What is the treatment for thyroid storm?

Treatment of Thyroid Storm

Thyroid storm requires immediate treatment with a combination of propylthiouracil or methimazole, potassium iodide, beta-blockers, corticosteroids, and supportive care to prevent mortality. 1

Diagnosis

Thyroid storm is an extreme hypermetabolic state characterized by:

• Fever 1
• Tachycardia disproportionate to fever 1
• Altered mental status (nervousness, restlessness, confusion, seizures) 1
• Gastrointestinal symptoms (vomiting, diarrhea) 1
• Cardiac arrhythmias 1
• Often precipitated by surgery, infection, labor, or delivery 1

Without treatment, thyroid storm can progress to shock, stupor, and coma with high mortality rates of 20-50% 2.

Treatment Algorithm

1. First-Line Medications

• Thionamides - Block new thyroid hormone synthesis

  • Propylthiouracil (PTU) - preferred in thyroid storm as it also blocks peripheral T4 to T3 conversion 3
  • Methimazole - alternative option 1

• Iodine Solutions - Block thyroid hormone release

  • Saturated solution of potassium iodide or sodium iodide 1
  • Alternatives: Lugol's solution or lithium carbonate 1, 4
  • Important: Administer iodine at least 1 hour AFTER thionamides to prevent increased hormone synthesis 4

• Beta-Blockers - Block peripheral effects of thyroid hormone

  • First choice for controlling cardiovascular symptoms 1
  • If beta-blockers contraindicated, use non-dihydropyridine calcium channel blockers 1

• Corticosteroids - Reduce T4 to T3 conversion and treat potential relative adrenal insufficiency

  • Dexamethasone is recommended 1

• Supportive Care

  • Oxygen therapy 1
  • Antipyretics 1
  • Appropriate monitoring 1
  • Treatment of precipitating factors 1

2. Second-Line Therapies for Refractory Cases

• Therapeutic Plasma Exchange (TPE)

  • Consider when conventional treatment fails 5, 6
  • Rapidly removes thyroid hormones and cytokines from circulation 6
  • Should be initiated early in severe cases with neurologic symptoms 6

• Other Adjunctive Therapies

  • Cholestyramine - binds thyroid hormones in intestine 4
  • Phenobarbital - for severe agitation 1

Special Considerations in Pregnancy

• The same treatment protocol applies in pregnancy 1
• Monitor fetal status with ultrasound, nonstress testing, or biophysical profile 1
• Avoid delivery during thyroid storm unless absolutely necessary 1

Common Pitfalls and Caveats

• Do not delay treatment while waiting for laboratory confirmation 1
• Never administer iodine before thionamides as this can worsen thyrotoxicosis 7
• Avoid radioactive iodine (I-131) - contraindicated in thyroid storm and pregnancy 1
• Monitor for agranulocytosis with thionamides - patients should report sore throat and fever immediately 1
• Be vigilant for cardiac complications - heart failure is a major risk 1

After Crisis Resolution

Once the acute crisis is controlled, definitive treatment of the underlying thyrotoxicosis should be planned, which may include:

• Continued medical therapy 4
• Thyroidectomy (for those who don't respond to medical therapy) 1
• Radioactive iodine ablation (once stable and not pregnant) 1, 4

Thyroid storm is a true endocrine emergency requiring prompt recognition and aggressive multidrug therapy to reduce mortality 4, 2.