From the Guidelines
Thyroid storm should be treated with a multi-faceted approach, including beta-blockers, thionamides, iodine solutions, and glucocorticoids, with the goal of reducing thyroid hormone production and alleviating symptoms. The treatment of thyroid storm involves several key components, including:
- Beta-blockers, such as propranolol 60-80 mg orally every 4-6 hours or IV esmolol/metoprolol for patients with contraindications to propranolol, to control heart rate and tremors 1
- Thionamides, such as methimazole 20-25 mg orally every 6 hours or propylthiouracil (PTU) 200-400 mg orally every 6 hours, to inhibit thyroid hormone synthesis 1
- Iodine solutions, such as Lugol's solution 10 drops orally every 8 hours or potassium iodide 5 drops every 6 hours, administered 1 hour after thionamides to prevent iodine utilization for hormone synthesis
- Glucocorticoids, such as hydrocortisone 100 mg IV every 8 hours, to block peripheral conversion of T4 to T3 and treat potential adrenal insufficiency The most recent and highest quality study, published in 2022, supports the use of beta-blockers, such as propranolol, in the treatment of thyroid storm 1. Additionally, the 2002 study published in the American Family Physician provides guidance on the diagnosis and treatment of thyroid storm in pregnancy, including the use of propylthiouracil, methimazole, and iodine solutions 1. However, the 2022 study is considered the most relevant and up-to-date guidance for the treatment of thyroid storm. The treatment of thyroid storm should prioritize reducing thyroid hormone production and alleviating symptoms, with the goal of preventing multi-organ failure and death. Supportive care, including aggressive cooling measures, IV fluids, nutritional support, and treatment of precipitating factors like infection, is also crucial in the management of thyroid storm.
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 (hyperthyroid crisis) may include propylthiouracil (PO), as it inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues 2.
- Key points:
- Propylthiouracil is effective in the treatment of hyperthyroidism
- It may be an effective treatment for thyroid storm Note that methimazole does not have direct information regarding thyroid storm treatment in its label 3.
From the Research
Treatment Options for Thyroid Storm
The treatment for thyroid storm, also known as hyperthyroid crisis, involves a multi-faceted approach to manage the condition. The following are some of the treatment options:
- Medications:
- Propranolol to inhibit the catecholamine-mediated peripheral effects of the circulating thyronines 4
- Propylthiouracil to inhibit thyroid hormone synthesis and to inhibit peripheral conversion of thyroxine to triiodothyronine (T3) 4
- Methimazole (MMI) as a first-line therapy to block production of thyroid hormones 5
- Iodine therapy: to block the glandular release of thyroid hormones 4
- Dexamethasone: along with general supportive therapy 4
- Therapeutic plasma exchange (TPE): as a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate 5, 6
- Thyroidectomy: as the treatment of choice if medical treatment fails to result in clinical improvement 7
Considerations for Treatment
When treating thyroid storm, it is essential to consider the following:
- Caution with β-blockers: in patients with underlying thyrocardiac disease, as they may cause circulatory failure from cardiogenic shock 8
- Monitoring and supportive care: to manage systemic complications and prevent cardiopulmonary failure 7
- Early intervention: to avoid delays in therapy and reduce mortality rates 7