American Thyroid Association Quick-Reference GUIDELINES Apps
Issue link: https://eguideline.guidelinecentral.com/i/521958
9 Î Empiric glucocorticoid coverage should be employed as part of the initial therapy for myxedema coma, with intravenous glucocorticoid administration, at doses appropriate for the stressed state, preceding levothyroxine administration. (S-L). Î Given the possibility that thyroxine conversion to triiodothyronine may be decreased in patients with myxedema coma, intravenous liothyronine may be given in addition to levothyroxine. High doses should be avoided given the association of high serum triiodothyronine during treatment with mortality. (W-L) Note: A loading dose of 5-20 μg can be given, followed by a maintenance dose of 2.5-10 μg every 8 hours, with lower doses chosen for smaller or older patients and those with a history of coronary artery disease or arrhythmia. Therapy can continue until the patient is clearly recovering (e.g., until the patient regains consciousness and clinical parameters have improved). Î Intravenous levothyroxine treatment in severely hypothyroid patients may lead to improvement in cardiovascular, renal, pulmonary, and metabolic parameters within a week. (W-L) Note: Serum thyroxine and triiodothyronine concentrations may improve or normalize with a similar time frame, with more gradual improvement in serum TSH. Thus, the therapeutic endpoints in myxedema coma should be improved mental status, improved cardiac function, and improved pulmonary function. Measurement of thyroid hormones every 1-2 days is reasonable to ensure a favorable trajectory in the biochemical parameters. While optimal levels for serum TSH and thyroid hormones are not well defined in this circumstance, failure of TSH to trend down or for thyroid hormone levels to improve could be considered indications to increase levothyroxine therapy and/or add liothyronine therapy, whereas high serum triiodothyronine could be considered an indication to decrease therapy given safety concerns. Î The ATA recommends against the use of levothyroxine as a form of therapy for hospitalized patients experiencing critical illness exhibiting the nonthyroidal illness syndrome. (S-M) Note: The few randomized controlled trials comparing levothyroxine therapy to no treatment have not shown significant clinical benefit and have raised safety concerns that limit support for this approach. Î The ATA recommends against the use of liothyronine as a form of therapy for hospitalized patients experiencing critical illness exhibiting the nonthyroidal illness syndrome. (W-M). Note: Although low doses of liothyronine have not been linked to harm in clinical trials, data showing any significant clinical benefit are also lacking.