What is the management of thyroid storm (hyperthyroid crisis)?

From the Guidelines

Thyroid storm management necessitates immediate initiation of treatment with beta-blockers, thionamides, iodine solutions, and corticosteroids to mitigate the severe hypermetabolic state and prevent life-threatening complications. The treatment approach should prioritize reducing thyroid hormone levels and addressing systemic effects.

• Beta-blockers such as propranolol 60-80 mg orally every 4-6 hours or IV esmolol should be administered for heart rate control 1.
• Thionamides like methimazole 20-25 mg orally every 6 hours or propylthiouracil (PTU) 200-250 mg every 4 hours should be given to block new hormone synthesis, with PTU preferred initially as it also blocks T4 to T3 conversion.
• One hour after starting thionamides, iodine solutions such as Lugol's solution 10 drops three times daily or saturated solution of potassium iodide (SSKI) 5 drops every 6 hours should be administered to block hormone release.
• Corticosteroids like hydrocortisone 100 mg IV every 8 hours should be given to block peripheral conversion of T4 to T3 and treat potential adrenal insufficiency.
• Supportive care, including aggressive cooling measures for hyperthermia, IV fluids for dehydration, glucose for hypoglycemia, and treatment of the precipitating cause, is crucial.
• Continuous cardiac monitoring is essential, and ICU admission is typically warranted to manage potential complications such as cardiac failure, which can occur in untreated thyroid storm 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.

Thyroid Storm Management:

• Propylthiouracil may be an effective treatment for thyroid storm by inhibiting the conversion of thyroxine to triiodothyronine in peripheral tissues 2.
• Propranolol can mask certain clinical signs of hyperthyroidism, and its abrupt withdrawal may lead to an exacerbation of symptoms, including thyroid storm 3. Key Considerations:
• Use propylthiouracil to inhibit thyroid hormone synthesis and conversion 2.
• Use propranolol with caution, as it may mask symptoms of hyperthyroidism and exacerbate thyroid storm if withdrawn abruptly 3.

From the Research

Thyroid Storm Management

Thyroid storm is a life-threatening condition that requires prompt and intensive treatment. The management of thyroid storm involves a combination of medications and supportive care to control the symptoms and prevent complications.

• Medications: The treatment regimen for thyroid storm typically includes:
  • Beta-adrenergic antagonists, such as propranolol, to inhibit the catecholamine-mediated peripheral effects of circulating thyronines 4
  • Antithyroid drugs, such as propylthiouracil, to inhibit thyroid hormone synthesis and peripheral conversion of thyroxine to triiodothyronine (T3) 4, 5
  • Inorganic iodide, such as potassium iodide, to block the glandular release of thyroid hormones 4, 5
  • Corticosteroids, such as dexamethasone, to support the patient's adrenal function and prevent adrenal crisis 4, 5
• Supportive Care: Patients with thyroid storm require close monitoring and supportive care to manage their symptoms and prevent complications. This may include:
  • Intensive care unit (ICU) admission for close monitoring and support 6
  • Fluid and electrolyte management to prevent dehydration and electrolyte imbalances
  • Cardiac monitoring and support to manage cardiac complications, such as tachycardia and hypertension
  • Respiratory support, such as oxygen therapy and mechanical ventilation, to manage respiratory complications, such as respiratory failure
• Alternative Routes of Administration: In some cases, patients with thyroid storm may require alternative routes of administration for their medications, such as rectal administration of iodide and propylthiouracil 5
• Newer Therapies: Newer therapies, such as esmolol, a beta-adrenergic antagonist, may be used to control hypersympathetic activity in patients with thyroid storm 7
• Clinical Guidelines: Clinical guidelines, such as those developed by the Japan Thyroid Association and Japan Endocrine Society, provide recommendations for the management of thyroid storm, including diagnosis, treatment, and prevention of complications 6