From the Guidelines
The treatment for acute thyrotoxicosis in the hospital setting involves a multi-drug approach targeting different aspects of thyroid hormone production and action, with beta-blockers such as propranolol being the initial management to control sympathetic symptoms like tachycardia and tremor. The management of thyrotoxicosis is crucial to prevent morbidity and mortality, and the approach should be individualized based on the severity of symptoms and the presence of underlying medical conditions 1.
Key Components of Treatment
- Beta-blockers: Propranolol (40-80mg every 4-6 hours) or esmolol infusion to control sympathetic symptoms like tachycardia and tremor 1
- Thionamides: Methimazole (20-25mg every 6 hours) or propylthiouracil (200-400mg every 6 hours) to block new thyroid hormone synthesis, with PTU preferred in thyroid storm due to its additional T4-to-T3 conversion inhibition
- Iodine solutions: SSKI 5 drops twice daily or Lugol's solution should be given at least one hour after thionamides to prevent iodine utilization for hormone synthesis
- Glucocorticoids: Hydrocortisone (100mg every 8 hours) to reduce T4-to-T3 conversion and treat potential adrenal insufficiency
- Cholestyramine: 4g four times daily to enhance thyroid hormone elimination through the gut
- Supportive care: IV fluids, cooling measures, and treatment of precipitating factors are essential to support the patient until hormone levels normalize
Severity-Based Management
The management of thyrotoxicosis should be based on the severity of symptoms, with mild symptoms (G1) being managed with beta-blockers and close monitoring, moderate symptoms (G2) requiring consideration of holding ICPi and endocrine consultation, and severe symptoms (G3-4) necessitating hospitalization and additional medical therapies including steroids, SSKI, or thionamide (methimazole or propylthiouracil) and possible surgery 1.
Monitoring and Follow-up
Regular monitoring of thyroid function every 2-3 weeks after diagnosis is crucial to catch the transition to hypothyroidism, and treatment should be adjusted accordingly 1. The goal of treatment is to normalize hormone levels, which typically requires 24-72 hours before clinical improvement becomes evident. The comprehensive approach to treating acute thyrotoxicosis in the hospital setting should prioritize the reduction of morbidity and mortality, and improvement of quality of life.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment of Thyrotoxicosis in Acute Setting Hospital
The treatment of thyrotoxicosis in the acute setting of a hospital involves several approaches, including the use of antithyroid medications.
- Propylthiouracil and methimazole are two commonly used thionamide antithyroid drugs for treating thyroid storm, a severe form of thyrotoxicosis 2.
- A comparative effectiveness study found no significant differences in mortality or adverse events between patients treated with propylthiouracil and those treated with methimazole for thyroid storm 2.
- Another study compared the efficiency and safety of methimazole and propylthiouracil in hyperthyroidism, finding that methimazole may have better efficacy in reducing thyroid hormone levels, but also a higher risk of hypothyroidism 3.
Non-Thionamide Antithyroid Drug Options
In some cases, non-thionamide antithyroid drugs may be used as alternatives for patients who are intolerant or unresponsive to thionamides.
- Non-thionamide agents, such as iodine compounds, potassium perchlorate, lithium, glucocorticoids, beta-blockers, and cholestyramine, can be used to control Graves' hyperthyroidism 4.
- Novel experimental agents, including B-cell depletors, CD40 blockers, TSH-receptor antagonists, blocking antibodies, and immune-modifying peptides, are being developed to target the immunopathogenesis of Graves' disease 4.
Side Effects of Antithyroid Drugs
The side effects of antithyroid drugs, including propylthiouracil and methimazole, should be considered when selecting a treatment.
- A systematic review and meta-analysis found that propylthiouracil has a higher risk of liver function injury and elevated transaminase levels compared to methimazole/carbimazole 5.
- However, methimazole/carbimazole may have a higher risk of birth defects during the first trimester of pregnancy, and propylthiouracil is recommended for use in this period 5.