Dexamethasone Administration in Hyperthyroid Patients Undergoing Thyroidectomy
Yes, it is safe and recommended to administer dexamethasone 8 mg IV preoperatively to hyperthyroid patients undergoing thyroidectomy, even when they cannot tolerate antithyroid drugs, as there is no evidence of increased risk of thyroid storm or perioperative complications. 1, 2
Evidence Supporting Safety in Hyperthyroid Patients
The combination of corticosteroids with other agents has been successfully used for rapid preoperative preparation in hyperthyroid patients requiring urgent surgery. 3
Betamethasone (a corticosteroid similar to dexamethasone) combined with iopanoic acid and propranolol was used safely in 14 hyperthyroid patients requiring urgent thyroidectomy, with no anesthetic incidents or postoperative complications. 3
A prospective study of 248 hyperthyroid patients undergoing thyroidectomy found zero cases of thyroid storm or mortality in both patients on antithyroid drugs and those who could not tolerate them (17 patients, 7%), with no difference in complications between groups. 2
Beneficial Effects of Dexamethasone in Thyroidectomy
Dexamethasone 8 mg IV administered preoperatively provides multiple benefits beyond PONV prevention that are particularly relevant in hyperthyroid patients:
Significantly reduces postoperative nausea and vomiting (PONV rate of 13% with ramosetron vs 35% with dexamethasone alone, but combination therapy achieves 10% PONV rate). 4
Decreases postoperative pain (p = 0.008) and reduces analgesic requirements (p = 0.048). 5
Reduces inflammation around the recurrent laryngeal nerve, which is critical given the 1.2%-5.0% incidence of hoarseness after thyroidectomy. 1
Thyroid Hormone Effects (Not a Contraindication)
Dexamethasone alters peripheral thyroid hormone metabolism but this does not contraindicate its use:
Dexamethasone increases reverse T3 (rT3) by approximately 50% within 24-32 hours and decreases active T3 by blocking peripheral conversion of T4 to T3. 6
In hyperthyroid patients, serum T4 may decrease from baseline (e.g., 23.5 to 18.4 mcg/dL after 3 days), which is actually beneficial in the perioperative setting. 6
These metabolic shifts represent a therapeutic advantage rather than a risk, as they help reduce circulating active thyroid hormone levels. 3, 6
Optimal Dosing and Timing
Administer dexamethasone 8 mg IV preoperatively, ideally 90 minutes before anesthesia induction or immediately after induction. 1, 7
The 8 mg dose is most effective for PONV prevention in thyroidectomy (p = 0.001), though 4-5 mg may provide equivalent antiemetic efficacy with less hyperglycemia risk. 1
For hyperthyroid patients with diabetes, consider 4 mg dexamethasone combined with a 5-HT3 antagonist (ondansetron 4 mg IV) rather than higher doses to minimize glucose elevation. 1
Critical Monitoring Requirements
Monitor blood glucose in diabetic patients, as dexamethasone causes dose-dependent transient hyperglycemia that is more pronounced with 8-10 mg doses than 4 mg doses in the first 24 hours. 1, 7
Watch for signs of airway compromise (stridor, difficulty breathing, rapidly expanding neck swelling) that may indicate hematoma rather than medication effects. 1
No steroid-related complications were observed in randomized controlled trials of thyroidectomy patients, and effects resolved by 24 hours postoperatively. 1
Important Clinical Pitfall
Do not withhold dexamethasone due to concerns about thyroid storm—there is no evidence linking perioperative corticosteroid use to increased thyroid storm risk, and the anti-inflammatory benefits outweigh theoretical concerns. 3, 2
- The metabolic effects of dexamethasone on thyroid hormone conversion actually favor reduced active T3 levels, which is protective rather than harmful in hyperthyroid patients. 6