# Thyroid Storm Pharmacotherapy > Thyroid storm management for NEET-PG Pharmacology: propylthiouracil loading, iodine after thionamide, propranolol, hydrocortisone, Burch-Wartofsky score. - Canonical URL: https://prepelephant.com/topics/neet-pg/pharmacology/thyroid-storm-pharmacotherapy - Exam / course: NEET-PG · Subject: Pharmacology - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Thyroid Storm Pharmacotherapy", PrepElephant, https://prepelephant.com/topics/neet-pg/pharmacology/thyroid-storm-pharmacotherapy ## Direct answer Block synthesis, block release, block peripheral conversion, and support the circulation — the four moves of thyroid storm, in that order. Propylthiouracil 600-1000 mg orally (or by nasogastric tube) then 250 mg every six hours comes first, because PTU inhibits thyroid peroxidase and also peripheral type 1 deiodinase. Iodine (saturated solution of potassium iodide or Lugol's) follows at least one hour after the thionamide — given first, it simply feeds new hormone synthesis (the Jod-Basedoff trap). Propranolol 60-80 mg every four to six hours (esmolol if unstable) tames adrenergic drive, hydrocortisone 100 mg IV every eight hours blocks conversion and covers relative adrenal insufficiency, and the trigger — infection, surgery, radioiodine, non-adherence — is treated in parallel. A Burch-Wartofsky score of 45 or more makes the diagnosis highly likely. ## What you must remember - **The sequence:** thionamide first, iodine at least one hour later, never reversed — iodine before blockade fuels a synthesis surge. - **Doses:** propylthiouracil 600-1000 mg load, then 250 mg every 4-6 hours; methimazole 60-80 mg daily is an alternative load but lacks peripheral conversion blockade. - **Beta-blockade:** propranolol 60-80 mg orally every 4-6 hours (high doses needed because clearance is accelerated); esmolol infusion when congestive failure or instability makes oral propranolol risky. - **Iodine options:** SSKI five drops every six hours or Lugol's 8-10 drops daily; ipodate/iopanoic acid where available blocks both release and conversion. - **Glucocorticoid:** hydrocortisone 100 mg IV every eight hours (dexamethasone 2 mg every six hours is the alternative) — inhibits T4-to-T3 conversion and treats storm-associated adrenal insufficiency. - **Adjuncts and escape hatches:** cholestyramine 4 g four times daily binds enterohepatic hormone; plasmapheresis, exchange transfusion or dialysis for refractory cases; cool the patient and correct the precipitant. - **Scoring:** Burch-Wartofsky — temperature, tachycardia, CNS signs, gastrointestinal upset, precipitant presence; 45 or more highly suggestive, 25-44 possible. - **Indian context:** PTU remains first choice here for storm and first-trimester thyrotoxicosis; note PTU hepatotoxicity limits its long-term use, so switch to methimazole (carbimazole) in the second trimester. ## The first six hours, hour by hour Picture the 34-year-old arriving febrile at 39.5 degrees, pulse 150 and irregular, delirious, with a goitre and recent radioiodine exposure. Hour zero: ICU admission, IV fluids, cooling blankets, cultures before antibiotics, and the Burch-Wartofsky tally reads 60. Give PTU 1000 mg via nasogastric tube at once. Hour one: propranolol 80 mg down the same tube, hydrocortisone 100 mg IV. Hour two: SSKI five drops — safely after the thionamide — shutting off hormone release from the gland. Hours three to six: dig cautiously if atrial fibrillation persists (digoxin requirements are high and toxicity lurks; avoid verapamil with beta-blockade), watch for shock needing cautious fluids, and arrange definitive therapy later. Atrial fibrillation with storm resists digoxin because the high hormone state increases clearance and receptor resistance — beta-blockade after blockade of synthesis is the logical anchor. Definitive steps come after stabilisation: radioiodine or thyroidectomy only once the patient is biochemically quieter, typically weeks later; the immediate pharmacology has one job — stop new hormone, stop release, stop conversion. ## Where the exam twists the knife The sequence question is deliberately seductive: "which drug is given first in thyroid storm" — the thionamide, with iodine delayed at least an hour; students who reflexively write "iodine" forget the Wolff-Chaikoff escape and new-synthesis fuelling. Second trap: why PTU rather than methimazole in storm — only PTU blocks peripheral conversion, a mechanism question that separates prepared candidates. Third: propranolol in a storm patient with heart failure — choose esmolol with invasive monitoring, or halve doses, because unopposed negative inotropy can collapse a borderline ventricle. Fourth: steroids are not optional decoration — they are simultaneously conversion blockers and therapy for relative adrenal insufficiency. Indian exam reality: PTU availability and monitoring of LFTs, the thyrotoxic periodic paralysis link (commonly asked in South Asian and East Asian men — treat with propranolol and cautious potassium), and the classic viva on why levothyroxine brands dominate Indian pharmacies while antithyroid drugs sit behind hepatotoxicity warnings. ## Frequently asked questions ### Which antithyroid drug is preferred in thyroid storm and why? Propylthiouracil, loaded at 600-1000 mg then 250 mg every six hours, because it blocks both thyroid hormone synthesis and peripheral T4-to-T3 conversion. ### Why must iodine be given after the thionamide? Iodine given before synthesis is blocked provides substrate for new hormone formation and can worsen the storm; a gap of at least one hour is standard. ### What dose of hydrocortisone is used in thyroid storm? 100 mg intravenously every eight hours, blocking conversion and covering relative adrenal insufficiency. ### How is the diagnosis of thyroid storm quantified? The Burch-Wartofsky score; 45 or more is highly suggestive of storm, 25-44 suggests impending storm. ### Which beta-blocker suits a storm patient with cardiac instability? Esmolol by infusion, for titratable short-acting blockade when oral propranolol and ventricular dysfunction coexist.