{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T15:43:48Z","timestamp":1789400628877,"version":"build-2803163510"},"reference-count":24,"publisher":"Bioscientifica","issue":"3","license":[{"start":{"date-parts":[[2024,7,1]],"date-time":"2024-07-01T00:00:00Z","timestamp":1719792000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["edm.bioscientifica.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,7,1]]},"abstract":"<jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>Thyroid storm is a clinical diagnosis characterized by life-threatening multisystemic organ involvement in the setting of uncontrolled hyperthyroidism. Current estimates suggest a mortality rate of up to 30%. Treatment often consists of the administration of thionamide medications, iodine solution(s), corticosteroids, and beta-blockers; in extreme circumstances, both plasmapheresis and thyroidectomy are subsequent therapeutic options. Thionamides are typically administered orally, with the intent of preventing further thyroid hormone synthesis; however, in the literature, there are instances whereby oral access cannot be obtained, and alternative routes of administration are required. We present a case of a patient who presented with a thyroid storm due to lack of adherence to methimazole. During admission, he was found to have significant abdominal pain and ultimately a duodenal perforation requiring strict nil-per-os (NPO) status, due to which he was unable to receive oral thionamides. Due to the lack of availability of intravenous formulations of thionamides in the United States, this patient was treated with an enema compound of propylthiouracil for a total of five per rectum (PR) doses. He would later develop hepatocellular injury, requiring discontinuation and eventual transition to oral methimazole. The literature pertaining to alternative-route thionamide administration is scant, and therefore this case report and literature review is written to provide an up-to-date review and further educate all levels of clinicians about this infrequent (but emergent) situation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Learning points<\/jats:title>\n                    <jats:list list-type=\"bullet\">\n                      <jats:list-item>\n                        <jats:p>Thyroid storm is a clinical diagnosis for which urgent recognition is required to prevent untoward mortality.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>Treatment for thyroid storm requires prompt administration of thionamides, iodine, corticosteroids, and beta-blockers. In extreme circumstances, treatment considerations include plasmapheresis and thyroidectomy.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>Infrequently, patients with a thyroid storm may not be able to tolerate oral medications, for which alternative routes of access are required.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>Currently, available alternatives include intravenous methimazole (in Europe and Japan), as well as both enema and suppository preparations of propylthiouracil and methimazole.<\/jats:p>\n                      <\/jats:list-item>\n                    <\/jats:list>\n                  <\/jats:sec>","DOI":"10.1530\/edm-24-0067","type":"journal-article","created":{"date-parts":[[2024,9,4]],"date-time":"2024-09-04T07:56:39Z","timestamp":1725436599000},"update-policy":"https:\/\/doi.org\/10.1530\/crossmarkpolicy-2","source":"Crossref","is-referenced-by-count":1,"title":["Rectal thionamide administration in the setting of thyroid storm: a case report and review of the literature"],"prefix":"10.1530","volume":"2024","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8709-2064","authenticated-orcid":true,"given":"Maxim John Levy","family":"Barnett","sequence":"first","affiliation":[{"name":"Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlo","family":"Casipit","sequence":"additional","affiliation":[{"name":"Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sri Ram Teja","family":"Sathi","sequence":"additional","affiliation":[{"name":"Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana Del Carmen Rivadeneira","family":"Rodriguez","sequence":"additional","affiliation":[{"name":"Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"416","reference":[{"key":"bib1","series-title":"JCEM Case Reports","first-page":"luae019","article-title":"A case of metastatic choriocarcinoma-related paraneoplastic thyroid storm","volume":"2","author":"Gupta","year":"2024","unstructured":"Gupta NGraham LCarpenter M & Gandhi GY. A case of metastatic choriocarcinoma-related paraneoplastic thyroid storm. JCEM Case Reports20242luae019. (https:\/\/doi.org\/10.1210\/jcemcr\/luae019)"},{"key":"bib2","series-title":"Journal