From the Guidelines
The initial management of thyroid storm requires prompt and aggressive treatment with a multimodal approach, starting with propylthiouracil or methimazole, followed by saturated solution of potassium iodide or sodium iodide, and supportive measures such as oxygen, antipyretics, and monitoring. The treatment should not be delayed for test results, and serum-free triiodothyronine (FT3), FT4, and TSH levels can help confirm the diagnosis 1.
Key Components of Treatment
- Propylthiouracil or methimazole to block new thyroid hormone synthesis
- Saturated solution of potassium iodide or sodium iodide to block thyroid hormone release
- Dexamethasone to reduce T4 to T3 conversion and address potential relative adrenal insufficiency
- General supportive measures, such as oxygen, antipyretics, and appropriate monitoring
- Treatment of the underlying cause of thyroid storm
Important Considerations
- Fetal status should be evaluated with ultrasound examination, nonstress testing, or a biophysical profile, depending on gestational age 1
- Delivery during thyroid storm should be avoided unless deemed necessary 1
- The perceived underlying cause of thyroid storm should be treated 1
Additional Measures
- Phenobarbital may be used in certain cases
- Reserpine, guanethidine, or diltiazem may be used with a history of severe bronchospasm
- Lithium may be used as an alternative to iodine solutions The goal of treatment is to rapidly control the life-threatening hypermetabolic state of thyroid storm and prevent complications such as shock, stupor, and coma 1.
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 initial dose is 300 mg daily. In patients with severe hyperthyroidism, very large goiters, or both, the initial dose may be increased to 400 mg daily; an occasional patient will require 600 to 900 mg daily initially 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.
The initial management of thyroid storm may involve the use of propylthiouracil at a dose of 300 mg daily, which can be increased to 400 mg daily or more in severe cases, as it inhibits the conversion of thyroxine to triiodothyronine. Additionally, propranolol may be used to mask the clinical signs of hyperthyroidism, but its withdrawal should be done with caution to avoid exacerbating symptoms, including thyroid storm 2, 2, 3.
- Key considerations:
- Propylthiouracil dose: 300 mg daily, potentially increased to 400 mg daily or more
- Propranolol use: may mask clinical signs of hyperthyroidism, but withdraw with caution to avoid exacerbating symptoms.
From the Research
Initial Management of Thyroid Storm
The initial management of thyroid storm involves a multi-step approach to reduce the severity of the condition and prevent further complications. Some of the key steps include:
- Administering anti-thyroid medications such as propylthiouracil or methimazole to reduce thyroid hormone production 4
- Using beta blockers like propranolol to control symptoms such as tachycardia and tremors
- Providing supportive care with intravenous fluids and medications to manage any related conditions
- In some cases, rectal administration of iodide and propylthiouracil may be considered for patients with upper gastrointestinal tract dysfunction 5
- Glucocorticoids like dexamethasone may be used to reduce peripheral triiodothyronine production and prevent recurrence of thyroid storm 6
Treatment Considerations
When managing thyroid storm, it is essential to consider the potential risks and benefits of different treatments. For example:
- Propylthiouracil may be associated with a risk of acute hepatitis, and patients should be monitored closely for signs of liver dysfunction 7
- Beta blockers should be used with caution in patients with certain medical conditions, such as asthma or heart failure
- Glucocorticoids may be necessary to prevent recurrence of thyroid storm, but they should be used at the lowest effective dose to minimize side effects
Special Considerations in Children
Thyroid storm in children can be particularly challenging to manage, and may be associated with seizures and encephalopathy 8. In these cases, prompt recognition and treatment of thyroid storm are critical to reduce morbidity and mortality. A multidisciplinary approach involving pediatric endocrinologists, neurologists, and other specialists may be necessary to provide optimal care.