Tugas

1. Thyroid Storm
A life threatening hypremetabolic state due to hyperthyroidism
Mortality rate is high (10-75%) despite treatment
Usually occurs as a result of previously unrecognized or poorly
treated hyperthyroidism
Thyroid hormone levels do not help to differentiate between
uncomplicated hyperthyroidism and thyroid storm

Thyroid storm triad

Extreme Fever (often >104F)
Tachycardia (can be accompanied with AFib, widened pulse
pressure)
Altered Mental Status

Burch and Wartofsky Score

Treatment
Initial stabilization includes airway protection,
oxygenation, fluids and cardiac monitoring
Treatment can then be divided into 5 areas:

General supportive care

Inhibition of thyroid hormone synthesis
Retardation of thyroid hormone release
Blockade of peripheral thyroid hormone effects
Identification and treatment of precipitating events

Thyroid Storm
Drug Treatment of Thyroid Storm
Decrease de novo synthesis:
Porpythiouracil
4 hrs
Methimazole

600-1000mg PO initially, followed by 200-250 mg q

Iodine
24 h, then
q6h or Lugol
Lithuim

Iaponoric acid (Telepaque) 1 gm IV q8h for the first

500 mg bid or Potassium iodide (SSKI) 5 drops PO
solution 8-10 drops PO q6h
800-1200 mg PO every day

40 mg PO initial dose, then 25 mg PO q6h

Prevent relases of hormone (after synthesis blockade intiated)

Prevent peripheral effects:

B-Blocker
Propanolol (IV) titrate 1-2 mg q 5min prn (may need
240-480mg
PO q day) or Esmolol (IV) 500 mcg/kg IV bolus,
then 50-200
mcg/kg per min maintenance
Other consideration:
Corticosteroids
Hydrocortisone 100 mg IV q 8 h or
dexamethosone 2 mg IV q 6 hr
Antipyretics
Cooling blanket
acteaminophen 650 mg PO q 4-6h

2.Hypertiroid therapy

Treatment Options
1. Symptom relief medications
2. Anti Thyroid Drugs ATD
Methimazole, Carbimazole
Propylthiouracil (PTU)
3. Radio Active Iodine treatment
RAI Rx.
4. Thyroidectomy Subtotal or
Total
5. NSAIDs and Corticosteroids for

Symptom Relief
1. Rehydration is the first step
2. blockers to decrease the sympathetic
excess
Propranalol, Atenelol, Metoprolol
3. Rate limiting CCBs if blockers
contraindicated
4. Treatment of CHF, Arrhythmias
5. Calcium supplementation
6. SSKI or Lugol solution for vascularity of
the gland

Anti Thyroid Drugs (ATD)

Imp. considerations

Methimazole

Propylthiouracil

Efficacy

Very potent

Potent

Duration of action

Long acting BID/OD

Short acting QID/TID

In pregnancy

Contraindicated

Safely can be given

Mechanism of action

Iodination, Coupling

Iodination, Coupling

Conversion of T4 to T3

No action

Inhibits conversion

Adverse reactions

Rashes, Neutropenia Rashes, Neutropenia

Dosage

20 to 40 mg/ OD PO

100 to 150mg qid PO

How long to give ATD

Reduction of thyroid hormones takes 2-8 weeks
Check TSH and FT4 every 4 to 6 weeks
In Graves, many go into remission after 12-18
months
In such pts ATD may be discontinued and followed
up
40% experience recurrence in 1 yr. Re treat for 3
yrs.
Treatment is not life long. Graves seldom needs
surgery
MNG and Toxic Adenoma will not get cured by ATD.
For them ATD is not the best. Treat with RAI.

Radio Active Iodine (RAI Rx.)

In women who are not pregnant (contraindication)
Graves disease not remitting with ATD
RAI Rx is the best treatment of hyperthyroidism in
adults
The effect is less rapid than ATD or Thyroidectomy
It is effective, safe, and does not require
hospitalization.
Given orally as a single dose in a capsule or liquid
form.
Very few adverse effects as no other tissue absorbs
RAI

Radio Active Iodine (RAI Rx.)

I123 is used for Nuclear Scintigraphy (Dx.)
I131 is given for RAI Rx. (6 to 8 milliCuries)
Goal is to make the patient hypothyroid
No effects such as Thyroid Ca or other malignancies
Never given for children and pregnant/ lactating
women
Not recommended with patients of severe
Ophthalmopathy
Not advisable in chronic smokers

Surgical Treatment

Subtotal Thyroidectomy, Total

Thyroidectomy
Hemi Thyroidectomy with contra-lateral
subtotal
ATD and RAI Rx are very efficacious and
easy so
Surgical treatment is reserved for
MNG( multinoduar Goiter) with
1.
2.
3.
4.
5.

Severe hyperthyroidism in children

Pregnant women who cant tolerate ATD
Large goiters with severe Ophthalmopathy
Large MNGs with pressure symptoms
Who require quick normalization of thyroid function

3. Hyperthyroidism management in
pregnancy

 Goal is to maintain FT4/FTI in high normal range using

lowest possible dose (minimize fetal exposure)
Measure FT4/FTI q2-4 weeks and titrate
Thioamides (PTU/methimazole) -> decrease thyroid
hormone synthesis by blocking organification of iodide
PTU also reduces T4->T3 and may work more quickly
PTU traditionally preferred (older studies found that methimazole
crossed placenta more readily and was associated with fetal aplasia
cutis; newer studies refute this)

 Effect of treatment on fetal thyroid function:

Possible transient suppression of thyroid function
Fetal goiter associated with Graves (usually drug-induced fetal
hypothyroidism)
Fetal thyrotoxicosis due to maternal antibodies is rare -> screen for
growth and normal FHR
Neonate at risk for thyroid dysfunction; notify pediatrician

Breastfeeding safe when taking PTU/methimazole

 Beta-blockers can be used for symptomatic relief (usually

Propanolol)
Reserve thyroidectomy for women in whom thioamide
treatment unsuccessful
Iodine 131 contraindicated (risk of fetal thyroid ablation
especially if exposed after 10 weeks); avoid
pregnancy/breastfeeding for 4 months after radioactive
ablation