BACKGROUND　　Malabsorption of thyroxine has been described in patients treated with drugs that modify an acidic environment．We determined whether there is an increased need for thyroxine in patients with euthyroid multinodular goiter and impaired secretion of gastric acid．

METHODS　　We assessed the dose of thyroxine required to obtain a low level of thyrotropin(0.05 to 0.20 mU per liter)in 248 patients with multinodular goiter of these 248 patients,53 also had Heli-cobacter pylori-related gastritis and 60 had atrophic gastritis of the body of the stomach (31 with evidence of H.pylori infection and 29 without such evidence)．The reference group comprised 135 patients with multinodular goiter and no gastric disorders．In addition．variation in the level of serum thyrotropin was prospectively studied in ll patients treated with thyroxine before and after H．pylori infection and both before and during treatment with omeprazole in 10 patients treated with thyroxine who had gastroesophageal reflux．

RESULTS　　The daily requirement ofthyroxine was higher(by 22 to 34 percent)in patients with H．pylori-related gastritis，atrophic gastritis．or both conditions than in the reference group．In prospective studies．the occurrence of H．pylori infection in the 11 patients treated with thyroxin led to an increase in the level of serum thyrotropin(P=0.002)，an effect that was nearly reversed on eradication of H．pylori infection．In a similar way，omeprazole treatment was associated with an increase in the level of serum thyrotropin in all 10 patients treated with thyroxine，an effect that was reversed by an increase in the thyroxine dose by 37 percent．

CONCLUSIONS　　Patients with inpaired acid secretion require an increased dose of thyroxine．suggesting that normal gastric acid secretion is necessary for effeetive absorption of oral thyroxine．

(N Engl J Med 2006；354：1787-95．April 27,2006)