A review of thyrotoxic storm is presented. Included are causes, symptomatology, and mortality rates. Special emphasis is placed on the strong correlation between adrenergic blockade and success rates in treating thyrotoxic storm. Pharmacotherapy of the acute storm patient is discussed in detail with respect to agents that (1) decrease production of thyroid hormones; (2) block release of preformed thyroid hormones from the gland; (3) blunt the effects of excess thyroid hormones on the various target organs (e.g., CNS and heart); and (4) serve to decrease the metabolic strain on all organ systems caused by thyrotoxic storm.
Get full access to this article
View all access options for this article.
References
1.
DeGrootLJStanburyJ.The thyroid and its diseases. 4th ed.New York: John Wiley & Sons, 1975: 368–72.
2.
NelsonNCBeckerWF.Thyroid crisis: diagnosis and treatment. Ann Surg1969; 170: 263.
3.
HetzelBS.The aetiology and pathogenesis of hyperthyroidism. Postgrad Med J1968; 44: 363–76.
RansomJKBayleyRH.Thyroid crisis. West J Surg1934; 42: 464–74.
8.
MaddockWGPedersonSCollerFA.Studies of the blood chemistry in crisis. JAMA1937; 109: 2130–5.
9.
McArthurJW.Thyrotoxic crisis: analysis of 36 cases seen at Massachusetts General Hospital during the past 25 years. JAMA1947; 134: 868–74.
10.
RivesJDShepardRM.Thyroid crisis. Am Surg1951; 17: 406–18.
11.
WaldsteinSS.A clinical study of thyroid storm. Ann Intern Med1960; 52: 626–42.
12.
MazzaferriMCSkillmanTG.Thyroid storm, a review of 22 episodes with special emphasis on the use of guanethidine. Arch Intern Med1969; 124: 684–90.
13.
GeffnerDLAzukizawaMHershmanJM.Propylthiouracil blocks extrathyroidal conversion of T4 to triiodothyronine and augments thyrotropin secretion in man. J Clin Invest1975; 55: 224.
14.
SelenkowHACollacoFM.Clinical pharmacology of antithyroid compounds. Clin Pharmacol Ther1961; 2: 191–219.
15.
SitarDSHunninghakeDB.Pharmacokinetics of propylthiouracil in man after a single oral dose. J Clin Endocrinol Metab1975; 40: 26–29.
16.
GilmanAGMuradF.Thyroid and antithyroid drugs. In: GilmanAGGoodmanLS eds. The pharmacological basis of therapeutics, New York: Macmillan, 1975: 1413.
17.
IngbarSH.Management of emergencies — thyrotoxic storm. N Engl J Med1966; 274: 1252–4.
HerbstALSelenkowHA.Hyperthyroidism in pregnancy. N Engl J Med1965; 273: 627–33.
20.
McGavackTH.Untoward hematologic responses to the antithyroid compounds. Am J Med1954; 17: 36.
21.
ArmheinJAKennyFMRossD.Granulocytopenia, lupus-like syndrome, and other complications of propylthiouracil therapy. J Ped1970; 76: 54–63.
22.
BestMM.A lupus-like syndrome following propylthiouracil administration. J Ky Med Assoc1964; 62: 47.
23.
LibrickLSussmanLBejarRThyrotoxicosis and collagen-like disease in three sisters of American Indian extraction. J Ped1970; 76: 64–70.
24.
RosoveMH.Agranulocytosis and antithyroid drugs. West J Med1977; 126: 339–43.
25.
BartelsEC.Agranulocytosis during propylthiouracil therapy. Am J Med1948; 5: 48.
26.
BeebeeRT.Fatal agranulocytosis during treatment of toxic goiter with propylthiouracil. Ann Intern Med1951; 34: 1035.
27.
ChevalleyJ.A four-year study of the treatment of hyperthyroidism with methimazoleJ Clin Endocrinol Metab1954; 14: 948.
28.
Van WinkleWJr.Clinical toxicity of thiouracil—survey of 5745 cases. JAMA1946; 130: 343.
29.
AMA Department of Drugs AMA drug evaluations. 3rd ed.Acton, Massachusetts: Publishing Sciences Group, 1977.
30.
WilliamsHEBeckerCE.Endocrine disorders. In: MelmonKLMorrelliHF eds. Clinical pharmacology: basic principles in therapeutics. New York: Macmillan1972: 313–5.
31.
JacksonI.Management of Thyrotoxicosis. Am J Hosp Pharm1975; 32: 933–9.
32.
KampmanJ.Pharmacokinetics of propylthiouracil. Acta Pharmacol Toxicol1974; 35: 361.
33.
