Treatment of Thyroid Storm
Thyroid storm requires immediate treatment with a multi-drug approach including thionamides, iodine solutions, beta-blockers, corticosteroids, and supportive care to prevent mortality. 1
First-Line Medications
1. Thionamides (Block Hormone Synthesis)
- Start with propylthiouracil (PTU) as first choice since it both inhibits thyroid hormone synthesis and peripheral conversion of T4 to T3 1, 2
- Alternatively, methimazole can be used if PTU is unavailable 1
- Recent evidence suggests no significant difference in mortality between propylthiouracil and methimazole (adjusted risk difference of 0.6%, 95% CI -1.8% to 3.0%) 3
2. Iodine Solutions (Block Hormone Release)
- Administer saturated potassium iodide solution or sodium iodide 1-2 hours AFTER starting thionamides 1
- Critical caveat: Never give iodine before thionamides as this can worsen thyrotoxicosis 1
3. Beta-Blockers (Control Adrenergic Effects)
- Essential for controlling tachycardia and other cardiovascular symptoms 1
- Consider esmolol (short-acting) for patients with hemodynamic instability 1
- Propranolol or atenolol can be used for symptomatic relief 4
4. Corticosteroids
- Administer dexamethasone or another corticosteroid to:
- Reduce peripheral conversion of T4 to T3
- Treat possible relative adrenal insufficiency 1
Treatment Algorithm Based on Severity
Mild to Moderate Symptoms (Still Life-Threatening)
- Beta-blockers for symptomatic relief 4
- Hydration and supportive care 4
- Thionamides to block hormone synthesis 1
- Iodine solutions 1-2 hours after thionamides 1
Severe Symptoms
- Hospitalize immediately 4
- Endocrine consultation is mandatory 4
- Beta-blockers for cardiovascular symptoms 4
- Aggressive hydration and supportive care 4
- Full thyroid storm protocol with thionamides, iodine solutions, and corticosteroids 1
Supportive Care
- Oxygen therapy as needed 1
- Antipyretics for fever control 1
- Identify and treat precipitating factors (infection, surgery, trauma) 1, 5
Refractory Cases
- Consider therapeutic plasma exchange (TPE) when patients fail conventional therapy 6
- TPE can effectively remove thyroid hormones bound to albumin, autoantibodies, and cytokines 6
- In one case study, TPE normalized thyroid hormone levels and resolved symptoms after 4 daily treatments 6
Monitoring and Follow-up
- Close monitoring of thyroid function every 2-3 weeks after initial stabilization 4
- Watch for transition to hypothyroidism, which is common after thyroid storm treatment 4
- Monitor for potential complications of therapy: