Expiration Dates and Medication Instructions

August 5, 2008 11:02 PM

I have two questions related to medications that I take (or should be taking). Question about Acidophilus expiration dates and how to take Synthroid inside.

First off, these questions are going to seem really silly, but an honest answer hopefully will contribute to the regularity with which I take my medications.

1) I have a bottle of Acidophilus (Lactobacillus Acidophilus, 10 mg) in the refrigerator. The expiration date says 07/08. Can I still take it, or should it be thrown away? If it were Tylenol, Benedryl, etc., I would continue to take it, but considering the nature of Acidophilus, I'm not sure if it's still effective (or even harmful) at this stage.

2) I have been taking Synthroid for over ten years (current dose .2 mg). When I began taking it, my endocrinologist's only directions were to take it first thing in the morning and wait an hour before eating anything. He said that, should I miss taking it first thing in the morning and end up eating something first, I must wait two hours until I can take the medication and wait another hour before consuming anything more. My Synthroid question is (and this is something I've tried to ask him a few times, but he just gives me a look, and I never end up getting an answer): So, I understand that having a buffer of time when I've not eaten solid food is important for the efficacy of this medication. But, does this include non-water beverages? Does drinking an iced tea or a soda count as 'food'? Can I drink a non-water beverage right before or after taking Synthroid? Or can I even take Synthroid with another liquid besides water? I don't drink milk at all, so I wouldn't be taking it with anything dairy. At this point, if I drink a soda first, for instance, I have been waiting two hours to take my medication. I'm wondering if that's unnecessary. Also (and yes, these are serious questions), would chewing gum or using toothpaste/mouthwash effect when I can take the Synthroid? Once again, do I have to wait until an hour passes to do either? Reading that sentence back, I know it doesn't sound logical, but I just mean that I swallow some amount of all of those substances (with the gum, I really just mean the minty saliva).

I realize these are probably silly questions, but, in the past, I've opted not to take the medication at all over these concerns.. which is obviously not the best thing. Anyway, thank you for your patience and your advice!

posted by Mael Oui to health (19 comments total)

IAND, but as my pharmacist sister explained it to me, it's not that you need an empty stomach to absorb synthroid, it's that certain minerals, especially iron, interfere with how it works. So in order to avoid having the synthroid reduced by the iron, pharmacists and doctors tell you to take it on an empty stomach.

But she also told me that it didn't really matter what you do as long as you do the same thing every day so your dose is consistent and adapted to what you are doing. So maybe I won't absorb quite as much if I take it with breakfast everyday, but my dosage can be adjusted to account for that if I do the same thing all the time, and frankly, I'm more likely to remember to take it (which is the most important part).

I don't know about the acidophilus, but the same sister told me not to use drugs and natural supplements that are expired.
posted by scrute at 11:19 PM on August 5

July ended five days ago. I'm all for using caution with expired meds and supplements, too, but it's not like these things are manufactured with some internal timer that goes off on exactly the last day of the month stamped on the bottom of the carton. Logically speaking, they weren't useful last Thursday but poisonous today.

As for the synthroid: I've been taking it forever, too, and my TSH has to stay in a very narrow, low range in order to keep my cancer in remission. My doc's always told me as well that the main thing with taking it is consistency. As long as your TSH, etc. levels are at a comfortable, consistent level for you, then you're doing it right, even if you happen to generally take it with a cup of tea or tend to have breakfast 40 minutes later rather than 60.

And if toothpaste affects it as well, then I'm in for a big surprise, because I take my Synthroid every single day right before I brush my teeth.
posted by scody at 11:44 PM on August 5

Oh, and I know that this isn't really answering your question, but... any chance you could find an endocrinologist who doesn't deal with your sincere questions by "giving you a look" and ignoring your concerns? In my experience, a good doctor welcomes (and answers!) questions, no matter how silly they might seem. The fact that you want to understand some simple details surrounding the management of your own health care is a good thing, not something to be shut down with a condescending look. Just my 2 cents.
posted by scody at 12:09 AM on August 6

There are specific issues with synthroid/levoxyl/TH. Strong bases (antacids, bitters, etc.) neutralize it, and foods containing iron, iodine or high levels of dietary fiber interfere with its uptake. It's easier to tell you not to eat, than it is to give you the laundry list of prohibitions.

