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The Use of Bile Acid Sequestrants to Lower Serum Thyroid Hormones in Iatrogenic Hyperthyroidism
Abstract
Hyperthyroidism occasionally must be rapidly restored to euthyroidism, especially if it is associated with an emergent condition such as myocardial infarction. Several modalities are available to render endogenous hyperthyroid patients to a euthyroid state rapidly. Few therapeutic options, however, are available to rapidly treat hyperthyroidism caused by ingestion of excess thyroid hormones, except perhaps the use of β-blockers. We observed hypothyroidism develop in two patients taking stable doses of levothyroxine after cholestyramine was added to their drug regimen. This finding led us to treat two patients with iatrogenic hyperthyroidism with cholestyramine. A euthyroid state was achieved in 72 to 96 hours whereas in three similar patients without cholestyramine treatment it had taken almost 8 days for serum thyroid hormone levels to fall into normal range. Our preliminary results suggest that bile acid sequestrants may be useful in treating exogenous thyroid-hormone-induced hyperthyroidism in emergent situations.
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“Treatment with cholestyramine (671) and charcoal hemoperfusion (672) have been used in this circumstance.”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [671]
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Ross, D. S., Burch, H. B., Cooper, D. S., Greenlee, M. C., Laurberg, P., Maia, A. L., Rivkees, S. A., Samuels, M., Sosa, J. A., Stan, M. N., et al. (2016) · Thyroid® · doi:10.1089/thy.2016.0229 · Cited by 2,938
“Treatment with cholestyramine (671) and charcoal hemoperfusion (672) have been used in this circumstance.”
MethodThyrotoxicosis and Thyroid Storm
Nayak, B. M., & Burman, K. D. (2006) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2006.09.008 · Cited by 392
“Cholestyramine was also found to be useful in rapidly decreasing thyroid hormone levels in a case of iatrogenic hyperthyroidism.”
BackgroundSurks, M. I., & Sievert, R. (1995) · New England Journal of Medicine · doi:10.1056/nejm199512213332507 · Cited by 349
Treatment with thyroid hormone
Biondi, B., & Wartofsky, L. (2014) · Endocrine Reviews · doi:10.1210/er.2013-1083 · Cited by 259
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Barbesino, G. (2010) · Thyroid · doi:10.1089/thy.2010.1635 · Cited by 146
“In addition, they appear to interfere with the enterohepatic circulation of thyroid hormone, a property that has been used to treat endogenous hyperthyroidism and thyroid hormone intoxication (66–68).”
Factors Affecting Gastrointestinal Absorption of Levothyroxine: A Review
Skelin, M., Lucijanić, T., Amidžić Klarić, D., Rešić, A., Bakula, M., Liberati-Čizmek, A.-M., Gharib, H., & Rahelić, D. (2017) · Clinical Therapeutics · doi:10.1016/j.clinthera.2017.01.005 · Cited by 133
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Sharma, A. R., & Stan, M. N. (2019) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2018.10.011 · Cited by 116
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Ross, D. S. (1998) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/s0889-8529(05)70305-4 · Cited by 100
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Liel, Y., Sperber, A. D., & Shany, S. (1994) · The American Journal of Medicine · doi:10.1016/0002-9343(94)90303-4 · Cited by 83
Treatment of hyperthyroidism with a combination of methimazole and cholestyramine
Mercado, M., Mendoza‐Zubieta, V., Bautista-Osorio, R., & Monteros, A. L. E. D. L. (1996) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jcem.81.9.8784067 · Cited by 67
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“The bile acid sequestrants cholestyramine, colestipol and colesevelam decrease the T4 concentration – probably via the augmented enterohepatic recycling of T4 [120, 121], although cholestyramine additionally forms a complex with T4 in the stomach and thus increases the amount of T4 excreted in the feces [122].”
BackgroundNayak, B. M., & Hodak, S. P. (2007) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2007.06.002 · Cited by 54
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Sebastián-Ochoa, A., Quesada‐Charneco, M., Fernández‐García, D., Reyes‐García, R., Rozas-Moreno, P., & Escobar‐Jiménez, F. (2008) · Thyroid · doi:10.1089/thy.2008.0094 · Cited by 31
“Bile acid sequestrants may also be useful in treating exogenous thyroid hormone–induced hyperthyroidism (13,14).”
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“It has been suggested that serum total T3 and total T4 level can decrease if thyroid hormone entering intestine from enterohaptic circulation is sequestered by sorbents, which may be beneficial to hyperthyroidism (Shakir et al., 1993; Surks and Sievert, 1995).”
