From the Guidelines
Thyroid storm management requires immediate and aggressive treatment with a multi-faceted approach, prioritizing supportive care, thionamides, iodine, beta-blockers, and glucocorticoids to reduce morbidity, mortality, and improve quality of life. Start by stabilizing the patient with supportive care including IV fluids, cooling measures, oxygen, and cardiac monitoring. Administer propylthiouracil (PTU) 600-1000 mg loading dose followed by 200-250 mg every 4-6 hours to block new thyroid hormone synthesis, or alternatively methimazole 20-25 mg every 6 hours, as recommended by the American College of Obstetricians and Gynecologists 1. One hour after starting thionamides, give potassium iodide (SSKI) 5 drops every 6 hours or Lugol's solution 10 drops every 8 hours to block thyroid hormone release.
Key Treatment Components
- Beta-blockers are essential to control adrenergic symptoms; use propranolol 60-80 mg orally every 4-6 hours or IV esmolol/metoprolol if the patient cannot take oral medications, as supported by recent guidelines 1.
- Glucocorticoids (hydrocortisone 100 mg IV every 8 hours) help prevent adrenal insufficiency and inhibit T4 to T3 conversion.
- Treat the underlying trigger of thyroid storm, which may include infection, trauma, surgery, or medication non-compliance.
- Supportive care should address hyperthermia, dehydration, and cardiac complications. This comprehensive approach targets multiple steps in thyroid hormone production and action, as thyroid storm represents extreme thyroid hormone excess with mortality rates of 10-30% even with treatment, making rapid intervention crucial 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.
Thyroid Storm Management:
- Propylthiouracil may be an effective treatment for thyroid storm by inhibiting the conversion of thyroxine to triiodothyronine in peripheral tissues 2.
- Propranolol can mask certain clinical signs of hyperthyroidism, and its abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm 3. Key Considerations:
- Use propylthiouracil with caution in the management of thyroid storm.
- Monitor patients closely when using propranolol in the management of thyroid storm, as abrupt withdrawal can worsen symptoms.
From the Research
Thyroid Storm Management
- Thyroid storm is a severe manifestation of thyrotoxicosis that requires prompt treatment to prevent mortality 4.
- The treatment regimen for thyroid storm typically includes:
- Propranolol to inhibit the catecholamine-mediated peripheral effects of the circulating thyronines 5.
- Propylthiouracil or methimazole to inhibit thyroid hormone synthesis and to inhibit peripheral conversion of thyroxine to triiodothyronine (T3) 5, 6.
- Iodine to block the glandular release of thyroid hormones 5.
- Dexamethasone along with general supportive therapy 5.
- Therapeutic plasma exchange (TPE) is an alternative treatment option for patients with thyroid storm who cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy 7.
- Studies have shown that TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines, and cytokines, and is likely beneficial for these patients 7.
- A comparative effectiveness study found no significant differences in mortality or adverse events between patients treated with propylthiouracil or methimazole for thyroid storm, suggesting that current guidelines recommending propylthiouracil over methimazole may merit reevaluation 6.
Treatment Options
- Propylthiouracil and methimazole are commonly used treatments for thyroid storm, with propylthiouracil being recommended over methimazole in some guidelines 6.
- TPE is a safe and effective treatment option for patients with thyroid storm who cannot tolerate or fail pharmacotherapy 7.
- Total thyroidectomy or radioactive iodine ablation are definitive therapies for thyroid storm, but require bridging to a euthyroid state prior to treatment to limit surgical complications 4.
Diagnosis and Clinical Presentation
- Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab), and with clinical signs and symptoms of end organ damage 4.
- Clinical signs and symptoms of thyroid storm include tachycardia, fever, agitation, and altered mental status, among others 4.