Hepatic Failure/GI/Endocrine Emergencies

General treatment measures include rewarming of the patient and treatment of the precipitating

illness. Because infection is a common precipitator of myxedema coma, all patients should undergo

a thorough infectious workup.

Guidelines from the American Thyroid Association recommend the following for patients with

myxedema coma:

Patients may have underlying adrenocorticotropic hormone deficiency, and restoration of

thyroid function can accelerate cortisol metabolism. Empiric intravenous corticosteroids at

doses appropriate for the stressed state should be administered before levothyroxine (strong

recommendation). Hydrocortisone is typically given in doses of 50 mg every 6 hours or 100

mg every 8 hours.

ii.

Thyroid hormone replacement should be initiated with intravenous levothyroxine. A loading

dose of 200–400 mcg should be given, with lower doses used in patients who are smaller or

older or who have a history of cardiac disease or arrhythmia (strong recommendation).

iii.

After the initial loading dose, the daily replacement dose should be 1.6 mcg/kg body weight

intravenously (strong recommendation). Daily therapy may be changed to the enteral route

after the patient improves clinically.

iv.

Because T4 to T3 conversion may be decreased in myxedema coma, intravenous liothyronine

may be given in addition to levothyroxine (weak recommendation). High serum T3 during

treatment is associated with mortality, so high doses should be avoided. A loading dose of 5–20

mcg can be given, followed by 2.5–10 mcg every 8 hours. Patients who are smaller or older or

who have a history of cardiac disease or arrhythmia should receive smaller doses. Treatment

can be continued until the patient has regained consciousness and clinical parameters have

improved.

Patients should be monitored for improvements in mental status, cardiac function, and

pulmonary function.

vi.

Measurement of thyroid hormones every 1–2 days is reasonable to ensure a favorable

trajectory. Optimal levels of TSH, T4, and T3 in this scenario have not been defined, but lack of

improvement may be an indication to increase the levothyroxine dose and/or add liothyronine.

High serum T3 can be considered an indication to decrease therapy for safety reasons (weak

recommendation).

with β1-adrenergic receptor agonist properties (epinephrine or dopamine) is preferred to increase

the patient’s heart rate and blood pressure.

Patient Case

A 23-year-old man (weight 80 kg) presents to the ED with an acute mental status change and a core body

temperature of 94°F (34.4°C). He has a history of hypothyroidism, but according to his family, he had

decided to stop taking all of his thyroid medications 1 week earlier. The team has given him a diagnosis of

myxedema coma. Which is the most appropriate treatment option for this patient?