Thyroid Storm

Introduction

Thyroid storm , also known as thyroid crisis, is an rare form thyrotoxicosis in an extreme fashion

The mortality that has been published has ranged from 20-100%, especially if prompt treatment isn’t initiated

Thyroid storm often occurs in people with Graves disease who have stopped medication or whose underlying condition is

undiagnosed

The pathophysiology is characterized by adrenergic hyperactivity either by increased release of thyroid hormones (with or

without increased synthesis) or increased receptor sensitivity.

Precipitants of Thyroid Storm include Infection, trauma, surgery, DKA, withdrawal of anti-thyroid medication, or radioactive

iodine therapy

Diagnosis can be difficult due to the disease mimicking other disease states such as withdrawal syndromes and sepsis

Clinical Detail

Properties

Propranolol/ Esmolol

Methimazole/

Propylthiouracel (PTU)

SSKI

Hydrocortisone

Dose

Propranolol: IV 0.5-1 mg

over 10 min or PO: 60-80

mg q4h

Esmolol IV: 500 mcg/kg

bolus then 50-200

mcg/kg/min infusion

Methimazole 60-80 mg in divded

dose

PTU: 500-1000 mg load then 250

mg q4h

5 drops PO q6h

IV: 300 mg load

then 100 mg

q8h

Administration

Propranolol IV: via slow IV

push ~10 min

Esmolol: Bolus and

continuous infusion

Place drops in water or

juice with administration

delayed for at least one

hour after initiation of

methimazole or PTU therapy

Via IV push

Formulation

Propranolol: PO/IV

Esmolol: IV

IV/PO

Adverse Effects

Bradycardia, hypotension

PTU: black box warning for severe

Evidence

Other pearls found at:

https://sites.google.com/presby.edu/pharmacy-friday

Drug

Purpose

Iodide: Lugol solution, Potassium Iodine (SSKI),

and lithium

Used to prevent the release of pre-formed thyroid hormone from the thyroid

gland

Thioureas: Methimazole/Propylthiouracel (PTU)

Inhibit thyroid peroxidase, an enzyme involved in the production of T3 and T4

through the iodination of tyrosine residues on thyroglobulin

Beta Blocker: Propranolol and Esmolol

Blocks β-adrenergic receptors to allow for effective treatment of systemic

effects, such as tremor, tachycardia, agitation, fever, diaphoresis, psychosis

Propranolol also blocker peripheral conversion of T4T3

Steroids: Hydrocortisone and Dexamethasone

Inhibition of peripheral conversion of T4 to T3 and treat relative adrenal

insufficiency.

There is very limited evidence for the use of these agents that are limited to case reports and data dating back to 1970s-90.

A great review article is Thyroid emergencies written by Joanna Klubo-Gwiezdzinska in the references below.

However, these drugs are recommended in the 2016 American Thyroid Association Guidelines for Diagnosis and

Management of Hyperthyroidism and other causes of Thyrotoxicosis.

Conclusions

Thiessen MEW. Thyroid and Adrenal Disorders in: Walls, R. Hockberge RS, Gausche-Hill M. (2018). Rosen’s emergency

medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.

Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin North Am. 2012 Mar;96(2):385-403.

Devereaux D and Tewelde SZ. Hyperthyroidism and thyrotoxicosis. Emerg Med Clin North Am. 2014 May;32(2):277-92.

Busti AJ, Herrington JD, Nuzum D. ” Why Propranolol Is Preferred to Other Beta-Blockers in Thyrotoxicosis or Thyroid Storm”,

Evidence Based Consult blog, December 21, 2018. Available at: https://www.ebmconsult.com/articles/propranolol-

preferred-thyroid-storm-thyrotoxicosis

References

Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 6, 2018, from

http://www.micromedexsolutions.com/

Idrose A. Hyperthyroidism. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A

Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.

Bahn RS, et al; American Thyroid Association; American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of

thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr

Pract 17:456-520, 2011. Erratum in: Endocr Pract 19:384, 2013.