SchuppanD.Preliminary pharmacokinetics studies of propylthiouracil in humans. J Pharmacokinet Biopharm1973; 1: 307.
34.
VanderlaanWP.Antithyroid drugs in practice. Mayo Clin Proc1972; 47: 962–5.
35.
GreerMAKammerHBoumaDJ.Short term antithyroid drug therapy for the thyrotoxicosis of Graves disease. N Engl J Med1977; 297: 173–6.
36.
KammerJ.Use of antithyroid drugs in a single daily doseJAMA1967; 209: 1325–7.
37.
Package insert for InderalrG (brand of propranolol HCl). New York: Ayerst Laboratories, 1979.
38.
MazzaferriMC.Propranolol as primary therapy for thyrotoxicosis. Arch Intern Med1976; 136: 50–6.
39.
LeeTCCoffeyRJMackinJThe use of propranolol in the surgical treatment of thyrotoxic patients. Ann Surg1973; 177: 643–7.
40.
ShandDG.Drug therapy: propranolol. N Engl J Med1975; 293: 20–5.
41.
NickersonMCollierB.Anticholinesterase agents. In: GoodmanLSGilmanA eds. The pharmacological basis of therapeutics. 5th ed.New York: Macmillan, 1975: 447–52.
42.
HughesG.Management of thyrotoxic crisis with a beta adrenergic blocking agent (PronethalolrG). Brit J Clin Pract1966; 20: 579.
43.
MarsdenCD.Effect of beta adrenergic blockade on finger tremor and achilles reflex time in anxious and thyrotoxic patients. Acta Endocrinol1968; 57: 353.
44.
DasGKreigerM.Treatment of thyrotoxic storm with intravenous administration of propranolol. Ann Intern Med1969; 70: 985–8.
45.
DorfmanSGVan HofeSYoungRLPropranolol for thyroid storm (letter). N Engl J Med1977; 296: 1120.
46.
BullockJLHarrisREYoungRL.Treatment of Thyrotoxicosis during pregnancy—propranolol. Am J Obstet Gynecol1975; 121: 242–5.
47.
GalaburdaMRosmanNPHaddowJE.Thyroid storm in an 11-year-old boy managed by propranolol. Pediatrics1974; 53: 920–2.
48.
BeckerFOSchwartzTB.Sympathetic blockade in hyperthyroidism. Arch Intern Med1972; 129: 967–71.
49.
McLartyDGBrownlieBEWAlexanderWDRemission of thyrotoxicosis during treatment with propranolol. Brit Med J1973; 2: 332–4.
50.
MichieWPeggCASHamer-HodgesDWBeta blockade and partial thyroidectomy for thyrotoxicosis. Lancet1974; 1: 1009–11.
51.
PeggCASStewartDJ.BewsherPDThe surgical management of thyrotoxicosis. Brit J Surg1973; 60: 765–9.
52.
PietrasRJRealMAPotichaGSCardiovascular response in hyperthyroidism — the influence of adrenergic blockade. Arch Intern Med1972; 129: 426–9.
53.
PimstoneB.Use and abuse of beta adrenergic blockade in surgery of hyperthyroidism. S Afr Med J1970; 44: 1059–61.
54.
BuckleRM.Treatment of thyroid crisis by beta adrenergic blockade. Acta Endocrin1968; 57: 168–76.
55.
BurrowGN.Hyperthyroidism during pregnancy. N Engl J Med1978; 298: 150–3.
56.
LangerAHungCMcNultyJAAdrenergic blockade — a new approach to hyperthyroidism during pregnancy. Obstet Gynecol1974; 44: 181–5.
57.
TurnstallME.The effect of propranolol on the onset of breathing at birth. Brit J Anesth1969; 41: 792.
58.
HellmanRKellyKMasonWD.Propranolol for thyroid storm (letter). N Engl J Med1977; 297: 671–2.
59.
BowdleTA.Propranolol for thyroid storm (letter). N Engl J Med1977; 296: 1121.
60.
AbramsJJSandlerJ.Propranolol for thyroid storm (letter). N Engl J Med1977; 296: 1120.
61.
EricksonMRubenfeldSGarberAJPropranolol does not prevent thyroid storm. N Engl J Med1977; 296: 263–4.
62.
Package insert for LopressorrG (brand of metoprolol tartrate). Ardsley, New York: Geigy Laboratories, 1979.
63.
NickersonMCollierB.Drugs inhibiting adrenergic nerves and structures innervated by them. In: GoodmanLSGilmanA eds. The pharmacological basis of therapeutics. 5th ed.New York: Macmillan, 1975: 557–9.
64.
DillonPTBabeJMeloniCRReserpine in thyrotoxic crisis. N Engl J Med1970; 283: 1020–3.
65.