BackgroundRole of colestipol in the treatment of hyperthyroidism
Hagag, P., Nissenbaum, H., & Weiss, M. (1998) · Journal of Endocrinological Investigation · doi:10.1007/bf03348036 · Cited by 16
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Self-citationThe Use of Konjac Glucomannan to Lower Serum Thyroid Hormones in Hyperthyroidism
Azezli, A., Bayraktaroğlu, T., & Orhan, Y. (2007) · Journal of the American College of Nutrition · doi:10.1080/07315724.2007.10719645 · Cited by 8
“studies suggest that bile acid sequestrants may be useful in treating exogenous thyroid-hormone-induced hyperthyroidism in emergent situations [14].”
BackgroundIntoxicación con levotiroxina: manifestaciones clínicas y manejo terapéutico
de Luis, D. A., Abad, L., Aller, R., Sagrado, M. G., & Dueñas, A. (2004) · Anales de Medicina Interna · doi:10.4321/s0212-71992004000100010 · Cited by 7
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“In 1993, a study [19] examined the use of bile acid sequestrants, such as cholestyramine, to lower thyroid hormone levels in two patients with iatrogenic hyperthyroidism due to excessive levothyroxine intake.”
Thyrotoxic Crisis: Thyroid Storm
Reyes-Castano, J. J., & Burman, K. D. (2013) · Humana Press eBooks · doi:10.1007/978-1-62703-697-9_9 · Cited by 4
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Manha, J. K., Spiro, A. J., Vietor, N. O., Hoang, T. D., & Shakir, M. K. M. (2025) · AACE Endocrinology and Diabetes · doi:10.1016/j.aed.2025.07.011 · Cited by 1
“Bile acid resin interferes with this reabsorption, reducing thyroid hormone levels, 9 and has been used to treat iatrogenic hyperthyroidism 8 and Graves' disease.”
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“Los principales datos analíticos fueron: hemograma, normal; HbA1c, 11,1%; T4 libre > 12 ng/dl (0,89-1,76); triyodotironina (T3) libre, 8,2 pg/ml (1,4-4,4); tirotropina (TSH) < 0,01 U/ml (0,35-5,35); anticuerpos antitiroglobulina, 3,9 U/ml (0-40); anticuerpos antimicrosomales, 146 U/ml (0-35); TSI, 6 mU/ml (< 5); tirog…”
Yip, L. (2007) · Elsevier eBooks · doi:10.1016/b978-0-7216-0693-4.50072-4
Cash, J. C., & Hall, M. A. (2020) · Springer Publishing Company eBooks · doi:10.1891/9780826153425.0020l
Thyrotoxic Crisis: Thyroid Storm
Reyes-Castano, J. J., & Burman, K. D. (2021) · Contemporary Endocrinology · doi:10.1007/978-3-030-67455-7_9
&NA; (1993) · Reactions Weekly · doi:10.2165/00128415-199304360-00057
Üzüm, A. K., & Yalın, G. Y. (2018) · Springer eBooks · doi:10.1007/978-3-319-78476-2_2
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Nair, C. G., & Babu, M. J. C. (2024) · Springer eBooks · doi:10.1007/978-981-97-3774-1_3
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Lamrini, R., Vial, T., Payen, C., & Evreux, J. (1997) · Lyon Pharmaceutique · doi:10.1016/s0024-7804(97)85033-6
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Ocampo, E. L., & Surks, M. I. (1997) · doi:10.1007/978-1-4757-2594-0_9
In a Bind: Role of Bile Acid Sequestrants in Lowering Thyroid Hormone Levels
Jacob, S., & Genere, N. (2026) · Clinical Thyroidology · doi:10.1177/23299711261436454
Metadata
- Authors
- Shakir, K. M. M., Michaels, R. D., Hays, J. H., & Potter, B. B.
- Affiliations
- Uniformed Services University of the Health Sciences (US)
- Corresponding author
- Shakir, K. M. Mohamed
- Venue
- Annals of Internal Medicine
- Publisher
- American College of Physicians
- Published
- 1993-01-15
- Volume
- 118
- Issue
- 2
- Pages
- 112-113
- ISSN
- 0003-4819 (ISSN-L)
- 1539-3704
- OpenAlex
- W2022517313
- Cited by
- 45
- References
- 0
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 1 · 2021: 2 · 2020: 1 · 2019: 2 · 2018: 2 · 2017: 1 · 2016: 2 · 2014: 2 · 2013: 1
- FWCI
- 1.80
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Surgery › Thyroid and Parathyroid Surgery
- Health Sciences › Medicine › Emergency Medicine › Poisoning and overdose treatments
- Keywords
- iatrogenic hyperthyroidism, bile acid sequestrants, cholestyramine, levothyroxine, thyroid hormone excess, hypothyroidism, euthyroidism, myocardial infarction, beta-blockers, serum thyroid hormones
- MeSH terms
- Cholestyramine Resin, Female, Humans, Hyperthyroidism, Male, Middle Aged, Preoperative Care, Thyroid Hormones, Thyroxine
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