• Dr. Paul Dhillon MB BCh CCFP

Are you ready for the big PIG storm?

Do you remember the order to give medications in Thyrotoxicosis?


  1. What are 5 causes for Thyroid Storm?

  2. What are 4 medications and the rationale for their use in treatment?

  3. Is there one drug that you should give after the other?

Answers in the blog post below.


Thyroid storm is uncommon enough in real life practice but something that could show up in your rural or urban emergency department so it’s easy to see it walking onto the pages of your examination.

DID YOU KNOW – Iodine administration should be at LEAST ONE HOUR after giving a thionamide such as PTU or Methimazole to prevent the Iodine from being used as a source for new hormone synthesis.


  1. Causes of Thyroid Storm/Thyrotoxicosis Graves Disease, thyroid surgery, trauma, acute iodine load, parturition/child birth, discontinuation of anti-thyroid drugs, toxic multinodular goitre, solitary toxic adenoma

  2. Four Medications (Big PIG)

  • B-Blocker for symptom control

  • Propylthiouracil (PTU) or methimazole/carbimazole to decrease new hormone synthesis and inhibit T4 to T3 conversion

  • Ioidine (Lugol’s Solution (potassium iodide-iodine) or Saturated Potassium Iodine) to block stored thyroid hormone release and inhibit hormone synthesis

  • Glucocorticoids (Hydrocortisone) prevents peripheral T4 to T3 conversion

EXAM TIP – Always remember to check if the patient could be pregnant on the exam! If so, PTU is the preferred drug in the first trimester instead of the more teratogenic methimazole and don’t forget to discuss the radioiodine or surgical options as well.

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