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甲状腺クリーゼ

著者: 赤水尚史 医療法人神甲会 隈病院

監修: 平田結喜緒 公益財団法人 兵庫県予防医学協会 健康ライフプラザ

著者校正済:2021/11/24
現在監修レビュー中
参考ガイドライン:
  1. 日本甲状腺学会・日本内分泌学会:甲状腺クリーゼの診療ガイドライン2017
患者向け説明資料

概要・推奨   

  1. 2017年にわが国の甲状腺クリーゼの診療ガイドラインが発表されている。この診療ガイドラインを基に治療方針を決定することが推奨される(推奨度1)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
赤水尚史 : 未申告[2021年]
監修:平田結喜緒 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 2017年にわが国の甲状腺クリーゼの診療ガイドラインが発表され、それに基づいて改訂した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 甲状腺クリーゼとは、甲状腺機能中毒症が重症化した状態のことで、心不全、不整脈、高体温などを伴い致死的なこともある状態である。
  1. 甲状腺中毒症に高熱、循環不全、意識障害、下痢・黄疸などの多臓器不全を合併しているときや、生体の非代償性状態で放置すれば生命を脅かすような状態が疑われるときに強く疑う。
病歴・診察のポイント  
  1. 全身性症候、臓器症候、甲状腺基礎疾患関連症候の3つに大別できる。

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文献 

著者: H B Burch, L Wartofsky
雑誌名: Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77.
Abstract/Text Although important strides in recognition and therapy have significantly reduced the mortality in this disorder from the nearly 100% fatality rate noted by Lahey, survival is by no means guaranteed. More recent series have yielded fatality rates between 20% and 50%. Although some authors have attributed this improvement, in part, to a relaxation of the diagnostic criteria for thyroid storm, it more likely represents improvements in early recognition and the beneficial effects of the serial addition of antithyroid, corticosteroid, and antiadrenergic therapies to the treatment of this disorder. Thyroid storm is a dreaded, fortunately rare complication of a very common disorder. Most cases of thyroid storm occur following a precipitating event or intercurrent illness. Effective management is predicated on a prompt recognition of impending thyroid storm which is, in turn, dependent on a thorough knowledge of both the typical and atypical presentations of this disorder. An unwavering commitment to an aggressive, multifaceted therapeutic intervention as outlined herein is critical to the obtainment of a satisfactory outcome.

PMID 8325286  Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77.
著者: Takashi Akamizu, Tetsurou Satoh, Osamu Isozaki, Atsushi Suzuki, Shu Wakino, Tadao Iburi, Kumiko Tsuboi, Tsuyoshi Monden, Tsuyoshi Kouki, Hajime Otani, Satoshi Teramukai, Ritei Uehara, Yosikazu Nakamura, Masaki Nagai, Masatomo Mori, Japan Thyroid Association
雑誌名: Thyroid. 2012 Jul;22(7):661-79. doi: 10.1089/thy.2011.0334. Epub 2012 Jun 12.
Abstract/Text BACKGROUND: Thyroid storm (TS) is life threatening. Its incidence is poorly defined, few series are available, and population-based diagnostic criteria have not been established. We surveyed TS in Japan, defined its characteristics, and formulated diagnostic criteria, FINAL-CRITERIA1 and FINAL-CRITERIA2, for two grades of TS, TS1, and TS2 respectively.
METHODS: We first developed diagnostic criteria based on 99 patients in the literature and 7 of our patients (LIT-CRITERIA1 for TS1 and LIT-CRITERIA2 for TS2). Thyrotoxicosis was a prerequisite for TS1 and TS2 as well as for combinations of the central nervous system manifestations, fever, tachycardia, congestive heart failure (CHF), and gastrointestinal (GI)/hepatic disturbances. We then conducted initial and follow-up surveys from 2004 through 2008, targeting all hospitals in Japan, with an eight-layered random extraction selection process to obtain and verify information on patients who met LIT-CRITERIA1 and LIT-CRITERIA2.
RESULTS: We identified 282 patients with TS1 and 74 patients with TS2. Based on these data and information from the Ministry of Health, Labor, and Welfare of Japan, we estimated the incidence of TS in hospitalized patients in Japan to be 0.20 per 100,000 per year. Serum-free thyroxine and free triiodothyroine concentrations were similar among patients with TS in the literature, Japanese patients with TS1 or TS2, and a group of patients with thyrotoxicosis without TS (Tox-NoTS). The mortality rate was 11.0% in TS1, 9.5% in TS2, and 0% in Tox-NoTS patients. Multiple organ failure was the most common cause of death in TS1 and TS2, followed by CHF, respiratory failure, arrhythmia, disseminated intravascular coagulation, GI perforation, hypoxic brain syndrome, and sepsis. Glasgow Coma Scale results and blood urea nitrogen (BUN) were associated with irreversible damages in 22 survivors. The only change in our final diagnostic criteria for TS as compared with our initial criteria related to serum bilirubin concentration >3 mg/dL.
CONCLUSIONS: TS is still a life-threatening disorder with more than 10% mortality in Japan. We present newly formulated diagnostic criteria for TS and clarify its clinical features, prognosis, and incidence based on nationwide surveys in Japan. This information will help diagnose TS and in understanding the factors contributing to mortality and irreversible complications.

