From the Guidelines
Inpatient management of hyperthyroidism should involve a combination of beta-blockers, thionamides, and supportive care to effectively control the hypermetabolic state and address the underlying pathophysiology. The most recent and highest quality study, 1, published in 2022, highlights the importance of individualized treatment approaches, including the use of beta-blockers such as propranolol to manage symptoms.
Key Components of Management
- Beta-blockers: propranolol 20-40mg every 6 hours or metoprolol 25-50mg every 6 hours to manage tachycardia and adrenergic symptoms
- Thionamides: methimazole 20-30mg daily (divided into 2-3 doses) to block new thyroid hormone synthesis
- Supportive care: aggressive fluid resuscitation, cooling measures for hyperthermia, nutritional support, and treatment of precipitating factors
- Cardiac monitoring: essential as patients are at risk for arrhythmias
Additional Considerations
- In severe cases or thyroid storm, higher doses of methimazole (up to 60-80mg daily) may be necessary
- Potassium iodide solution (SSKI) 5 drops twice daily or Lugol's solution 10 drops three times daily may be administered to block thyroid hormone release
- Hydrocortisone 100mg every 8 hours may be added in thyroid storm to block peripheral conversion of T4 to T3 and support potential adrenal insufficiency
Transition to Outpatient Management
Once stabilized, patients should transition to outpatient management with continued thionamides and consideration of definitive therapy (radioactive iodine or surgery) as recommended by studies such as 1 and 1. This approach prioritizes morbidity, mortality, and quality of life outcomes, and is supported by the most recent and highest quality evidence available.
From the FDA Drug Label
Thyroid function tests should be monitored periodically during therapy Once clinical evidence of hyperthyroidism has resolved, the finding of a rising serum TSH indicates that a lower maintenance dose of methimazole should be employed.
The management strategies for inpatient hyperthyroidism include:
- Monitoring thyroid function tests periodically during therapy
- Adjusting the dose of methimazole based on clinical evidence of hyperthyroidism and serum TSH levels 2
From the Research
Management Strategies for Inpatient Hyperthyroidism
The management of inpatient hyperthyroidism involves several strategies, including:
- Antithyroid medications, such as methimazole and propylthiouracil, which inhibit the synthesis of thyroid hormone 3, 4, 5
- Radioactive iodine ablation of the thyroid gland, which is the most widely used treatment in the United States 4, 6
- Surgical thyroidectomy, which is considered for patients with concurrent cancer, in pregnancy, for compressive symptoms, and in Graves' disease with ophthalmic manifestations 4, 6
- Beta blockers, which are used to treat cardiovascular manifestations such as hypertension and tachycardia 6
Treatment Options
Treatment options for hyperthyroidism depend on the underlying diagnosis, the presence of contraindications to a particular treatment modality, the severity of hyperthyroidism, and the patient's preference 4, 7. The choice of treatment should be individualized and patient-centered 7.
Preoperative Management
Preoperatively, patients should be on antithyroid medications to establish a euthyroid state and on beta blockers for any cardiovascular manifestations 6.
Special Considerations
Thyroid storm is a rare but life-threatening condition that can occur with thyrotoxicosis and must be treated with a multidisciplinary approach and ultimately, definitive treatment of the hyperthyroidism 6. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes, and may lead to unintentional weight loss and increased mortality 7.