From the Guidelines
Thyroid storm is a life-threatening medical emergency requiring immediate treatment with multiple medications to block thyroid hormone production and effects, starting with beta-blockers such as propranolol 60-80 mg orally every 4-6 hours or IV esmolol to control cardiovascular symptoms. The treatment approach should prioritize reducing morbidity, mortality, and improving quality of life. According to the most recent and highest quality study 1, propranolol is the most widely studied nonselective beta-blocker to treat the increased heart rate and tremor associated with thyrotoxicosis.
Key Treatment Components
- Beta-blockers: propranolol 60-80 mg orally every 4-6 hours or IV esmolol to control cardiovascular symptoms
- Thionamides: methimazole 20-25 mg orally every 6 hours or propylthiouracil 200-400 mg every 4-6 hours to block new hormone synthesis
- Iodine therapy: potassium iodide 5 drops every 6 hours or Lugol's solution, initiated one hour after starting thionamides, to block hormone release
- Corticosteroids: hydrocortisone 100 mg IV every 8 hours to reduce T4 to T3 conversion and treat potential adrenal insufficiency
- Supportive care: fever management with acetaminophen, cooling blankets, and treating the underlying trigger (infection, trauma, surgery)
Clinical Considerations
- Thyroid storm results from excessive thyroid hormone release overwhelming the body's compensatory mechanisms, causing hyperthermia, tachycardia, agitation, and potentially multi-organ failure
- Mortality remains high (10-30%) even with treatment, so patients require ICU admission with continuous cardiac monitoring and frequent reassessment of thyroid function
- The perceived underlying cause of thyroid storm should be treated, and depending on gestational age, fetal status should be evaluated with ultrasound examination, nonstress testing, or a biophysical profile if applicable 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. The treatment for thyroid storm (thyrotoxic crisis) may include propylthiouracil (PO), as it inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues, making it a potentially effective treatment option 2.
- Key points:
- Propylthiouracil inhibits thyroid hormone synthesis
- It does not inactivate existing thyroid hormones
- It may be effective in treating thyroid storm by inhibiting thyroxine to triiodothyronine conversion
From the Research
Treatment Overview
The treatment for thyroid storm (thyrotoxic crisis) involves several approaches, including:
- First-line therapy with methimazole (MMI) or propylthiouracil (PTU) to block the production of thyroid hormones 3
- β-adrenergic blockade using propranolol to inhibit the peripheral effects of thyroid hormones 4
- Therapeutic plasma exchange (TPE) as a second-line treatment for severe or otherwise untreatable thyrotoxicosis 3, 5
- Early thyroidectomy as the treatment of choice if medical treatment fails to result in clinical improvement 6
Medical Treatment
Medical treatment is based on three principles:
- Counteracting the peripheral effects of thyroid hormones
- Inhibition of thyroid hormone synthesis
- Treatment of systemic complications 6 The use of propylthiouracil and methimazole has been compared in a study, which found no significant differences in mortality or adverse events between the two treatment groups 7
Therapeutic Plasma Exchange
Therapeutic plasma exchange (TPE) is an effective and safe treatment option for reducing circulating thyroid hormones in severe thyrotoxicosis when other forms of treatment are contraindicated or in case of urgent thyroid and non-thyroid surgery 5 TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines, and cytokines, and is likely beneficial for patients with thyroid storm 3