Today I saw another patient who struggles with her pharmacist’s instructions to take her thyroid replacement by itself long before breakfast and her other medications.
“I keep forgetting to do it that way, so then I go without it for that day”, she told me.
“Then I think you should just take it with breakfast and your morning medications”, I answered.
“Really?” Her eyes widened as I continued.
“Well, I’m just a country doctor, but it seems to me that if you take levothyroxine with all your other pills at breakfast and you get a little less into your system, two things happen. First, you’re more likely to get the medication on board every day. And, second, if you really get a little less than you need because of interference from food and other medicines, don’t we check your TSH every so often to make sure your pituitary is happy with that amount?”
“Yes, we do”, she agreed.
“So maybe we just have to give you a slightly higher dose if you take it that way, so what’s the big deal?” I asked.
“That makes sense”, she agreed.
“I think this morning routine thing is kind of like saying never open any windows in the winter because you’ll freeze to death”, I suggested. “But we both know that if you open some windows, the thermostat will make your furnace crank out more heat until the house is exactly the temperature you set it at.”
“That seems so straightforward”, she concluded.
As we wrapped up our visit, I finished my speech:
“I think a lot of doctors get hung up on theoretical fine points that don’t matter a whole lot in real, clinical, practice. There are drugs we can’t easily measure levels or effects of, so then we probably should dose them according to what works best. Like, old statin drugs, like simvastatin, don’t stay in your system for 24 hours. So we dose them before bed, which is when we make the most cholesterol. But modern ones, like atorvastatin, work for 24 hours so when you take them doesn’t matter. But so many pharmacists still slap a label on these newer drugs saying to take them at night. And I hear too many people say they have a hard time remembering to take medications at night.”
A medicine taken at the “wrong” time is usually a whole lot more effective than one you completely forget to take.
(You can quote me on that.)
A Country Doctor Writes: 
I used to spend half my clinic time in Miami urging people to eat more green leafy vegetables. Then my patients on warfarin would be told by the pharmacist to avoid them entirely! Ended up explaining to people that as long as they ate veggies regularly, we could just adjust the dose. So simple. Fortunately many fewer folks taking warfarin these days.
Thank you again. I’m just a country PA, sometimes I think it’s just me going crazy in this digital industrial medical machine. I feel less alone. I give the same talk to my patients all the time. Don’t give up the good fight!
Great advice from a former pharmacist!!
I take Levothyrozine, but take it at bedtime as I couldn’t remember to take it 2 hours after I ate in the morning. Too much of a hassle, so I’ve been taking it nightly with my other nightly meds and my numbers have been good. So as you suggest, take it in the morning with your other pills, or like me, take it at bedtime if you take nighttime meds. Seems to work either way.
Hmm… I’ve been doing this all along, for the reasons given above. Also, though statins work best taken at bedtime, many (myself included) forget evening meds, so I let them know that taking them in the morning, though second best, will still work better than forgetting them entirely.
Keeping it simple is the way to go. I too give my patient’s the same advise. Many are so hung up on taking it exactly on time with empty stomach they are stressing themselves. I myself am taking thyroid meds and have never taken like the pharmacist suggests and I have been on the same dose for 45 years. Thanks for the validation.