From the Guidelines
Thyroid storm management requires immediate hospitalization in an intensive care unit with a multifaceted approach, prioritizing the administration of beta-blockers, thionamides, iodine, and corticosteroids to control adrenergic symptoms, inhibit thyroid hormone synthesis and release, and support the body through this life-threatening hypermetabolic state. The management of thyroid storm involves a combination of pharmacological interventions and supportive care measures.
- Administering beta-blockers such as propranolol to control adrenergic symptoms like tachycardia and hypertension is crucial, as seen in the treatment of thyroid storm 1.
- Inhibiting thyroid hormone synthesis with thionamides, either methimazole or propylthiouracil (PTU), is also essential, with PTU preferred initially as it also blocks T4 to T3 conversion, although the study by 1 does not specify the exact dosing.
- One hour after starting thionamides, administering iodine to block thyroid hormone release, using either Lugol's solution or potassium iodide, is necessary, as indicated in the study 1.
- Corticosteroids like dexamethasone should be given to inhibit peripheral conversion of T4 to T3 and treat potential adrenal insufficiency, as mentioned in the study 1. The study 1 emphasizes the importance of general supportive measures, such as oxygen, antipyretics, and appropriate monitoring, in the management of thyroid storm. It is also crucial to identify and treat the underlying cause of thyroid storm, as well as to evaluate fetal status with ultrasound examination, nonstress testing, or a biophysical profile, depending on gestational age, as noted in the study 1.
From the FDA Drug Label
Propylthiouracil inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues and may therefore be an effective treatment for thyroid storm. Beta-adrenergic blockade may mask certain clinical signs of hyperthyroidism. Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptoms of hyperthyroidism, including thyroid storm.
To manage thyroid storm,
- Propylthiouracil may be an effective treatment as it inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues 2.
- Propranolol may be used to manage symptoms of hyperthyroidism, but abrupt withdrawal should be avoided as it may exacerbate symptoms, including thyroid storm 3. Key considerations include:
- Monitoring for signs of hyperthyroidism
- Avoiding abrupt withdrawal of propranolol
- Using propylthiouracil to inhibit thyroid hormone synthesis and conversion 2
From the Research
Management of Thyroid Storm
- Thyroid storm is a potentially lethal complication of hyperthyroidism, with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis 4.
- First-line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment 4, 5.
- Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy 4.
Treatment Options
- Therapeutic plasma exchange (TPE) is an option for patients who cannot tolerate or fail pharmacotherapy, and is likely beneficial for these patients 4.
- TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines, and cytokines 4.
- Surgical management, such as emergent thyroidectomy, may be necessary in some cases, especially when medical management is not effective or appropriate 5.
Comparison of Treatment Outcomes
- A comparative effectiveness study found no significant differences in mortality or adverse events between patients treated with propylthiouracil or methimazole for thyroid storm 6.
- The study suggested that current guidelines recommending propylthiouracil over methimazole for treatment of thyroid storm may merit reevaluation 6.
Clinical Diagnosis and Treatment
- Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab), and with clinical signs and symptoms of end organ damage 7.
- Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications 7.