Inpatient compliance with levothyroxine timing : a clinical audit of administration practices and patient knowledge

Abstract

Introduction: Levothyroxine, which is absorbed in the small intestine and, hence, is affected by the presence of food, is best taken up (60-80%) after a period of fasting. Hence, guidelines recommend that it is taken on an empty stomach, at least 30 min before food, caffeine-containing drinks and some medication.1-3 On busy wards with medication and meal rounds possibly functioning independently, sticking to this standard is challenging, and made more so by the knowledge gap. This audit aimed to evaluate inpatient compliance with timing recommendations, assess patient knowledge and identify concurrently prescribed medications that affect levothyroxine absorption. Material(s) and Method(s): This prospective audit was carried out at the Sherwood Forest Trust from August 26 to September 19, 2024. Inpatients who were taking levothyroxine were identified, and data were collected by reviewing EPMA and structured questionnaires administered to patients, assessing compliance, concurrent interacting medications and patient knowledge. The audit was performed against National Institute of Health and Care Excellence (NICE) guidelines, which state that levothyroxine should be administered at least 30 min before meals or other medication.3-5 Results and Discussion: Out of 51 patients audited, only 21.6% reported being compliant pre-admission. This dropped to 13.7% during inpatient stay (Fig 1). Only 3.9% of patients recalled being advised by a healthcare provider (pharmacist or GP) on correct timing, and the same proportion recalled having received leaflets/written education materials. Patients using dosette boxes took levothyroxine with other medication, and many were unaware that taking it with coffee or tea affected absorption,6 often taking levothyroxine before meals, but with a cup of coffee or tea. Concurrent prescriptions of proton pump inhibitors (PPIs) and calcium were common, with nearly 81.5% of patients on PPIs taking them at the same time as levothyroxine (Fig 2). Curiously, concurrent iron administration was not noted, in contrast to an audit at North Cumbria Integrated Care NHS Trust,7 which showed that 84% were taking it at the same time. Hospital morning routines, which consist of nursing shift handovers and mealtimes between 08;00 and 09;00, mean that levothyroxine is often taken with breakfast or during bundled morning rounds, limiting adherence to guidelines. Patient understanding of what constitutes an 'empty stomach' was inconsistent, with tea/coffee often substituted for water, and pharmacy labels were often brief, stating only 'take in the morning'. EPMA was also open-ended and did not provide alerts for concurrently administered interacting medications; neither did it provide a default closed window for administration. These systemic and educational gaps suggest the need for multi-level interventions to improve adherence. Conclusion(s): This audit elucidates unsatisfactory compliance with levothyroxine administration guidelines in hospitalised patients. Knowledge gaps, hospital routines and lack of enabling scaffolding via EPMA have been observed to be barriers to meeting the standards. Implemented interventions include default early-morning (06:00-07:00 h) EPMA scheduling paired with interacting medication alerts, updated pharmacy labels specifying 30 min before food, including coffee/tea, nursing team briefings and patient education material. Further planned interventions include flagging thyroxine for annual medication review and monitoring adherence to guidelines.