EMCrit 292 – IV T3 for Myxedema Coma, A Different Take with Eve Bloomgarden

So we recently did a Myxedema Episode with Arti Bhan. On the show, we were supposed to have a 2nd endocrinologist, but due to scheduling issues, it didn't work out. For a different take on IV T3, today we have that endocrinologist on the show.

Eve Bloomgarden, MD

Dr. Eve Bloomgarden, MD is an endocrinologist at Northwestern Memorial Hospital and an assistant professor in the Division of Endocrinology, Metabolism and Molecular Medicine at Northwestern University Feinberg School of Medicine. Dr. Bloomgarden received her medical degree from New York University and completed residency and fellowship training at the Hospital of the University of Pennsylvania. Dr. Bloomgarden’s clinical expertise is in the diagnosis and management of thyroid disorders and thyroid cancer as well as general endocrinology. She is a clinician educator and contributes to the medical education of students, residents, and fellows. She loves spending time with her husband, also a physician, and their two young children. The COVID crisis has brought out her social media voice and her strength as an advocate for her fellow healthcare workers.

If the Patient Looks Crappy...

This is when to consider combined therapy in Dr. Bloomgarden's practice

Always Give Steroids First

I think this is even more critical if you are using LT3

Combined LT4/LT3 Dosing Strategy

LT4 200-300 mcg

&

LT3 5-10 mcg IV then 2.5-5 mcg q8 hrs (until pt stabilizes and then switch to just LT4)

American Thyroid Association Guidelines

* Guidelines from American Thyroid Assoc.

21c. In patients with myxedema coma being treated with levothyroxine, should liothyronine therapy also be initiated?

■  Recommendation

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. 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).

Weak recommendation. Low-quality evidence.

Not Many Patients Treated with LT3 in this Review

Japanese Review of Treatment Options for Myxedema

Want More Eve?

* Check her out on the Curbsiders

More Myxedema and Thyroid on EMCrit

* IBCC chapter & cast - Myxedema coma (decompensated hypothyroidism)

* Decompensated Hypothyroidism ("Myxedema Coma")(Opens in a new browser tab)

* Thyroid Storm(Opens in a new browser tab)

* Podcast 149 – Thyroid Storm