What is the treatment for thyroid storm (hyperthyroid crisis)?

From the Guidelines

Thyroid storm should be treated with a multi-targeted approach using the "5 Bs": Beta-blockers, Block hormone synthesis, Block hormone release, Block T4 to T3 conversion, and Block enterohepatic circulation, as well as supportive care to reduce morbidity, mortality, and improve quality of life. The management of thyroid storm involves a combination of medications and supportive care to control the symptoms and prevent complications.

• Beta-blockers, such as propranolol 60-80 mg orally every 4 hours or IV esmolol/metoprolol if unable to take oral medications, are used to control sympathetic symptoms 1.
• Block hormone synthesis with thionamides, such as propylthiouracil 200-400 mg every 4-6 hours or methimazole 20-25 mg every 6 hours.
• Block hormone release with iodine solutions, such as SSKI 5 drops every 6 hours or Lugol's solution 10 drops every 8 hours, started 1 hour after thionamides.
• Block T4 to T3 conversion with high-dose glucocorticoids, such as hydrocortisone 100 mg IV every 8 hours.
• Block enterohepatic circulation with cholestyramine 4 g orally four times daily. Supportive care is crucial, including aggressive cooling, IV fluids, glucose supplementation, and treatment of the precipitating cause (infection, surgery, trauma, medication non-compliance) 1. Thyroid storm occurs when excess thyroid hormone overwhelms the body's compensatory mechanisms, causing multi-organ dysfunction with mortality rates of 10-30% even with treatment. Early recognition and aggressive management in an ICU setting are essential for survival. 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 the patient is pregnant. Unless deemed necessary, delivery during thyroid storm should be avoided. It is essential to note that the treatment should not be delayed for test results, and a standard series of drugs should be used to treat 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, 5
  • Methimazole (MMI) as an alternative to propylthiouracil 5, 6
  • Iodine to block the glandular release of thyroid hormones 4
  • Dexamethasone along with general supportive therapy 4
  • Corticosteroids (CSs) in severe cases 6
• Therapeutic Plasma Exchange (TPE):
  • TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines, and cytokines, and is likely beneficial for patients who cannot tolerate or fail pharmacotherapy 5, 7
  • Plasmapheresis is a second-line treatment for severe or otherwise untreatable thyrotoxicosis when rapid euthyroidism is desired 7
• Surgery:
  • Thyroidectomy may be considered as the treatment of choice if medical treatment fails to result in clinical improvement 8
  • Early thyroidectomy should be considered in cases where medical treatment is not effective 8

Treatment Goals

The primary goal of treatment is to rapidly reduce thyroid hormone levels and alleviate symptoms. Treatment should be initiated promptly, as any delay can increase the risk of mortality 8. The treatment regimen should be tailored to the individual patient's needs, taking into account the severity of the condition and any underlying health issues.

Important Considerations

• Monitoring: Close monitoring of the patient's condition is crucial, as thyroid storm can be life-threatening if left untreated or if treatment is delayed 8
• Multimodal Treatment: In severe cases, multimodal treatment, including administration of antithyroid drugs, iodine, corticosteroids, and selective beta1-adrenergic antagonists, may be preferable to improve outcomes 6