From the Guidelines
Thyroid storm treatment requires immediate medical attention and a multi-faceted approach, prioritizing beta-blockers like propranolol to control adrenergic symptoms, thionamides to block new thyroid hormone synthesis, and supportive care to manage vital functions. The treatment regimen should include beta-blockers like propranolol (60-80 mg orally every 4-6 hours) to control adrenergic symptoms such as tachycardia and hypertension, as recommended by the most recent study 1. Thionamides are essential to block new thyroid hormone synthesis; propylthiouracil (PTU) is preferred initially (600-1000 mg loading dose, then 200-250 mg every 4-6 hours) because it also blocks peripheral T4 to T3 conversion, as noted in 1. Alternatively, methimazole (20-25 mg every 6 hours) can be used. Iodine solutions like Lugol's solution (10 drops three times daily) or potassium iodide should be administered 1 hour after thionamides to prevent iodine utilization for new hormone synthesis.
Key aspects of treatment include:
- Beta-blockers to control heart rate and tremors
- Thionamides to block thyroid hormone synthesis
- Iodine solutions to prevent new hormone synthesis
- Corticosteroids to reduce T4 to T3 conversion and treat potential adrenal insufficiency
- Supportive measures such as aggressive cooling, intravenous fluids, and glucose administration. The most recent and highest quality study 1 supports the use of beta-blockers in thyroid storm treatment, and the American Association of Clinical Endocrinologists Medical Guidelines also discuss the use of beta-blockers in conditions characterized by an excess of thyroid hormones. Overall, the goal of treatment is to restore a euthyroid state and manage vital functions until the patient stabilizes, typically over 24-72 hours, as noted in 1 and 1.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Methimazole inhibits the synthesis of thyroid hormones and thus is effective in the treatment of hyperthyroidism. The FDA drug label does not answer the question.
From the Research
Thyroid Storm Treatment
- Treatment of thyroid storm involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications 2
- The goal of treatment is to achieve a euthyroid state, and various treatments and methodologies can be used to achieve this state 2
- ED treatment focuses on diagnosing and managing the trigger, resuscitation, administration of steroids, thionamides, iodine, and cholestyramine, and treatment of hyperthermia and agitation 3
- Beta blockers should be administered in the absence of severe heart failure, and the emergency clinician should be prepared for rapid clinical deterioration and employ a multidisciplinary approach to treatment 3
Treatment Modalities
- Pharmacological treatments, such as beta blockers, steroids, thionamides, iodine, and cholestyramine, can be used to manage thyroid storm 3, 4
- Mechanical treatments, such as extracorporeal membrane oxygenation (ECMO) support, therapeutic plasma exchange (TPE), and continuous renal replacement therapy (CRRT), can be used in severe cases 4
- Surgical treatments, such as thyroidectomy, can be used in patients who fail medical therapy or have severe cardiac involvement 4, 5
Mortality and Prognosis
- The mortality rate of thyroid storm is currently reported at 10% 5
- Patients who have survived thyroid storm should receive definite therapy for their underlying hyperthyroidism to avoid any recurrence of this potentially fatal condition 5
- In-ICU and 6-month postadmission mortality rates for patients with thyroid storm requiring ICU admission are 17% and 22%, respectively 6
- Multiple organ failure and early cardiogenic shock seem to markedly impact the prognosis, suggesting a prompt identification and an aggressive management 6