What is the treatment for thyroid storm?

Treatment of Thyroid Storm

Thyroid storm requires immediate multi-drug therapy without waiting for laboratory confirmation: start propylthiouracil (preferred) or methimazole first, followed 1-2 hours later by potassium iodide, plus beta-blockers and corticosteroids, with all patients requiring hospitalization and severe cases needing ICU admission. 1, 2, 3

Immediate Stabilization and Hospitalization

• Hospitalize all patients immediately, with severe cases requiring ICU admission 2, 3
• Provide supplemental oxygen and position patient head-up to improve respiratory function 2
• Do not delay treatment while awaiting laboratory confirmation—mortality rises from 10-20% to as high as 75% with treatment delays 2, 4
• Initiate continuous cardiac monitoring and frequent vital sign assessment 1

Step 1: Block Thyroid Hormone Synthesis (Start First)

Propylthiouracil is the preferred first-line agent because it both inhibits thyroid hormone synthesis AND blocks peripheral conversion of T4 to T3, unlike methimazole which only blocks synthesis 1, 2, 5

• Administer propylthiouracil immediately as the initial medication 2, 3
• If propylthiouracil is unavailable, methimazole can be used as an alternative 1, 3
• Monitor for agranulocytosis, a serious adverse effect of thionamides 1, 2, 3

Step 2: Block Thyroid Hormone Release (Give 1-2 Hours After Thionamides)

Critical timing: Administer saturated potassium iodide solution or sodium iodide 1-2 hours AFTER starting thionamides 1, 2, 3

• Never give iodine before thionamides—this is a critical pitfall that can worsen thyrotoxicosis by providing substrate for additional hormone synthesis 1, 3

Step 3: Control Cardiovascular Symptoms with Beta-Blockers

Beta-blockers are essential for controlling tachycardia and cardiovascular manifestations 1, 2, 3

For Hemodynamically Stable Patients:

• Propranolol 60-80 mg orally every 4-6 hours is preferred because it also blocks peripheral T4 to T3 conversion 1

For Hemodynamically Unstable Patients:

• Esmolol is the beta-blocker of choice due to its ultra-short half-life allowing rapid titration 1
• Loading dose: 500 mcg/kg (0.5 mg/kg) IV over 1 minute 1
• Maintenance infusion: Start at 50 mcg/kg/min, titrate up to maximum 300 mcg/kg/min as needed 1
• Monitor continuously for hypotension, bradycardia, and heart failure 1

If Beta-Blockers Are Contraindicated:

• Use non-dihydropyridine calcium channel blockers (diltiazem 15-20 mg IV over 2 minutes, then 5-15 mg/h maintenance) 1, 3

Step 4: Reduce Peripheral T4 to T3 Conversion

Administer corticosteroids (dexamethasone preferred) to block peripheral conversion of T4 to T3 and treat potential relative adrenal insufficiency 1, 2, 3

Supportive Care

• Administer antipyretics for fever control 1, 3
• Provide aggressive hydration 1, 3
• Identify and treat precipitating factors (infection, surgery, trauma, childbirth, medication non-compliance) 1, 2
• Treat gastrointestinal symptoms and provide nutritional support 3

Monitoring Requirements

• Monitor thyroid function every 2-3 weeks after initial stabilization 1, 2
• Watch for transition to hypothyroidism, which commonly occurs after thyroid storm treatment and may require levothyroxine replacement 1, 2
• Monitor for cardiac complications including heart failure and arrhythmias 1, 2, 3
• Serial assessment for agranulocytosis with thionamide use 1, 2, 3

Expected Clinical Response

Clinical improvement should occur within 12-24 hours of initiating treatment—if no improvement, consider alternative therapies or early thyroidectomy 4, 6

Special Populations

Pregnancy:

• Treatment protocol is identical to non-pregnant patients 1, 2, 3
• Monitor fetal status continuously 1, 2, 3
• Avoid delivery during thyroid storm unless absolutely necessary 1, 2, 3

Refractory Cases

For patients not responding to conventional therapy within 12-24 hours, consider 7, 6:

• Therapeutic plasma exchange 7
• Cholestyramine to bind thyroid hormones in the gut 6, 8
• Lithium carbonate or potassium perchlorate as alternative agents 6
• Early thyroidectomy if medical management fails 4

Definitive Treatment Planning

After the acute crisis resolves, plan definitive treatment of underlying thyrotoxicosis 2, 3:

• Continued medical therapy
• Thyroidectomy
• Radioactive iodine ablation