The toothpaste thing isn't going to be an issue, unless you swallow it - which most people don't. Gum should not have any effect either.

In general, liquids are dealt with by the body in about a half hour. Solid food is slower, and can take up to two hours. I haven't suffered any ill effects from having coca-cola in the morning, but YMMV - everyone's body is different.

The important thing is to get regular tests of your TSH/TH levels, so you can see whether your current situation is working. If you find that you're on a high dose, and your TSH levels are still too high, you probably need to change something. Otherwise, you're good.
posted by Citrus at 6:36 AM on August 6

As far as the acidophilus, it's not going to be dangerous, but as you said it might be less effective.

Unlike regular supplements, probiotics are made up of beneficial 'live' bacteria. Frankly, a lot of brands are already mediocre at best, because of low dosage, or poor handling. Label counts list the fresh, factory count, not the dose after being trucked/shipped/stored. Personally I prefer to take supplements in the 5-10 billion range (such as Reuteri or Culturelle) to guarantee I'm getting a reasonable dose by the time I take it.

If interested, let me know the brand and I can give you more information.
posted by for_serious at 6:50 AM on August 6

Seriously, i've always ignored the recommendation about Synthroid. The reason is I'm taking Synthroid, Cortef, and DDAVP every day altogether, and Synthroid says not to consume with food, and Cortef says to consume with food, I think, and that's just too much of an inconvenience to separate them. So I take them altogether, and have been for 15 years now, and have never suffered any ill effects from it.
posted by Perpetual Seeker at 7:22 AM on August 6

After I repeatedly failed to work the daily dose into my rushed morning routine, my doc suggested I take Synthroid before I go to bed, which I've done for two years with no harm done.
posted by Heretic at 8:15 AM on August 6

Another long-term thyroid-hormone-taker chiming in, basically to second what others are saying. The reason for the empty-stomach directions is because of the way certain foods will interfere with the absorption of the medicine, and the main thing is to stick to a consistent schedule and make sure your levels are monitored regularly. I take a combination of levoxyl and Armour Thyroid, and my doctor and I tweaked my dosage and schedule until it worked for me - where "it worked" meant "I would be able to take it at about the same time and under about the same circumstances, every day, and that regimen gave the appropriate results."

But some days your schedule might not work out. Some days you're staying at your in-laws' house and they want to feed you breakfast first thing in the morning. On occasions like that I just take the meds anyway- I've never had trouble from the occasional pill-with-breakfast.

Of course, IANAE and this isn't medical advice, etc. Just an anecdote. :)
posted by oblique red at 1:12 PM on August 6

Thank you for all your responses! I'm a bit clearer now.. for_serious, the Acidophilus is not a quality brand like Culturelle. It's just Nature's Bounty and guarantees 'millions' of bacteria at time of bottling. So, I'm thinking, it's okay to use it up, but it won't be as effective? Just as long as it's not dangerous! I have about half the bottle left, though..

As far as the Synthroid goes, we're discounting any problems with proximity of gum/toothpaste/mouthwash with the medication..

When I was in school, I was actually much better about taking my medication because I'd be up at the same time every day. Now I have no set schedule, and my bed and waking times vary wildly, so large chunks of time pass without taking my medication. And not only am I inconsistent about taking it, I'm inconsistent about when I take it. I did start to do what Heretic does: taking the medication before bed ('bed' being a time when most people are starting to wake up), and I was doing that consistently for a while, but then lost that routine. Mostly because I wanted to drink something (I'm not much of a water drinker) before going to bed. Okay, so, as I understand it from all of your responses (and Perpetual Seeker, Heretic, and oblique red's cases), consistency is really the most important consideration, even if it goes against instructions. And Citrus says that liquids are dealt with within half an hour, so I really should keep that amount of time between non-water drinks and medication? Thank you scrute and Citrus for the more 'medical' type explanations.. That was extremely helpful. Okay, I think I finally have it all clear here! Thank you all again!

