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CASE REPORT
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Which is better? Tricyclic antidepressant or selective serotonin reuptake inhibitor for depression in hypothyroidism: A case study


 Department of Internal Medicine, College of Health Sciences, University of Abuja, Abuja, Nigeria

Correspondence Address:
Yakubu Lawal,
Department of Internal Medicine, College of Health Sciences, University of Abuja, Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/trp.trp_7_22

Patients with hypothyroidism frequently have associated depressive disorder which may require antidepressant therapy. The clinical significance of drug–drug interaction between replacement thyroid hormones and antidepressants has remained controversial. Against this background, we present a case report of a suspected clinically significant drug–drug interaction between levothyroxine and an antidepressant in a patient with hypothyroidism and depressive disorder. A relevant patient's details were retrieved from the case notes. Extensive literature search of drug–drug interaction between replacement thyroid hormones and antidepressants was done using databases such as PubMed, PubMed Central, Google Scholar, and Embase. A 25-year-old woman was recently diagnosed with primary hypothyroidism associated with a major depressive disorder. She was stabilized on levothyroxine 100 μg daily with clinical and biochemical euthyroidism 2 months later. Due to lack of significant improvement in her depressive state, she was commenced on paroxetine 20 mg nocte. Subsequently, the depressive symptoms remarkably subsided, but the symptoms of hypothyroidism recurred. Supervised and regular intake of levothyroxine was confirmed. The patient did not ingest supplements containing biotin, calcium, iron, magnesium, and she was not on other medications. Levothyroxine was stored as per product insert at 20°C–25°C (68°F–77°F), and it was protected from light and moisture. After ruling out these confounders, the dose of levothyroxine was gradually increased at 4-weekly interval to 300 μg daily until biochemical and clinical euthyroidism was achieved, though with suspicion of thyroid hormone resistance. On re-appearance of hypothyroidism symptoms even at such a high dose of levothyroxine, drug–drug interaction between levothyroxine and paroxetine was suspected, leading to the replacement of paroxetine with amitriptyline. Biochemical and clinical euthyroidism was subsequently achieved, and the patient even began to complain of thyrotoxic symptoms, until levothyroxine dose was gradually titrated downward to 100 μg daily to achieve and maintain clinical and biochemical euthyroidism. Levothyroxine may be better co-administered with tricyclic antidepressants than selective serotonin reuptake inhibitors (SSRIs) because of the suspected clinically significant drug–drug interaction demonstrated between levothyroxine and paroxetine (SSRI).


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