What is the treatment for thyroid storm?

Thyroid Storm Treatment

Immediately initiate multi-drug therapy with thionamides, iodine (given 1-2 hours AFTER thionamides), beta-blockers, and corticosteroids without waiting for laboratory confirmation, as treatment delays significantly increase mortality. 1, 2, 3

Immediate Resuscitation and Hospitalization

• Hospitalize all patients with thyroid storm in an ICU setting for severe cases, as this is a life-threatening endocrine emergency with mortality rates of 10-20% that can rise to 75% with treatment delays. 2, 4
• Provide supplemental oxygen and position the patient head-up to improve respiratory function. 2
• Establish continuous cardiac monitoring and frequent vital sign assessment. 1

Step 1: Block New Thyroid Hormone Synthesis (Give FIRST)

Propylthiouracil (PTU) is the preferred first-line thionamide because it uniquely inhibits both thyroid hormone synthesis AND peripheral conversion of T4 to T3, making it superior to methimazole in thyroid storm. 1, 5

• Administer PTU 60-80 mg orally every 4-6 hours (typical dosing, adjust based on clinical response). 1
• Alternative: Methimazole can be used if PTU is unavailable or contraindicated. 1, 3
• Critical caveat: Monitor for agranulocytosis (usually within first 3 months) and severe hepatotoxicity—stop immediately if fever, sore throat, or signs of liver injury develop. 2, 5

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

Administer saturated solution of potassium iodide (SSKI) or sodium iodide 1-2 hours after starting thionamides—NEVER before. 1, 2, 3

• Critical pitfall: Giving iodine before thionamides can paradoxically worsen thyrotoxicosis by providing substrate for new hormone synthesis. 1, 3

Step 3: Control Adrenergic Symptoms with Beta-Blockade

Propranolol is the preferred beta-blocker because it provides dual benefit: controlling cardiovascular symptoms AND blocking peripheral T4 to T3 conversion. 1

• Standard dosing: Propranolol 60-80 mg orally every 4-6 hours. 1
• For hemodynamically unstable patients requiring vasopressor support: Use esmolol due to its ultra-short half-life allowing rapid titration. 1
  • Loading dose: 500 mcg/kg (0.5 mg/kg) IV over 1 minute
  • Maintenance: Start at 50 mcg/kg/min, titrate up to maximum 300 mcg/kg/min
  • Monitor continuously for hypotension and bradycardia 1
• If beta-blockers are contraindicated (severe heart failure, bronchospasm): Use non-dihydropyridine calcium channel blockers like diltiazem 15-20 mg (0.25 mg/kg) IV over 2 minutes. 1, 3

Step 4: Reduce Peripheral T4 to T3 Conversion

Administer dexamethasone or another corticosteroid to block peripheral conversion of T4 to T3 and treat potential relative adrenal insufficiency that commonly accompanies thyroid storm. 1, 2, 3

Step 5: Supportive Care and Treat Precipitating Factors

• Aggressively treat hyperthermia with antipyretics (avoid aspirin as it may increase free thyroid hormone levels). 1, 3
• Provide hydration and electrolyte repletion. 1
• Identify and treat the precipitating trigger (infection, surgery, trauma, medication non-compliance, iodinated contrast)—this is essential as thyroid storm rarely occurs spontaneously. 2, 6, 7
• Prepare for potential rapid clinical deterioration requiring advanced airway management. 6

Monitoring Requirements

• Do NOT delay treatment waiting for thyroid function tests—diagnosis is clinical, and thyroid hormone levels do not distinguish uncomplicated thyrotoxicosis from thyroid storm. 2, 4
• 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 initiation. 1, 2
• Monitor for cardiac complications including heart failure and arrhythmias. 1, 2
• Adjust beta-blocker doses when patient becomes euthyroid due to increased drug clearance during hyperthyroidism. 2

Special Populations

Pregnancy: Use the same treatment protocol as non-pregnant patients, but monitor fetal status closely and avoid delivery during active thyroid storm unless absolutely necessary. 1, 2, 3

Definitive Treatment Planning

After the acute crisis resolves, plan definitive treatment of underlying thyrotoxicosis with continued medical therapy, thyroidectomy, or radioactive iodine ablation to prevent recurrence. 2, 3, 8

If medical management fails to produce clinical improvement within 12-24 hours, consider early thyroidectomy as mortality from cardiopulmonary failure increases significantly with prolonged crisis. 4, 7