Oh, scody: Yeah, I didn't like that my doctor just didn't humor my question, but I really can't fault him overall. I had been taking the medication for many years when I tried to bring this up for clarification. It must have looked really stupid to wait all that time! He's actually been extremely good to me; I've been going to him since I was 11, and I'm 27 now. Even with 'the look', I doubt I'd find a better doctor in the area! Incidentally, my Mom gave me the same look when I asked her, so I figured I'd never have this answered!

If any of you look back here: Have any of you switched from Synthroid to Armour Thyroid (or vice versa)?
posted by Mael Oui at 10:13 PM on August 6

Mael Oui,

Glad I could help! Yeah, 'millions' of bacteria is not necessarily as impressive as it sounds!

As long as the pills are dry, and there's no unusual odor or color, I'd keep taking them, maybe double up. Pull the capsule apart; if it's still a powder, you're good. If it's hardened together -still not dangerous- but a waste of time. You can also try Yo+Plus yogurt, it's guaranteed a minimum of 1 billion per serving, at time of use. Blackberry Pomegranate is yummy!
posted by for_serious at 6:55 AM on August 7

I've been using Levoxyl ever since diagnosis. Synthroid is the same chemical (TH), but by a different manufacturer. I don't know much about Armour Thyroid, so I can't speak to it. The only warning my endocrinologist gave me was that I should never use generics, and insist on DAW to get the brand names. According to him, it makes a difference. Otherwise, the only reason not to use Synthroid was it's higher expense.
posted by Citrus at 10:16 AM on August 7

Thanks for the advice, for_serious! 'Millions' did look really impressive, now I know better! I'll go sniff and examine them right now!

Citrus, I'm not too familiar with Levoxyl, but since it's the same chemical as Synthroid, I think I'll ask my doctor about it. He didn't really discuss options with me when I started (I was in high school at the time and probably not interested in understanding what was happening to me). Synthroid is becoming too pricey, and I was also told that generics weren't acceptable. I have read articles about hypothyroid patients demanding to switch from Synthroid to Armour Thyroid because of the side effects and wondered if I was taking the right one.
posted by Mael Oui at 10:58 PM on August 7

The notion that you shouldn't take generic thyroid hormone has been vastly overblown -- in fact, there was a lawsuit several years ago in which Synthroid had to settle for close to $90 million related to price gouging based on false claims of the dangers related to generic thyroid hormone. The problem between brand-name and generic is not one of quality (they are indeed the exact same active ingredient); it's one of bioequivalence.

What this means, practically, is that issue when switching from brand-name to generic (or between different versions of the generic) is simply to find a dose that will keep you steadily at a comfortable TSH for you -- but with the understanding that the dose that works for you on Synthroid might be slightly different than the dose that works for you on levoxyl, which might be slightly different than the dose that works for you on levothryoxine.

For me, for example, the difference between Synthroid and levoxyl is very slight (except for price!); I'm comfortable on comparable doses (in my case, 175 mcg) of the two. But if I take the exact same dose of levothyroxine, it will generate hyperthyroid symptoms (shortness of breath, palpitataions, anxiety) within a few days. It's not that there's anything wrong with levothyroxine per se, just that 175 mcg of levothryoxine has a different effect than 175 mcg of levoxyl.
posted by scody at 11:28 PM on August 7

If I recall correctly, my doctor's explanation to me (which was probably simplified for my lack of knowledge) was that the problem with generics was that it would be harder to find and maintain the right dosage. At the very least, he didn't tell me generics would be dangerous, but I guess that I would need to have more frequent blood tests to make sure I was on the right dosage.

It's only been the last year or two that I've been trying to educate myself about my condition and options, mostly because I'm suffering from some side effects (I think). I had read about the lawsuit (and possibly something about problems with the FDA). I think it's time to start questioning my doctor, and your explanation is extremely helpful, scody!
posted by Mael Oui at 2:56 AM on August 10

Probably echoing what others have said, but my endocrinologist told me the reason for asking specifically for generic is that, yeah, you can't depend on your pharmacy to sell you the same generic "brand" of any drug. They buy the one that's cheaper, since, given the nature of generic medications, they're all "equivalent". But your thyroid is so sensitive to even slight changes in the dose that those tiny changes between brands can cause undesirable reactions. It's not a problem to take generic levothyroxine, it's a problem if you can get the levothyroxine made by the same drug manufacturer from month to month, but that's really hard to do.
posted by eldiem at 8:03 AM on August 10

you can't depend on your pharmacy to sell you the same generic "brand" of any drug. [...] it's a problem if you can get the levothyroxine made by the same drug manufacturer from month to month, but that's really hard to do.

