What is the evidence for using colestiramine in the treatment of thyroid storm?

Cholestyramine in Thyroid Storm Treatment

Cholestyramine is a recommended adjunctive treatment in thyroid storm management as part of a multipronged therapeutic approach, though it is not a first-line agent. 1, 2

Pathophysiological Basis for Cholestyramine Use

Cholestyramine works in thyroid storm by:

• Binding thyroid hormones in the intestine
• Interrupting enterohepatic circulation of thyroid hormones
• Enhancing elimination of thyroid hormones from the body

Standard Treatment Protocol for Thyroid Storm

The American Academy of Family Physicians recommends a stepwise approach to thyroid storm management 3:

1. First-line medications:

   • Thionamides: Propylthiouracil (PTU) or methimazole to block new hormone synthesis
   • Beta-blockers: Propranolol 60-80 mg orally every 4-6 hours or 1-2 mg IV (preferred due to its additional T4-to-T3 conversion blocking effect)
   • Corticosteroids: Dexamethasone to reduce T4-to-T3 conversion and treat potential adrenal insufficiency

2. Second-line medications:

   • Iodine solutions: Saturated solution of potassium iodide (SSKI) or sodium iodide (should be administered 1 hour AFTER thionamides to prevent iodine utilization for hormone synthesis)
   • Cholestyramine: To enhance elimination of thyroid hormones

3. Supportive measures:

   • Oxygen
   • Antipyretics
   • Appropriate monitoring
   • Treatment of the precipitating cause

Evidence for Cholestyramine in Thyroid Storm

While specific high-quality studies on cholestyramine in thyroid storm are limited, it is included in recent comprehensive reviews of thyroid storm management. A 2023 review in the American Journal of Emergency Medicine specifically mentions cholestyramine as part of the standard treatment protocol 1, and a 2025 narrative review in Endocrine Practice describes cholestyramine as part of the multipronged approach to thyroid storm management 2.

Special Considerations

• In patients with severe thyroid storm refractory to conventional treatment, therapeutic plasma exchange may be considered, as reported in case studies 4
• Non-selective beta-blockers are associated with higher mortality compared to selective beta-1 antagonists in Japanese nationwide surveys 5
• For patients with contraindications to beta-blockers, non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) can be used as alternatives 3

Practical Application

For a patient presenting with thyroid storm:

1. Begin thionamide therapy immediately (methimazole or PTU)
2. Add beta-blockade (preferably propranolol if no contraindications)
3. Administer corticosteroids
4. Add iodine solution 1 hour after thionamide
5. Add cholestyramine as an adjunctive therapy to enhance hormone elimination
6. Provide supportive care and treat the underlying trigger

Monitoring Response

Monitor:

• Vital signs, especially heart rate and temperature
• Mental status
• Thyroid function tests
• Organ function (liver, kidney, cardiac)
• Adjust therapy based on clinical response

The combination of these treatments targets different aspects of thyroid hormone excess, with cholestyramine specifically enhancing elimination of circulating hormones through the gastrointestinal tract.