Initial Treatment for Thyroid Storm
The initial treatment for thyroid storm requires immediate administration of a combination of propylthiouracil (PTU), potassium iodide, beta-blockers, corticosteroids, and supportive care to prevent mortality. 1
First-Line Medications
1. Blocking Thyroid Hormone Synthesis
- Administer propylthiouracil (PTU) as the first-line agent since it both inhibits thyroid hormone synthesis and blocks peripheral conversion of T4 to T3 1, 2
- Alternatively, methimazole can be used if PTU is unavailable, though recent evidence suggests similar outcomes between the two medications 1, 3
2. Blocking Thyroid Hormone Release
- Administer saturated potassium iodide solution or sodium iodide 1-2 hours after starting thionamide therapy 1
- Critical timing: Never administer iodine before thionamides as this can worsen thyrotoxicosis 1
3. Controlling Adrenergic Effects
- Administer beta-blockers (propranolol or atenolol) for controlling tachycardia and other cardiovascular symptoms 1, 4
- For hemodynamically unstable patients, consider esmolol for its short half-life and ability to carefully titrate beta-blockade 1
- Propranolol has the added benefit of blocking peripheral conversion of T4 to T3 1, 4
4. Reducing Peripheral Conversion of T4 to T3
- Administer dexamethasone or another corticosteroid to reduce peripheral conversion of T4 to T3 and treat possible relative adrenal insufficiency 1
Treatment Based on Severity
Severe Symptoms (Grade 3-4)
- Hospitalize immediately, preferably in ICU for severe cases 1, 5
- Hold immune checkpoint inhibitors (if applicable) until symptoms resolve 6
- Obtain endocrine consultation for all patients 6
- Provide beta-blockers, hydration, and supportive care 6
- Consider additional medical therapies including steroids, potassium iodide solution, and thionamides (methimazole or propylthiouracil) 6
Moderate Symptoms (Grade 2)
- Consider holding immune checkpoint inhibitors (if applicable) until symptoms return to baseline 6
- Consider endocrine consultation 6
- Provide beta-blockers for symptomatic relief, hydration, and supportive care 6
Supportive Care
- Provide oxygen therapy as needed 1
- Administer antipyretics to control fever 1, 5
- Identify and treat precipitating factors (infection, surgery, childbirth, etc.) 1, 7
- Monitor thyroid function every 2-3 weeks after initial stabilization 6
Special Considerations
Monitoring for Complications
- Watch for transition to hypothyroidism, which commonly occurs after thyroid storm treatment 6
- Monitor for agranulocytosis with thionamide use 1
- Monitor for cardiac complications such as heart failure 1, 7
Refractory Cases
- For thyroid storm refractory to conventional treatment, consider therapeutic plasma exchange 8
- Consider early thyroidectomy if medical treatment fails to result in clinical improvement within 12-24 hours 7
Clinical Pearls
- Thyroid storm diagnosis is primarily clinical; laboratory values may not differ significantly from uncomplicated thyrotoxicosis 7, 5
- Mortality can reach 10-20% even with treatment, and may rise to 75% if therapy is delayed 7
- The most common cause of death is cardiopulmonary failure, particularly in elderly patients 7
- A multidisciplinary approach involving critical care and endocrinology specialists is essential 5