From the Guidelines
Thyroid storm management requires immediate and aggressive treatment with a combination of medications, including propylthiouracil or methimazole, saturated solution of potassium iodide or sodium iodide, dexamethasone, and phenobarbital, along with general supportive measures. The treatment should not be delayed for test results, and serum-free triiodothyronine (FT3), FT4, and TSH levels can help confirm the diagnosis 1. The perceived underlying cause of thyroid storm should be treated, and depending on gestational age, fetal status should be evaluated with ultrasound examination, nonstress testing, or a biophysical profile.
Key components of treatment include:
- Propylthiouracil or methimazole to block new thyroid hormone synthesis
- Saturated solution of potassium iodide or sodium iodide to block thyroid hormone release
- Dexamethasone to reduce T4 to T3 conversion and treat potential adrenal insufficiency
- Phenobarbital for its sedative and antipyretic effects
- General supportive measures, such as oxygen, antipyretics, and appropriate monitoring
It is crucial to monitor cardiac function closely as patients are at risk for arrhythmias and heart failure, and to treat the precipitating cause of the thyroid storm, such as infection or medication non-compliance 1. Delivery during thyroid storm should be avoided unless deemed necessary, and fetal status should be evaluated regularly.
The goal of treatment is to rapidly control the symptoms of thyroid storm, prevent complications, and improve morbidity, mortality, and quality of life outcomes. With prompt and aggressive treatment, it is possible to reduce the mortality rate associated with thyroid storm and improve patient outcomes 1.
From the FDA Drug Label
Propylthiouracil inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues and may therefore be an effective treatment for thyroid storm. Beta-adrenergic blockade may mask certain clinical signs of hyperthyroidism. Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptoms of hyperthyroidism, including thyroid storm.
Management of thyroid storm may involve the use of propylthiouracil to inhibit the conversion of thyroxine to triiodothyronine in peripheral tissues, and propranolol to control adrenergic symptoms.
- Propylthiouracil is used to treat hyperthyroidism and may be effective in thyroid storm by reducing the production of thyroid hormones 2.
- Propranolol is used to control adrenergic symptoms of hyperthyroidism, but its withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm 3.
From the Research
Management of Thyroid Storm
- The management of thyroid storm involves a multi-faceted approach, including the use of medications such as propranolol, propylthiouracil, iodine, and dexamethasone, as well as general supportive therapy 4.
- Propylthiouracil and methimazole are two commonly used medications for the treatment of thyroid storm, with some guidelines recommending propylthiouracil over methimazole, although recent studies have found no significant difference in outcomes between the two treatments 5.
- The diagnostic strategy for thyroid storm may involve the use of Burch-Wartofsky scoring or Akamizu's diagnostic criteria, and treatment aims to address multiple aspects of the condition, including reducing thyroid hormone production and alleviating symptoms 6.
- The treatment of thyroid storm also involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation, in order to limit surgical complications and prevent exacerbation of thyrotoxicosis 7.
- Key considerations in the management of thyroid storm include:
- Reducing thyroid hormone production using medications such as propylthiouracil or methimazole
- Blocking the release of thyroid hormones using iodine
- Inhibiting the peripheral conversion of thyroxine to triiodothyronine (T3) using propylthiouracil
- Providing general supportive therapy, including management of symptoms and prevention of complications
- Bridging to a euthyroid state prior to definitive therapy, such as total thyroidectomy or radioactive iodine ablation 4, 5, 6, 7.