What is the management of thyroid storm (hyperthyroid crisis)?

From the Guidelines

Thyroid storm management requires immediate, aggressive treatment with a multi-faceted approach targeting the underlying pathophysiology, prioritizing beta-blockers, thionamides, iodine therapy, and glucocorticoids to control adrenergic symptoms, block hormone synthesis and release, and provide supportive care. Treatment should begin with beta-blockers, typically propranolol 60-80 mg orally every 4-6 hours or 1-2 mg IV slowly, to control adrenergic symptoms like tachycardia and hypertension, as recommended by the American Association of Clinical Endocrinologists Medical Guidelines for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism 1. Simultaneously, thionamides should be administered to block new thyroid hormone synthesis; propylthiouracil (PTU) 200-400 mg orally every 4-6 hours is preferred initially as it also blocks peripheral T4 to T3 conversion, followed by methimazole 20-25 mg every 6 hours. One hour after starting thionamides, iodine therapy should be initiated to block thyroid hormone release, using Lugol's solution (10 drops three times daily) or potassium iodide (5 drops every 6 hours) 1.

Key Components of Thyroid Storm Management

• Beta-blockers: propranolol 60-80 mg orally every 4-6 hours or 1-2 mg IV slowly
• Thionamides: propylthiouracil (PTU) 200-400 mg orally every 4-6 hours, followed by methimazole 20-25 mg every 6 hours
• Iodine therapy: Lugol's solution (10 drops three times daily) or potassium iodide (5 drops every 6 hours)
• Glucocorticoids: hydrocortisone 100 mg IV every 8 hours to reduce T4 to T3 conversion and treat potential relative adrenal insufficiency
• Supportive care: aggressive cooling measures for hyperthermia, IV fluids for dehydration, glucose supplementation for hypoglycemia, and electrolyte replacement as needed

Monitoring and Definitive Treatment

Patients require ICU-level monitoring with frequent vital sign checks, cardiac monitoring, and assessment of mental status. Once stabilized, definitive treatment of the underlying hyperthyroidism should be planned, typically with radioactive iodine ablation or thyroidectomy after achieving a euthyroid state. The underlying trigger for thyroid storm must be identified and treated, whether infection, medication non-compliance, or other stressors 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 may mask certain clinical signs of hyperthyroidism, and abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm 3. Key Considerations:
• Use propylthiouracil to inhibit thyroid hormone synthesis and conversion 2.
• Use propranolol with caution, as it may mask signs of hyperthyroidism and exacerbate symptoms upon withdrawal 3.

From the Research

Thyroid Storm Management

Thyroid storm is a life-threatening endocrine emergency that requires prompt and aggressive management. The following are key aspects of thyroid storm management:

• Diagnosis: Thyroid storm is diagnosed based on clinical criteria, including exaggerated signs and symptoms of hyperthyroidism and varying degrees of organ decompensation 4.
• Treatment: Treatment should be initiated promptly, targeting all steps of thyroid hormone formation, release, and action 4. This may include the use of antithyroid medications such as propylthiouracil or methimazole.
• Medications: Propylthiouracil and methimazole are commonly used to treat thyroid storm, with some guidelines recommending propylthiouracil over methimazole 5. However, a recent study found no significant difference in outcomes between the two medications 5.
• Supportive Care: Patients with thyroid storm may require supportive care, including vasopressors, extracorporeal membrane oxygenation, renal replacement therapy, mechanical ventilation, and/or therapeutic plasmapheresis 6.
• Surgical Intervention: In some cases, surgical intervention such as total thyroidectomy may be necessary to achieve a euthyroid state 7.

Prognosis and Mortality

The prognosis and mortality of thyroid storm are significant concerns:

• Mortality Rate: The mortality rate of thyroid storm is estimated to be between 10% and 50% with treatment, and up to 100% without treatment 8.
• Risk Factors: Multiple organ failure and early cardiogenic shock are associated with increased mortality in patients with thyroid storm 6.
• Outcome: Patients who survive thyroid storm should receive definitive therapy for their underlying hyperthyroidism to avoid recurrence of the condition 4.

Special Considerations

The following are special considerations in the management of thyroid storm:

• Critically Ill Patients: Critically ill patients with thyroid storm require close monitoring and aggressive management to prevent complications and improve outcomes 5.
• Thyroid Storm-Triggering Factors: Identifying and addressing thyroid storm-triggering factors, such as amiodarone use or antithyroid-drug discontinuation, is crucial in preventing recurrence of the condition 6.