of Intensive Care Medicine","first-page":"131","article-title":"Thyroid storm","volume":"30","author":"Chiha","year":"2015","unstructured":"Chiha MSamarasinghe S & Kabaker AS. Thyroid storm. Journal of Intensive Care Medicine201530131\u2013140. (https:\/\/doi.org\/10.1177\/0885066613498053)"},{"key":"bib3","series-title":"Journal of Clinical Endocrinology and Metabolism","first-page":"1","article-title":"Prospective multicenter registry-based study on thyroid storm: the guidelines for management from Japan are useful","author":"Furukawa","year":"2024","unstructured":"Furukawa YTanaka KIsozaki OSuzuki AIburi TTsuboi KIguchi MKanamoto NMinamitani KWakino S, et al.Prospective multicenter registry-based study on thyroid storm: the guidelines for management from Japan are useful. Journal of Clinical Endocrinology and Metabolism20241\u201310. (https:\/\/doi.org\/10.1210\/clinem\/dgae124)"},{"key":"bib4","series-title":"Endocrinology and Metabolism Clinics of North America","first-page":"263","article-title":"Life-threatening thyrotoxicosis: thyroid storm","volume":"22","author":"Burch","year":"1993","unstructured":"Burch HB & Wartofsky L. Life-threatening thyrotoxicosis: thyroid storm. Endocrinology and Metabolism Clinics of North America199322263\u2013277. (https:\/\/doi.org\/10.1016\/S0889-8529(1830165-8)"},{"key":"bib5","series-title":"Indian Journal of Endocrinology and Metabolism","first-page":"428","article-title":"Perioperative management for non-thyroidal surgery in thyroid dysfunction","volume":"26","author":"Malhotra","year":"2022","unstructured":"Malhotra B & Bhadada SK. Perioperative management for non-thyroidal surgery in thyroid dysfunction. Indian Journal of Endocrinology and Metabolism202226428\u2013434. (https:\/\/doi.org\/10.4103\/ijem.ijem_273_22)"},{"key":"bib6","series-title":"Thyroid","first-page":"1343","article-title":"2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis","volume":"26","author":"Ross","year":"2016","unstructured":"Ross DSBurch HBCooper DSGreenlee MCLaurberg PMaia ALRivkees SASamuels MSosa JAStan MN, et al.2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid2016261343\u20131421. (https:\/\/doi.org\/\/10.1089\/thy.2016.0229)"},{"key":"bib7","series-title":"Thyroid","first-page":"215","article-title":"Management of severe thyrotoxicosis when the gastrointestinal tract is compromised","volume":"21","author":"Alfadhli","year":"2011","unstructured":"Alfadhli E & Gianoukakis AG. Management of severe thyrotoxicosis when the gastrointestinal tract is compromised. Thyroid201121215\u2013220. (https:\/\/doi.org\/10.1089\/thy.2010.0159)"},{"key":"bib8","series-title":"Thyroid","first-page":"661","article-title":"Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surverys","volume":"22","author":"Akamizu","year":"2012","unstructured":"Akamizu TSatoh TIsozaki OSuzuki AWakino SIburi TTsuboi KMonden TKouki TOtani H, et al.Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surverys. Thyroid201222661\u2013679. (https:\/\/doi.org\/10.1089\/thy.2011.0334)"},{"key":"bib9","series-title":"Journal of Drug Delivery Science and Technology","first-page":"104861","article-title":"Drug delivery systems for thyroid disease treatment: a mini review on current therapies and alternative approaches","volume":"87","author":"Kerrigan","year":"2023","unstructured":"Kerrigan LBStewart SADom\u00ednguez-Robles JBrady AJAbu Ammar ADonnelly RFPermana AD & Larra\u00f1eta E. Drug delivery systems for thyroid disease treatment: a mini review on current therapies and alternative approaches. Journal of Drug Delivery Science and Technology202387104861. (https:\/\/doi.org\/10.1016\/j.jddst.2023.104861)"},{"key":"bib10","series-title":"Endocrine Journal","first-page":"1025","article-title":"2016 Guidelines for the management of thyroid storm from the Japan Thyroid Association and Japan Endocrine Society (first edition)","volume":"63","author":"Satoh","year":"2016","unstructured":"Satoh TIsozaki OSuzuki AWakino SIburi TTsuboi KKanamoto NOtani HFurukawa YTeramukai S, et al.2016 Guidelines for the management of thyroid storm from the Japan Thyroid Association and Japan Endocrine Society (first edition). Endocrine Journal2016631025\u20131064. (https:\/\/doi.org\/10.1507\/endocrj.EJ16-0336)"},{"key":"bib11","series-title":"Clinical Endocrinology 2020","first-page":"485","article-title":"Treating hyperthyroidism in the critically ill patient with rectal methimazole","volume":"92","author":"Zamora","unstructured":"Zamora JM, Joy G, Mattman A & Ur E. Treating hyperthyroidism in the critically ill patient with rectal methimazole. Clinical Endocrinology 202092485\u2013487. (https:\/\/doi.org\/10.1111\/cen.14159)"},{"key":"bib12","series-title":"BMJ Case Reports","volume":"14","author":"Lee","unstructured":"Lee JSG,  Brown, Semrad AM & Zeki AA. Getting around the gut: a unique management challenge of thyroid storm precipitated by amphetamine-associated duodenal ischaemia leading to compromised enteric absorption. BMJ Case Reports 2021 14 e238889. (https:\/\/doi.org\/\/10.1136\/bcr-2020-238889)"},{"key":"bib13","article-title":"An alternative route of treatment for refractory vasodilatory shock due to thyroid storm","volume":"160","author":"Wiggins","unstructured":"Wiggins A, Leschorn H & Tekwani S. An alternative route of treatment for refractory vasodilatory shock due to thyroid storm. Chest 2021 160 A631. (https:\/\/doi.org\/10.1016\/j.chest.2021.07.602)"},{"key":"bib14","series-title":"Thyroid","first-page":"403","article-title":"Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm","volume":"1995","author":"Yeung","unstructured":"Yeung SCJ, Go R & Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid19955403\u2013405. (https:\/\/doi.org\/10.1089\/thy.1995.5.403)"},{"key":"bib15","series-title":"Thyroid","first-page":"627","article-title":"Rectal administration of propylthiouracil in hyperthyroid patients: comparison of suspension enema and suppository form","volume":"12","author":"Jongjaroenprasert","unstructured":"Jongjaroenprasert W, Akarawut W, Chantasart D, Chailurkit L &  Rajatanavin R.Rectal administration of propylthiouracil in hyperthyroid patients: comparison of suspension enema and suppository form. Thyroid 2002 12627\u2013631. (https:\/\/doi.org\/10.1089\/105072502320288500)"},{"key":"bib16","series-title":"American Journal of Medicine","first-page":"69","volume":"88","author":"Walter","unstructured":"Walter RM & Bartle WR. Rectal administration of propylthiouracil in the treatment of Graves\u2019 disease. American Journal of Medicine 1990 8869\u201370. (https:\/\/doi.org\/10.1016\/0002-9343(90)90130-6)"},{"key":"bib17","series-title":"Journal of Clinical Endocrinology and Metabolism","first-page":"180","volume":"54","author":"Nabil","unstructured":"Nabil N, Miner DJ & Amatruda JM. Methimazole: an alternative route of administration. Journal of Clinical Endocrinology and Metabolism1982 54180\u2013181. (https:\/\/doi.org\/10.1210\/jcem-54-1-180)"},{"key":"bib18","series-title":"International Journal of Clinical Pharmacology, Therapy, and Toxicology","first-page":"285","volume":"26","author":"Bartle","unstructured":"Bartle WR, Walker SE & Silverberg JD. Rectal absorption of propylthiouracil. International Journal of Clinical Pharmacology, Therapy, and Toxicology 1988 26285\u2013287."},{"key":"bib19","series-title":"Clinical Pharmacokinetics 1991","first-page":"110","volume":"21","author":"van Hoogdalem","unstructured":"van Hoogdalem EJ, de Boer AG & Breimer DD. Pharmacokinetics of rectal drug administration, Part II. Clinical applications of peripherally acting drugs, and conclusions. Clinical Pharmacokinetics 199121110\u2013128. (https:\/\/doi.org\/10.2165\/00003088-199121020-00003)"},{"key":"bib20","series-title":"Endocrine Practice","first-page":"43","volume":"12","author":"Zweig","year":"2006","unstructured":"Zweig SB, Schlosser JR, Thomas SA, Levy CJ & Fleckman AM. Rectal administration of propylthiouracil in suppository form in patients with thyrotoxicosis and critical illness: case report and review of literature. Endocrine Practice20061243\u201347. (https:\/\/doi.org\/10.4158\/EP.12.1.43)"},{"key":"bib21","series-title":"Southern Medical Journal 1997 90","author":"Cansler","unstructured":"Cansler CL, Latham JA, Brown PM, Chapman WH & Magner JA. Duodenal obstruction in thyroid storm. Southern Medical Journal 1997 90. (https:\/\/doi.org\/\/10.1097\/00007611-199711000-00018)"},{"key":"bib22","series-title":"Endocrine Abstracts 2008 15 349","author":"Letham","unstructured":"Letham C, Khan ASA, Kawafi KR, Houta S & Norris AJ. Use of rectal anti-thyroid medications as an alternative to oral route. Endocrine Abstracts 2008 15 349."},{"key":"bib23","series-title":"Endocrinology, Diabetes and Metabolism Case Reports","volume":"2021","author":"Maung","unstructured":"Maung AC, Cheong MA, Chua YY & Gardner DSL. When a storm showers the blood clots: a case of thyroid storm with systemic thromboembolism. Endocrinology, Diabetes and Metabolism Case Reports 2021 2021. (https:\/\/doi.org\/10.1530\/EDM-20-0118)"},{"key":"bib24","article-title":"World Journal of Clinical Cases 2022 108768\u20138774","author":"Baik","unstructured":"Baik SM, Pae Y & Lee JM. High scored thyroid storm after stomach cancer perforation: a case report. World Journal of Clinical Cases 2022 108768\u20138774. 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