Specific Management

Specific management aims to stop the peripheral effects of thyroid hormones and reduce hormone levels.

As the condition is rare, has a high mortality, and is part of a spectrum of disease, discussion with an endocrinologist is advised. Thyroid hormone levels do not define thyroid storm but normal levels should prompt a search for other diseases.

Strategies to stop peripheral effects

Beta blockers

Propanolol 1 mg IV over 1 minute; if necessary repeat at 5-minute intervals; max. total dose 10 mg


Esmolol usually within range 50-200 micrograms/kg/minute


Metoprolol up to 5 mg at rate 1–2 mg/minute, repeated after 5 minutes if necessary, total dose 10-15 mg

Titrate until heart rate about 100 bpm. This helps with reducing rate related heart failure. Any betablocker can be used but only Propanolol has been shown to also prevent peripheral conversion of T4 to T3. The doses of beta blocker required may be higher than in other situations as their metabolism is increased in thyrotoxicosis.

Propanolol is a useful beta blocker to use in this situation as it also prevents peripheral conversion of T4 to T3.

If the patient cannot tolerate beta blockers – such as those with severe asthma,, rate control can be achieved with a calcium channel blocker such as:

  • Verapamil 5-10 mg over at least 2 min IV
  • Diltazem 0.25 mg/kg administered over a period of 2 minutes. If the response was inadequate, a second dose of 0.35 mg/kg given over a period of 2 minutes, 15 minutes later [16].

Hydrocortisone 200 mg IV


Dexamethasone 2 mg IV

Steroids reduce the peripheral effects of thyroid hormones and will also treat associated hypoadrenalism if present.

Lowering circulating hormone levels

Two treatments with different actions are available. Both of these should be given however propylthiouracil should be given an hour before Lugol iodine.

In small doses iodine can lead to increased hormone production, nut in high doses (as given here) it is inhibitory and prevents its release. Propylthiouracil is given first to prevent initial iodine treatment increasing production.

Prevent synthesis

Propylthiouracil  150-300 mg PO QDS

Prevent release with iodine

Lugol iodine (5% iodine, potassium iodide 10%)10 drops daily PO.