Rapid Preoperative Optimization of the Thyrotoxic Patient Awaiting Oncological Surgery: a Lithium-Based Multimodal Protocol Using Immediate-Release and Slow-Release Formulations

Abstract

Patients referred for thyroidectomy or other urgent surgery in the setting of active thyrotoxicosis present a recurring clinical dilemma, particularly in endocrine and oncological practice. Standard guidance is to render the patient euthyroid before operation to avoid precipitating thyroid storm, but the conventional thionamide-based pathway requires several weeks. In patients with aggressive or rapidly progressive thyroid malignancy, or with non-thyroidal cancer requiring surgery in a thyrotoxic state, this delay can allow tumour progression to the point of inoperability. There is therefore a genuine need for a structured, rapid optimization strategy that achieves operative safety within days rather than weeks. This review summarizes the rationale and evidence for a multimodal rapid-preparation protocol built around lithium carbonate, an inhibitor of thyroid hormone release that acts independently of the thionamide pathway and is therefore useful when thionamides are contraindicated, not tolerated, or too slow. Two operational variants are presented: one using immediate-release lithium, and one using slow-release lithium for settings where immediate-release preparations are unavailable. Each is combined with beta-adrenergic blockade, glucocorticoids, inorganic iodine, and bile-acid sequestrants, with therapeutic plasma exchange reserved as rescue. Dosing, serum-level targets, monitoring, drug-interaction caveats, and the limitations of the underlying evidence are discussed. The aggregate evidence is dominated by case series, small cohorts, and systematic reviews of these, rather than randomized trials; the protocol should be applied selectively, under close biochemical and renal monitoring, and with multidisciplinary input.