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

From the Guidelines

Thyroid storm treatment requires immediate and aggressive management with a multi-faceted approach, prioritizing beta-blockers, thionamides, iodine solutions, and corticosteroids to rapidly reduce circulating thyroid hormone levels and support the body through this life-threatening condition. The treatment should start with beta-blockers like propranolol (60-80 mg orally every 4-6 hours) to control adrenergic symptoms such as tachycardia and hypertension, as suggested by 1. Next, administer thionamides to block new thyroid hormone synthesis; propylthiouracil (PTU) is preferred initially (600-1000 mg loading dose, then 200-250 mg every 4-6 hours) because it also blocks peripheral T4 to T3 conversion, as mentioned in 1. One hour after starting thionamides, give iodine solutions like Lugol's solution (5-10 drops three times daily) or potassium iodide (SSKI, 5 drops every 6 hours) to block thyroid hormone release. Corticosteroids such as hydrocortisone (100 mg intravenously every 8 hours) help reduce T4 to T3 conversion and treat potential adrenal insufficiency.

Some key points to consider in the treatment of thyroid storm include:

• General supportive measures, such as oxygen, antipyretics, and appropriate monitoring, are also important, as stated in 1.
• The perceived underlying cause of thyroid storm should be treated, as mentioned in 1.
• Depending on gestational age, fetal status should be evaluated with ultrasound examination, nonstress testing, or a biophysical profile, as suggested by 1.
• Unless deemed necessary, delivery during thyroid storm should be avoided, as stated in 1.
• Patients require ICU-level monitoring with frequent vital sign checks and cardiac monitoring, as this comprehensive approach targets multiple aspects of thyroid hormone production and action.

It is essential to note that while 1 provides guidance on managing atrial fibrillation, its relevance to thyroid storm treatment is limited, and 1 remains the primary source for guiding treatment decisions in this context.

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 the treatment of thyroid storm in its label 3.

From the Research

Treatment for Thyroid Storm

The treatment for thyroid storm, also known as hyperthyroid crisis, typically involves a combination of medications and supportive care. The primary goals of treatment are to reduce thyroid hormone production, block the release of thyroid hormones, and manage systemic complications.

• Medications:
  • Thionamide medications, such as methimazole or propylthiouracil, to prevent further thyroid hormone synthesis 4, 5, 6
  • Iodine solution to block the release of thyroid hormones 4, 5
  • Beta-blockers to manage symptoms such as tachycardia and tremors 5
  • Corticosteroids to reduce inflammation and prevent adrenal crisis 5, 7
• Alternative Routes of Administration:
  • Intravenous thionamides (available in Europe and Japan) for patients who cannot tolerate oral medications 4
  • Rectal administration of thionamides, such as propylthiouracil, as an alternative route 4
• Supportive Care:
  • Intensive care unit (ICU) admission for close monitoring and supportive care 8
  • Treatment of systemic complications, such as cardiac dysfunction and respiratory failure 8, 7
• Surgical Intervention:
  • Thyroidectomy may be considered in extreme cases where medical treatment fails 4, 8
  • Plasmapheresis may be used as a therapeutic option in patients who do not respond to conventional treatment 6