Can I give paracetamol to treat fever in a patient with thyroid storm?

Can You Give Paracetamol for Fever in Thyroid Storm?

Yes, you should administer antipyretics including paracetamol (acetaminophen) to control fever in thyroid storm as part of essential supportive care, but this is only one component of comprehensive multi-drug therapy that must be initiated immediately. 1, 2

Critical Context: Fever Control is Supportive, Not Primary Treatment

Thyroid storm is a life-threatening endocrine emergency with 30-75% mortality even with treatment, requiring immediate multi-drug therapy targeting thyroid hormone synthesis, release, and peripheral effects. 3, 4 Fever management with antipyretics is part of supportive care but does not address the underlying hypermetabolic crisis. 1, 2, 5

Specific Approach to Fever Management in Thyroid Storm

Antipyretic Administration

• Paracetamol (acetaminophen) is recommended as part of supportive treatment to control the marked hyperpyrexia (often >40°C/104°F) characteristic of thyroid storm. 1, 2, 3
• Aggressive fever control is essential because hyperpyrexia contributes to the hypermetabolic state and multiorgan decompensation. 3, 4

Important Caveat About NSAIDs

• Avoid NSAIDs in thyroid storm if there is evidence of severe manifestations such as kidney injury, cardiac dysfunction, or gastrointestinal complications, which are common in this condition. 6
• The cardiovascular collapse, renal insufficiency, and coagulopathy that characterize thyroid storm make NSAIDs particularly risky. 3
• Paracetamol is the safer antipyretic choice in this setting. 6

The Complete Treatment Algorithm (Antipyretics Are Just One Component)

Immediate Multi-Drug Therapy Required

You cannot simply give paracetamol and expect to manage thyroid storm. The following must be initiated simultaneously: 1, 2

1. Block New Hormone Synthesis (First Step)

• Propylthiouracil 500-1000 mg loading dose, then 250 mg every 4 hours (preferred because it also blocks peripheral T4 to T3 conversion). 1, 2
• Alternative: Methimazole 20 mg every 4-6 hours if PTU unavailable. 1, 2

2. Block Hormone Release (1-2 Hours AFTER Thionamides)

• Saturated solution of potassium iodide or sodium iodide. 1, 2
• Critical pitfall: Never give iodine before thionamides—this can worsen thyrotoxicosis by providing substrate for more hormone synthesis. 2

3. Control Cardiovascular Symptoms

• Beta-blockers are essential: Propranolol 60-80 mg orally every 4-6 hours in stable patients. 1, 2
• For hemodynamically unstable patients: Esmolol 500 mcg/kg IV loading dose, then 50 mcg/kg/min maintenance infusion (preferred due to ultra-short half-life allowing rapid titration). 1
• Alternative if beta-blockers contraindicated: Diltiazem 15-20 mg IV over 2 minutes. 1, 2

4. Reduce Peripheral T4 to T3 Conversion

• Dexamethasone or hydrocortisone to block peripheral conversion and treat potential relative adrenal insufficiency. 1, 2

5. Supportive Care (Where Antipyretics Fit)

• Antipyretics (paracetamol) for fever control. 1, 2
• Aggressive IV hydration and electrolyte management. 1
• Oxygen therapy as needed. 1, 2
• Identify and treat precipitating factors (infection, surgery, labor/delivery). 1, 2, 3

Mandatory Hospitalization and Monitoring

• All thyroid storm patients require ICU admission with continuous cardiac monitoring. 1, 2
• Immediate endocrine consultation is mandatory. 1
• Monitor for cardiac complications (heart failure, arrhythmias), agranulocytosis from thionamides, and hepatotoxicity. 1, 2

Why Fever Control Alone is Inadequate

The fever in thyroid storm is not simply an infection-related pyrexia—it reflects profound thermoregulatory dysfunction from the hypermetabolic state. 3, 4 While antipyretics help reduce body temperature and may improve patient comfort, they do not address:

• The excessive circulating thyroid hormone driving the crisis. 4, 7
• The cardiovascular decompensation (tachycardia >140 bpm, heart failure, shock). 3, 4
• The altered mental status ranging from agitation to coma. 3, 4
• The multiorgan system failure. 3, 4

Special Considerations

Pregnancy

• The same aggressive treatment protocol applies, including antipyretics. 1, 2
• Thyroid storm affects <1% of pregnant women with hyperthyroidism but carries extremely high maternal and fetal mortality. 3
• Avoid delivery during active storm unless absolutely necessary—delivery can precipitate or worsen the crisis. 1

Treatment Failure

• If conventional therapy fails, consider therapeutic plasma exchange or emergent thyroidectomy. 5, 8

In summary: Yes, give paracetamol for fever in thyroid storm, but recognize this is merely supportive care within a comprehensive, life-saving multi-drug protocol that must be initiated immediately in an ICU setting. 1, 2, 3