A 72-year-old woman is brought in with body temperature 31°C, heart rate 38/min, blood pressure 84/50 mmHg, and altered sensorium. Skin is dry and puffy, deep tendon reflexes show delayed relaxation. Free T4 is undetectable and TSH is 78 mIU/L. Along with supportive care, the most appropriate drug regimen is:

• A IV levothyroxine alone
• B IV hydrocortisone alone pending repeat thyroid function tests
• C IV levothyroxine plus IV hydrocortisone ✓
• D Oral levothyroxine via nasogastric tube once rewarmed

Explanation

Myxoedema coma carries high mortality and is treated with parenteral levothyroxine, passive rewarming, ventilatory support if needed, and empiric hydrocortisone. Cortisol cover is essential because myxoedema coma frequently coexists with relative adrenal insufficiency, either from autoimmune polyglandular disease or hypothalamo-pituitary failure, and rapid thyroid hormone replacement accelerates cortisol clearance and can precipitate adrenal crisis. Oral therapy is inappropriate given impaired absorption and gut motility in coma.

Reference: Williams Textbook of Endocrinology, 14th ed.

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Written and medically reviewed by the StethoPrep medical team.