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Thyrotoxic Storm Following Thyroidectomy Medication

  • Author: Peter F Czako, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jan 21, 2015
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

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Antithyroid agents

Class Summary

These agents block thyroid hormone synthesis.

Propylthiouracil (PTU)

 

Thiourea agent that blocks production of thyroid hormones. In addition, inhibits peripheral deiodination of T4 to T3. Preferred over MMI in thyroid storm.

Methimazole (Tapazole)

 

Active moiety of parent compound carbimazole. Blocks incorporation of iodine into thyroglobulin within 1 h of ingestion.

Methimazole was initially thought to be associated with neonatal aplasia cutis (ie, defect in the neonatal scalp) and was thought to be more likely to cross the placenta than PTU. However, recent studies by Wing et al concluded that PTU and MMI are equally effective and safe in the treatment of hyperthyroidism in pregnancy.

Lithium (Eskalith, Lithotabs)

 

Used in patients intolerant to iodine; impairs thyroid hormone release.

Potassium Iodide (Thyro-Block, Pima)

 

Inhibits thyroid hormone secretion. Contains 8 mg of iodide per drop. May be mixed with juice or water for intake.

Iodide treatment is reserved for the treatment of thyroid storm. It is also used for 10-14 d prior to surgical procedure, including thyroidectomy. Can be used with Graves thyrotoxicosis but exacerbates thyrotoxicosis from toxic multinodular goiter and toxic adenoma.

Sodium ipodate (Oragrafin)

 

One of the most effective inhibitors of deiodinase, which converts T4 to the more biologically active T3. Reduction in conversion of T4 to T3 can greatly reduce T3 levels and thyrotoxic symptoms.

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Glucocorticoids

Class Summary

These agents reduce iodine uptake and antibody titers of thyroid-stimulating antibodies with stabilization of the vascular bed.

Dexamethasone (Decadron, Dexone)

 

Has many pharmacologic benefits but significant adverse effects. Stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6, IL-2, IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of inflammatory cells into affected areas. Suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. Breaks down granulocyte aggregates and improves pulmonary microcirculation. Has inhibitory effect on conversion of T4 to T3.

Adverse effects include hyperglycemia, hypertension, weight loss, GI bleeding or perforation synthesis, cerebral palsy, adrenal suppression, and death. Most of the adverse effects of corticosteroids are dose dependent or duration dependent.

Readily absorbed via the GI tract and metabolized in the liver. Inactive metabolites are excreted via the kidneys. Lacks salt-retaining property of hydrocortisone.

Patients can be switched from an IV to PO regimen in a 1:1 ratio.

Hydrocortisone (Cortef, Solu-Cortef)

 

Elicits anti-inflammatory properties and causes profound and varied metabolic effects. Modifies the body's immune response to diverse stimuli.

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Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties.

Acetaminophen (Feverall, Panadol)

 

Inhibits action of endogenous pyrogens on heat-regulating centers; reduces fever by a direct action on the hypothalamic heat-regulating centers, which, in turn, increases the dissipation of body heat via sweating and vasodilation.

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Beta-adrenergic blockers

Class Summary

These agents inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.

Propranolol (Inderal, Betachron E-R)

 

DOC to counter peripheral action of thyroid hormone; blocks beta-adrenergic receptors; prevents conversion of T4 to T3.

Esmolol (Brevibloc)

 

Ultra–short-acting agent that selectively blocks beta1-receptors with little or no effect on beta2-receptor types. Particularly useful in patients with elevated arterial pressure, especially if surgery is planned. Shown to reduce episodes of chest pain and clinical cardiac events compared with placebo. Used successfully in thyrotoxicosis and thyroid storm. Can be discontinued abruptly if necessary.

Useful in patients at risk for experiencing complications from beta-blockade; particularly those with reactive airway disease, mild-moderate LV dysfunction, and/or peripheral vascular disease. Short half-life of 8 min allows for titration to desired effect and quick discontinuation if needed.

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Antihypertensive agents

Class Summary

These agents reduce blood pressure.

Guanethidine (Ismelin)

 

For use in patients with congestive cardiac failure, bronchospasm, or history of asthma.

Reserpine

 

For use in patients with congestive cardiac failure, bronchospasm, or history of asthma; successful treatment has been documented in cases of thyroid storm resistant to large doses of propranolol.

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Contributor Information and Disclosures
Author

Peter F Czako, MD, FACS Chief, Division of Endocrine Surgery, Medical Director, North Tower Operating Rooms, Surgical Administration, William Beaumont Hospital; Associate Professor, Department of Surgery, Oakland University William Beaumont School of Medicine; Royal Oak Surgical Associates, PC

Peter F Czako, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Michigan State Medical Society, American Association of Endocrine Surgeons, Detroit Surgical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nafisa K Kuwajerwala, MD Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Breast Disease

Disclosure: Nothing to disclose.

Gunateet Goswami, MD Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital

Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, Michigan State Medical Society

Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers

Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Pankaj Chaturvedi, MBBS, MS, FACS Professor of Head and Neck Surgery, Department of Head and Neck Surgery, Tata Memorial Hospital, India

Pankaj Chaturvedi, MBBS, MS, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of India

Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD Fellow in Bariatric/Advanced Laparoscopic Surgery, University of Missouri Healthcare

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dean Toriumi, MD Associate Professor, Department of Otolaryngology, University of Illinois Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Mimi S Kokoska, MD Physician, Department of Otolaryngology-Head and Neck Surgery, Aurora Health Care

Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American College of Surgeons, American Head and Neck Society

Disclosure: Nothing to disclose.

References
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Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.
Table. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis
Uncomplicated Thyrotoxicosis Thyroid Storm
1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess of 106o C, dehydration
2. Sinus tachycardia, heart rate 100-140 2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure
3. Diarrhea, increased appetite with loss of weight 3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice
4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma
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