From the Guidelines
Thyroid storm treatment should prioritize a multi-faceted approach, including hospitalization in an intensive care unit, beta-blockers like propranolol, antithyroid medications such as methimazole or propylthiouracil, iodine therapy, and corticosteroids, to rapidly control this life-threatening condition. The treatment regimen should be individualized based on the patient's medical comorbidities and the underlying cause of the thyroid storm. According to the most recent study 1, beta-blockers like propranolol are essential in treating the increased heart rate and tremor associated with thyrotoxicosis, and may also reverse some of the reduced systemic vascular resistance associated with the hormonal disease.
Key components of the treatment regimen include:
- Beta-blockers like propranolol (60-80 mg orally every 4-6 hours) to control sympathetic symptoms such as tachycardia and hypertension
- Antithyroid medications, typically methimazole (20-25 mg orally every 6 hours) or propylthiouracil (PTU, 200-250 mg orally every 4 hours), with PTU preferred initially as it also blocks peripheral conversion of T4 to T3
- Iodine therapy, which should begin one hour after starting antithyroid drugs, with potassium iodide (SSKI, 5 drops orally every 6 hours) or Lugol's solution (10 drops orally every 8 hours) to block thyroid hormone release
- Corticosteroids like hydrocortisone (100 mg intravenously every 8 hours) to reduce T4 to T3 conversion and treat potential adrenal insufficiency
- Supportive measures, including fever control with acetaminophen, cooling blankets, and treating the underlying trigger of the thyroid storm, as well as fluid resuscitation, electrolyte replacement, and nutritional support.
It is crucial to note that the perceived underlying cause of thyroid storm should be treated, and fetal status should be evaluated with ultrasound examination, nonstress testing, or a biophysical profile, depending on gestational age, as mentioned in the study 1. Unless deemed necessary, delivery during thyroid storm should be avoided.
From the FDA Drug Label
Propylthiouracil inhibits the conversation of thyroxine to triiodothyronine to peripheral tissues and may therefore be an effective treatment for thyroid storm. The treatment for a thyroid storm may include propylthiouracil as it inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues, making it a potentially effective treatment option 2.
- Key points:
- Propylthiouracil is used to treat hyperthyroidism
- It may be effective in treating thyroid storm by inhibiting the conversion of thyroxine to triiodothyronine
- However, propranolol may also be used to manage symptoms of thyroid storm, but it may mask certain clinical signs of hyperthyroidism and abrupt withdrawal may exacerbate symptoms, including thyroid storm 3.
From the Research
Treatment Overview
The treatment for a thyroid storm is a multidrug approach that aims to decrease new hormone synthesis, inhibit the release of thyroid hormone, and block the peripheral effects of thyroid hormone.
- Medical treatment is based on three principles:
- This approach uses thionamides, iodine, beta-adrenergic receptor antagonists, corticosteroids in certain circumstances, and supportive therapy 5
- Certain conditions may warrant the use of alternative therapy with cholestyramine, lithium carbonate, or potassium perchlorate 5
Surgical Intervention
In some cases, thyroidectomy may be considered as a treatment option, especially if medical treatment fails to result in clinical improvement 4, 6
- Thyroidectomy is a potential therapeutic choice for cases of thyroid storm refractory to medical management 6
Administration of Medications
Rectal administration of iodide and propylthiouracil is an effective alternative for patients in thyroid storm with upper gastrointestinal tract dysfunction 7
Emergency Situations
Thyroid storm can occur in emergency situations, such as following rapid sequence intubation, and requires immediate treatment to prevent high mortality rates 8