Which of the following best describes the treatment for thyroid storm?

• A. Supportive care; PTU (prophythiouracil); potassium iodine, sodium iodine, or Lugol solution; beta-blockade for peripheral effects; dexamethasone to prevent peripheral conversion of T4 to T3
• B. Methimazole alone is insufficient for thyroid storm
• C. Hydrocortisone only
• D. Antibiotic therapy with penicillin

Answer: (C)

Thyroid storm requires rapid, comprehensive therapy that both stops new hormone production and release and mitigates the body’s response, while supporting organ function. The best approach combines antithyroid medication, iodine to block release, beta-blockade to blunt adrenergic symptoms, and a glucocorticoid to reduce peripheral conversion of T4 to T3 and to address potential adrenal insufficiency, all with supportive care.

Propylthiouracil is preferred initially because it not only inhibits new thyroid hormone synthesis but also decreases peripheral conversion of T4 to the more active T3. After giving the antithyroid drug, iodine (potassium iodide, sodium iodide, or Lugol solution) is used to acutely inhibit release of thyroid hormone from the gland, a effect that is most effective when given after antithyroid therapy to avoid simply driving more hormone production. Beta-blockers are essential for controlling rapid heart rate, tremor, and other adrenergic manifestations, though they don’t treat the underlying thyrotoxicosis by themselves. A glucocorticoid like dexamethasone (or hydrocortisone) helps reduce the conversion of T4 to T3 and provides coverage for potential adrenal insufficiency in a critical illness.

Giving hydrocortisone alone misses the crucial steps of blocking synthesis, preventing release, and controlling adrenergic symptoms, so it would not adequately treat a thyroid storm by itself.