIS WITH PROLONGED CARDIAC EFFECT DUE TO EXCESS LIOTHYRONINE CONSUMPTION 'OVER THE COUNTER': A CASE REPORT AND RECOMMENDATIONS FOR POLICY MAKERS]

Abstract

Background: Exogenous excessive thyroid hormone intake may result in severe thyrotoxicosis and might be harmful to human health. In spite of this, a growing number of people consume over-the-counter (OTC) products that also contain Triiodothyronine (T3) and Thyroxine (T4). We report a case of Liothyronine-containing tablets consumption causing T3-induced thyrotoxicosis. A 33-year-old obese man (BMI=40 kg/m2) with no thyroid disease had typical signs of substantial thyrotoxicosis (including wide complex tachycardia and chest pain), which were confirmed by endocrine tests: both low thyrotropin (TSH) and free T4 as well as elevated free T3 (FT3). Prior to hospitalization, he had not been exposed to iodinated radiocontrast media and had not taken medications containing iodine, such as amiodarone. However, we discovered that the patient consumed tablets containing Liothyronine (135 µg/tablet) for five days prior to hospitalization following the suggestion of a non-registered individual, who introduced himself as a nutritionist. The tablets were misleadingly presented to the patient as a "weight loss" dietary supplement. The tablets were discontinued and a short term therapy that included Amiodarone (before FT3 arrived) was initiated along with Cholestyramine. After three days in the intensive care unit, the patient's heart rate stabilized and his FT3 level decreased substantially. Following investigations, the Israeli Ministry of Health (MOH) published a warning on its website advising the public to avoid these tablets. After follow-up in the community, a repeat echocardiogram revealed a borderline left ventricle dysfunction. During the four years since the patient was released from our hospital, his TSH levels have been normal.

Conclusions: Liothyronine consumption has been associated with substantial thyrotoxicosis and cardiac damage. The Liothyronine tablets were provided to the patient by an unauthorized party, as a weight losing nutritional supplement. However, this was done without a medical examination or indication. The increase in demand for "weight-losing" products 'over the counter', the lack of effective enforcement in the chain, the way these products are presented and the possibility of those who are not authorized to market and supply them, emphasize the need to settle the regulation of this issue as soon as possible.