I don't mean to be argumentative, and perhaps your situation is different where you live, but in my experience this statement is simply false. I've been on the same generic (Levoxyl) made by the same manufacturer (King pharmaceuticals) literally for years without a problem in terms of either availability or consistency in dose.

After my pharmacy recently switched me to Levothroid (Forest pharmaceuticals) because they were out of Levoxyl for the first time in about five years, that's when I felt hyperthyroid symptoms. And I knew already they'd switched me, because A) they told me in the first place (which they're legally required to do, I believe), and B) even if they hadn't, you can instantly tell the difference between different brands of thyroid hormone because the shape of the pill is different (Synthroid is round, Levoxyl is quasi-diamond-shaped; Levothroid is oval), as is the color assigned to signify each dosage level (Levoxyl 175 mcg is turquoise; Levothroid 175 mcg is purple).

So when they told me they were out of Levoxyl, I agreed to take the Levothroid to see if I felt comfortable on it (since the diff between Synthroid and Levoxyl isn't bad for me); if I didn't, I'd just go back and ask them to switch me back to Levoxyl, since they were going to have it back in stock within a few days, anyway. Which is basically what wound up happening.
posted by scody at 11:36 AM on August 10

I think I mis-typed. It's a problem if you can't get the same brand of levothyroxine (the generic name for the drug we're talking about) every single time you fill your prescription. I was told in my state (Illinois) the pharmacy needed permission to switch from brand to generic and vice versa from the doc, but I don't know if that was specific to thyroid med. I do know that I take other medications and have had one manufacturer's generic replaced by another's without the pharmacy needing to tell me. They said the pills looked different but it was the same medication I'd been taking (extended-release metformin, to be specific), and suffered some unpleasant side effects from it.

The pharmacy does not have a legal obligation to sell you the same manufacturer's version of a generic every time the way they do when you are prescribed a name-brand drug, and that's the case for name brands. Just to be clear, I have nothing against generics.
posted by eldiem at 8:08 PM on August 11

From Scody:
For me, for example, the difference between Synthroid and levoxyl is very slight (except for price!); I'm comfortable on comparable doses (in my case, 175 mcg) of the two. But if I take the exact same dose of levothyroxine, it will generate hyperthyroid symptoms (shortness of breath, palpitataions, anxiety) within a few days. It's not that there's anything wrong with levothyroxine per se, just that 175 mcg of levothryoxine has a different effect than 175 mcg of levoxyl.

As a clarification: Levoxyl (as branded) is technically not a generic.

You're right about the bio-equivalence thing. Generally, the max dose of Levoxyl is 112 mcg. I didn't even think that they made a 175 mcg pill.

However, generics do have six-sigma issues compared to Synthroid and Levoxyl. My endocrinologist worries not about the efficacy, but the consistency from pill to pill. Remember, this stuff is dosed out in micrograms. Small manufacturing inconsistencies from cost-cutting don't effect your 1000 milligram pain killer - it doesn't matter if that's off by a microgram or three. TH replacements are much more sensitive.

That said, there are people who get along on generics. It's just that my doctor doesn't trust them.
posted by Citrus at 8:09 AM on August 12

Aha, I see now why we're talking past each other. I've been on thryoid hormone since the early-mid '90s (uphill! both ways! to the pharmacy! for our steam-powered thyroids!), back when Levoxyl was the generic. Only after the Synthroid lawsuit/settlement in the late '90s were Levoxyl and the others able to market themselves as acceptable (branded) alternatives to Synthroid. So I and my docs have tended to refer to anything that wasn't specifically Synthroid as generic (and, looking at my HMO's formulary, I see that they categorize it the same way: Synthroid is on the "branded" tier at one price, and Levoxyl/Levothroid/Unithroid are all on the "generic" tier at a lower price).
posted by scody at 10:37 AM on August 12