Thread by @mendesthiagob

❗️Thyroid storm treatment includes

- Beta-blocker
- Methimazole (MMI)/propylthiouracil (PTU)
- Iodine
- Corticosteroids

🤔There is a great discussion about which antithyroid drug to use in this setting

🧐This is a methimazole x propylthiouracil in thyroid storm 🧵

Let's start with a poll
Which drug would you use?

PTU blocks T4 -> T3 conversion. As T3 is the active hormone, this is an advantage in an emergency setting.

MMI is safer than PTU, especially concerning liver injury. In an emergency setting with potential liver damage, it is also an advantage.

Let's dive into data!

In a retrospective analysis of 356 patients from Japan:

- 9% did not use an antithyroid drug
- 13% used PTU only
- 77,5% used MMI only
- 0,5% used both PTU and MMI

❗️Drug choice did not affect mortality, even after correction in a multivariate analysis.

pubmed.ncbi.nlm.nih.gov/26387649/

Another retrospective analysis of 1,324 pts, also from Japan:

- MMI alone: 66%
- PTU alone: 6%
- Both MMI and PTU: 7%
- No antithyroid drug: 21%

Mortality (not adjusted):
MMI alone: 8.8%
PTU alone: 13%
P: 0.13 for MMI x PTU x PTU+MMI x none

pubmed.ncbi.nlm.nih.gov/26886648/

An assessment of 1,244 pts treated in Taiwan showed a more balanced choice between MMI and PTU:

- PTU: 47%
- MMI: 46%

According to the authors: "outcomes were similar between the two medications."

pubmed.ncbi.nlm.nih.gov/32676839/

What about the American Thyroid Association guideline?

They list both MMI and PTU as options but prefer PTU.

There is a fragment in which it is written that thyroid storm is an exception for the rule that MMI should be used in "virtually every patient".

pubmed.ncbi.nlm.nih.gov/27521067/

Ok, it is clear that in Japan MMI is preferred (solid clinical data).

In Europe and in the US, maybe PTU is preferred (solid data for lowering T3).

There is a very interesting and easy-to-read editorial discussing different approaches

pubmed.ncbi.nlm.nih.gov/31140377/

Let's wrap up with the same poll.
Which drug would you use?

Do you have any thoughts or evidence to add?

Please, help me in making this 🧵 better!