Other endocrine emergencies





This chapter will review the pharmacologic management of adrenal and thyroid dysfunction according to the clinical practice guidelines and expert opinion.


Thyroid storm


Definition


A life-threatening condition caused by an excess of thyroid hormone resulting in cardiovascular and central nervous system dysfunction and hyperpyrexia.


Precipitating factors





  • Abrupt discontinuation of antithyroid medications



  • Acute illness (sepsis/infection, surgery or trauma)



  • Graves’ disease



  • Radioiodine therapy



  • Parturition



  • Drugs (salicylates, amiodarone, anesthetics, pseudoephedrine)



Pharmacologic management ( table 7.1 )




Table 7.1

Pharmacologic Management of Thyroid Storm

Data from Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid . 2016;26(10):1343–1421.























































DRUG STANDARD DOSING COMMENTS
Thionamides: Decrease Thyroid Hormone Synthesis
Propylthiouracil PO: 500–1000 mg ×1 then 250 mg q4h First-line
Decrease conversion of T4 to T3
Preferred in pregnant or lactating women
ADR: agranulocytosis (rare), bleeding, hepatotoxicity, renal failure, vasculitis
Methimazole PO: 20 mg q6–8h For allergy or intolerance to propylthiouracil
ADR: similar to propylthiouracil, but less hepatotoxicity than propylthiouracil
Iodine: Inhibit Thyroid Hormone Release
Saturated solution of potassium iodide (SSKI) PO: 5 drops q6h
PR: 250–500 mg q6h
Start 1 h after thionamide started to prevent iodine serving as a substrate for new thyroid hormone production and worsening hyperthyroidism
Use in conjunction with thionamides
Lugol solution PO: 8 drops q6h
PR: 5–10 drops q8–6h
Lithium PO: 300 mg q6–8h Reserve for patients with iodine intolerance or CI
Goal: 0.6–1 mEq/L
Avoid in CrCl <30
β-Blockers: Control Heart Rate
Propranolol PO: 60–80 mg q4–6h
IV: 0.5–1 mg over 10 min ×1 then 1–2 mg over 10 min PRN
Caution in congestive heart failure
Decrease conversion of T4 to T3 at high doses
Use with caution in renal/hepatic impairment
Esmolol 250–500 mcg IV ×1 then 50–100 mcg/kg/min Short-acting
Rapid-titration
Bile Acid Sequestrants: Decrease Enterohepatic Recycling of Thyroid Hormones
Cholestyramine PO: 1–4 g BID Off-label use. Use with a thionamide and propranolol
Glucocorticoids: Decrease Conversion of T4 to T3
Hydrocortisone IV: 300 mg ×1 then 100 mg q8h Adjunct therapy
Alternative: Dexamethasone 1–2 mg q6h



  • Note: Pyrexia: use acetaminophen instead of aspirin since aspirin can increase serum free T4 and T3


ADR , Adverse drug reaction; BID , Twice daily; Cl , Contraindication; CrCl , Creatinine clearance; IV , Intravenously; PO , Orally; PR , Per rectum; PRN , As needed


Myxedema coma


Definition


Severe hypothyroidism characterized by decreased mental status, hypothermia, cardiovascular instability, hyponatremia, hypoglycemia, and hypoventilation.


Risk factors





  • Noncompliance to thyroid replacement therapy



  • Chronic hypothyroidism



  • Infection



  • Myocardial infarction



  • Cold exposure



  • Surgery



  • Drugs (sedatives, opioids, amiodarone, lithium)



Management



Feb 28, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Other endocrine emergencies
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