2026 ETA/BTA Joint Consensus Statement: Management of Endocrine Emergencies — Thyroid Storm

Full title: Joint Consensus Statement by European Thyroid Association (ETA), British Thyroid Association (BTA), Society for Endocrinology (SfE): Management of Endocrine Emergencies — Thyroid Storm, published in European Thyroid Journal, 2026 Core positioning: Multidisciplinary ICU-endocrine joint consensus for thyroid storm (TS). Thyroid storm is a clinical diagnosis, not purely biochemical. Treatment should be initiated immediately upon clinical suspicion, do not wait for full lab confirmation. The consensus emphasizes parallel multi-target therapy + precipitant control + ICU supportive care, highlights refractory thyroid storm rescue strategy and post-storm definitive management of underlying hyperthyroidism, aligned with prior KTA DTC follow-up guideline and NASIT thyroid intervention statement.

1. Definition, Epidemiology & Precipitants

Thyroid storm is life-threatening decompensation of severe thyrotoxicosis, manifested by extreme hypermetabolism and multi-organ dysfunction, mortality remains 10–20%.

• Common triggers: infection, non-thyroid surgery / thyroid operation, trauma, childbirth, iodine contrast, amiodarone, poor adherence to antithyroid drugs, DKA.
• Underlying etiology: majority Graves’ disease; also toxic multinodular goiter, toxic adenoma, thyroiditis.

2. Diagnostic Framework

Clinical diagnosis first; scoring systems as auxiliary tools

1. Burch-Wartofsky Point Scale (BWPS): ≥45 points: highly suggestive thyroid storm; 25–44: suspected impending storm; <25: unlikely.
2. JTA criteria: classifies into definite TS (TS1) / suspected TS (TS2), combining biochemistry + organ damage.

Key reminder: Normal or near-normal TSH cannot rule out storm in critical illness; free T3 / free T4 elevation supports diagnosis but normal thyroid hormones do not absolutely exclude TS.

Clinical manifestations:

• Fever (>38℃);
• CNS disturbance: agitation, delirium, seizure, coma;
• Cardiovascular: sinus tachycardia, atrial fibrillation, heart failure, shock;
• GI/hepatic: vomiting, diarrhoea, jaundice, transaminitis.

3. Core Treatment Principle: 4 parallel pillars (start simultaneously in ICU/HDU)

Pillar 1: Block new thyroid hormone synthesis

• PTU preferred (inhibits synthesis + peripheral T4→T3 conversion): loading dose 500–1000 mg PO/NG, then 250 mg q4h.
• If PTU unavailable: MMI loading 60 mg, then 20 mg q8h.

Pillar 2: Block thyroid hormone release (admin ≥1h after ATD)

• Lugol iodine / SSKI, 5 drops q6h for 3–7 days; stop once stable, avoid long-term use.

Never give iodine before ATD: may worsen hormone overproduction.

Pillar3: Block adrenergic effects + reduce peripheral conversion

• Propranolol (preferred, blocks T4 to T3): oral 40–80 mg q6h; IV propranolol / landiolol for unstable patients.
• Caution in decompensated heart failure: use selective beta1 blocker with inotropic support, avoid pure beta-blockers in cardiogenic shock.

Pillar4: Reduce peripheral conversion + anti-inflammatory effect

• Hydrocortisone 100 mg IV q8h / dexamethasone 2 mg q6h; also reduce cytokine storm and protect against relative adrenal insufficiency.

4. Supportive Care & Precipitant Control (highest priority alongside drugs)

1. Cooling: paracetamol; avoid aspirin (displaces thyroid hormone from binding protein, increases free hormone). Cooling blanket for hyperpyrexia.
2. IV fluid resuscitation, electrolyte correction, monitor glucose.
3. Search and treat trigger: blood culture, chest imaging, rule out infection, ischemia.
4. Monitor: continuous cardiac monitoring, lactate, liver function, calcium, renal function.

5. Refractory Thyroid Storm Rescue (when standard therapy fails)

1. Cholestyramine: binds intestinal thyroid hormone, interrupt enterohepatic circulation.
2. Plasmapheresis: rapid removal of protein-bound T4/T3, for severe refractory cases.
3. ECMO: for refractory cardiogenic shock / respiratory failure.
4. Emergency total thyroidectomy: after partial stabilization in selected patients.

6. Special Populations

1. Pregnancy: PTU preferred in first trimester; beta-blocker with caution; iodine limited duration. Avoid MMI in early pregnancy.
2. Elderly / frailty: atypical presentation (apathetic thyroid storm, no fever or agitation). Lower beta-blocker starting dose, close HF monitoring.
3. Heart failure: distinguish high-output heart failure; may require inotropes alongside selective beta blockade.

7. Post-storm Definitive Management (critical consensus recommendation)

Once stabilized (days to weeks):

• Choose definitive therapy for underlying hyperthyroidism: radioiodine or thyroidectomy;
• Continue ATD until euthyroidism;
• Long-term thyroid follow-up aligned with thyroid nodule / cancer guidelines (KTA 2026 DTC follow-up).

Thyroid storm is a medical emergency, not a standalone disease; recurrence risk remains unless underlying hyperthyroidism is definitively managed.

8. Contraindications & Common Pitfalls

❌ Delay treatment pending lab results; ❌ Iodine administered before antithyroid drug; ❌ Aspirin for fever control; ❌ Overtreating mild thyrotoxicosis as thyroid storm; ❌ Forgetting precipitant workup (infection is #1 trigger).

9. Evidence Gaps

1. Limited large RCTs; recommendations based on registries, case series and expert opinion.
2. Optimal timing and threshold for plasmapheresis / emergency surgery remain debated.
3. Apathetic thyroid storm in elderly has low recognition rate.

10. Cross alignment with prior guideline series

1. This ETA/BTA 2026 joint consensus: life-threatening thyroid emergency, immediate multi-pillar ICU treatment.
2. NASIT 2026 thyroid artery embolization statement: TAE procedure can rarely precipitate thyroid storm; this consensus defines the emergency management pathway.
3. KTA 2026 DTC follow-up guideline: covers chronic surveillance for thyroid neoplasia; this statement addresses acute life-threatening thyrotoxic crisis.
4. 2026 Italian postoperative hypoparathyroidism guideline: neck surgery complications (hypoparathyroidism), while this statement covers perioperative thyroid storm risk.

Disclaimer: This summary is for academic study only, not direct clinical practice. Thyroid storm is a life-threatening endocrine emergency requiring ICU + endocrinology MDT co-management.