Cholestyramine in thyroid storm

Q: 24 years old female is admitted to ICU with thyroid storm. Endocrine service suggested adding cholestyramine. How does it help in thyroid storm?

Answer: By default, thyroid hormones are hepatically metabolized. They get conjugated with glucuronide and sulfate, and these conjugated products get excreted in bile. Free thyroid hormones are released in intestine and are reabsorbed. Cholestyramine is a bile acid sequestrant. It interrupts T3, T4 enterohepatic circulation and thus recycling of thyroid hormone. It is a valuable adjuvant treatment in thyroid storm, particularly in patients who are thionamides intolerant.

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References:

1. Solomon BL, Wartofsky L, Burman KD. Adjunctive cholestyramine therapy for thyrotoxicosis. Clin Endocrinol (Oxf) 1993; 38:39. 

2. Kaykhaei MA, Shams M, Sadegholvad A, et al. Low doses of cholestyramine in the treatment of hyperthyroidism. Endocrine 2008; 34:52.

3. Tsai WC, Pei D, Wang TF, et al. The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves' hyperthyroidism. Clin Endocrinol (Oxf) 2005; 62:521.