PMID 22690898  Thyroid. 2012 Jul;22(7):661-79. doi: 10.1089/thy.2011.0・・・
著者: Tetsurou Satoh, Osamu Isozaki, Atsushi Suzuki, Shu Wakino, Tadao Iburi, Kumiko Tsuboi, Naotetsu Kanamoto, Hajime Otani, Yasushi Furukawa, Satoshi Teramukai, Takashi Akamizu
雑誌名: Endocr J. 2016 Dec 30;63(12):1025-1064. doi: 10.1507/endocrj.EJ16-0336. Epub 2016 Oct 15.
Abstract/Text Thyroid storm is an endocrine emergency which is characterized by multiple organ failure due to severe thyrotoxicosis, often associated with triggering illnesses. Early suspicion, prompt diagnosis and intensive treatment will improve survival in thyroid storm patients. Because of its rarity and high mortality, prospective intervention studies for the treatment of thyroid storm are difficult to carry out. We, the Japan Thyroid Association and Japan Endocrine Society taskforce committee, previously developed new diagnostic criteria and conducted nationwide surveys for thyroid storm in Japan. Detailed analyses of clinical data from 356 patients revealed that the mortality in Japan was still high (∼11%) and that multiple organ failure and acute heart failure were common causes of death. In addition, multimodal treatment with antithyroid drugs, inorganic iodide, corticosteroids and beta-adrenergic antagonists has been suggested to improve mortality of these patients. Based on the evidence obtained by nationwide surveys and additional literature searches, we herein established clinical guidelines for the management of thyroid storm. The present guideline includes 15 recommendations for the treatment of thyrotoxicosis and organ failure in the central nervous system, cardiovascular system, and hepato-gastrointestinal tract, admission criteria for the intensive care unit, and prognostic evaluation. We also proposed preventive approaches to thyroid storm, roles of definitive therapy, and future prospective trial plans for the treatment of thyroid storm. We hope that this guideline will be useful for many physicians all over the world as well as in Japan in the management of thyroid storm and the improvement of its outcome.

PMID 27746415  Endocr J. 2016 Dec 30;63(12):1025-1064. doi: 10.1507/en・・・
著者: Trevor E Angell, Melissa G Lechner, Caroline T Nguyen, Victoria L Salvato, John T Nicoloff, Jonathan S LoPresti
雑誌名: J Clin Endocrinol Metab. 2015 Feb;100(2):451-9. doi: 10.1210/jc.2014-2850. Epub 2014 Oct 24.
Abstract/Text CONTEXT: Thyroid storm (TS) is a rare but life-threatening manifestation of thyrotoxicosis. Predictive features and outcomes remain incompletely understood, in part because studies comparing TS with hospitalized thyrotoxic patients have rarely been performed.
OBJECTIVES: Our objectives were to compare the diagnosis and outcomes in TS versus hospitalized compensated thyrotoxic (CT) patients and to assess differences in diagnostic classification using the Burch-Wartofsky scores (BWSs) or Akamizu (Ak) criteria for identifying TS.
DESIGN, SETTING, AND PATIENTS: This was a retrospective cohort study of hospitalized patients during a 6-year period at an academic tertiary hospital, with age ≥ 18 years, TSH <0.01 mIU/L, and clinically diagnosed TS or CT.
OUTCOME MEASURES: In-patient mortality, hospital and intensive care unit length of stay, intubation, and ventilator duration were assessed.
RESULTS: Twenty-five TS and 125 CT patients were identified and analyzed. All but 1 TS patient received thionamides, β-blockade, glucocorticoids, and iodides within 24 hours of diagnosis. CT patients received thionamides and β-blockade alone. In the acute hospital setting, rates of fever (>100.4 °F), heart rate (>100 beats/min), altered mentation, and a precipitating event were all higher for TS than for CT patients. Altered mentation was the only clinical feature significantly different between TS and the subset of CT patients defined as TS by BWS or Ak criteria (P < .001). TS patients had greater in-patient mortality, hospital and intensive care unit length of stay, and ventilation requirements than CT patients.
CONCLUSIONS: In acutely hospitalized thyrotoxic patients, the presence of central nervous system dysfunction distinguished clinically diagnosed TS from patients with BWS- or Ak-defined TS. Because TS patients had significantly worse outcomes in this study, thyrotoxic patients with possible TS and central nervous system dysfunction may derive the greatest benefit from aggressive supportive and TS-specific treatments.

PMID 25343237  J Clin Endocrinol Metab. 2015 Feb;100(2):451-9. doi: 10・・・

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