CanaryJJ.Effects of oral and intramuscular administration of reserpine in thyrotoxicosisN Engl J Med1957; 257: 435–42.
66.
RiddleMCSchwartzTB.New tactics for hyperthyroidism: sympathetic blockade. Ann Intern Med1970; 72: 749–51.
67.
GaffneyTE.Effects of guanethidine on triiodothyronine-induced hyperthyroidism in man. N Engl J Med1961; 256: 16–20.
68.
WaldsteinSS.Guanethidine in hyperthyroidism. JAMA1964; 189: 609–12.
69.
LeeWY.Studies of thyroid and sympathetic nervous system interrelationships: the effects of guanethidine on manifestations of hyperthyroidism. J Clin Endocrinol1962; 22: 879–85.
70.
GoldsteinSKillipT.Catecholamine depletion in thyrotoxicosis: effect of guanethidine on cardiovascular dynamics. Circulation1965; 21: 219–27.
71.
WilliamsRH.Textbook of endocrinology. 4th ed.Philadelphia: WB Saunders, 1968: 215–6.
72.
GuytonA.Textbook of medical physiology. 4th ed.Philadelphia: WB Saunders, 1971: 409.
73.
IngbarSH.Management of emergencies — thyrotoxic storm. N Engl J Med1966; 274: 1252–4.
74.
GoldsmithPEEiseleML.Effect of iodine on release of thyroid hormone in hyperthyroidism. J Clin Endocrinol Metab1956; 6: 130–7.
75.
VagenakisAG.Adverse effects of iodides on thyroid function. Med Clin North Am1975; 59: 1075–8.
76.
WolfJ.Iodine goiter and the pharmacological effects of excess iodide. Am J Med1969; 47: 101–17.
77.
BravermanLE.Changes in thyroidal function during adaptation to large doses of iodides. J Clin Invest1963; 47: 1216–31.
78.
CarswellFKerrMMHutchinsonJH.Congenital goiter and hypothyroidism produced by maternal ingestion of iodides. Lancet1970; 1: 1241–3.
79.
GalinaMP.Iodine during pregnancy — an apparent cause of neonatal death. N Engl J Med1962; 267: 1124–7.
80.
SchouM.Occurrence of goiter during lithium treatment. Br Med J1968; 3: 710–3.
81.
KristensenOAndersonHHPallisgaardG.Lithium carbonate in the treatment of thyrotoxicosis. Lancet1976; 1: 603–5.
82.
LazarusJHAddisonGMRichardsARTreatment of thyrotoxicosis with lithium carbonate. Lancet1974; 2: 1160–2.
83.
TempleRBermanMCarlsonHEThe use of lithium in Graves disease. Mayo Clin Proc1972; 47: 872–7.
84.
BafaqueehHHMyersDH.Lithium and thyrotoxicosis (letter). Lancet1976; 1: 1247.
85.
CubihT.Lithium and thyrotoxicosis (letter). Lancet1976; 1: 1247.
86.
TempleRBermanMRobbinsJThe use of lithium in the treatment of thyrotoxicosis. J Clin Invest1972; 57: 2746–56.
87.
IngbarSH. In: WernerSCIngbarSH eds. The thyroid. 3rd ed.New York: Harper and Row, 1971: 663.
88.
WernerSCPlatmanSR.Remission of hyperthyroidism (Graves disease) and altered pattern of serum thyroid binding induced by prednisone. Lancet1965; 2: 751–6.
89.
DuickDSWarrenDMNicoloffJTEffect of single dose dexamethasone on the concentration of serum triiodothyronine in man. J Clin Endocrinol Metab1974; 39: 1151–4.
90.
DeGrootLJHoyeK.Dexamethasone suppression of T3 and T4. J Clin Endocrinol Metab1976; 42: 976–8.
91.
WilliamsDEChopraIOrgiazziJAcute effects of corticosteroids on thyroid activity in Graves disease. J Clin Endocrinol Metab1975; 41: 354–61.
92.
LarsenPR.Salicylate-induced increases in free triiodothyronine in human serum. J Clin Invest1972; 51: 1125–34.
93.
MaazE.Concomitant occurrence of hyperthyroid crisis and ketoacidotic diabetic coma. Z Gesamte Inn Med1974; 29: 498–503.
94.
ChamberlainDAWhiteRJHowardMRPlasma digoxin concentrations in patients with atrial fibrillation. Brit Med J1970; 3: 429–32.
95.
CroxsonMSIbbertsonHK.Serum digoxin in patients with thyroid disease. Br Med J1975: 3: 566–8.
96.
DohertyJE.Digoxin metabolism in hypo and hyperthyroidism, studies with tritiated digoxin. Ann Intern Med1966; 64: 489–507.
