Published: 3 September 2026

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Prednisone-induced thyrotoxic periodic paralysis

Published: 3 September 2026
Prescriber Update 47(3): 44–45
September 2026

The prednisone data sheet was recently updated to include a warning on thyrotoxic periodic paralysis (TPP).¹ This article describes TPP and how prednisone contributes to the condition.

What is TPP?

TPP is a complication of hyperthyroidism characterised by recurrent attacks of muscle weakness and hypokalaemia due to a sudden intracellular shift of potassium. Serious clinical consequences (eg, ventricular arrhythmia, respiratory failure) may result if TPP is left undiagnosed and untreated.³

TPP predominantly affects males of Asian descent, but is increasingly recognised in Western countries.^2,3 A New Zealand study found higher rates of TPP in patients of Polynesian descent compared with those of European descent.⁴

Pathophysiology

TPP is likely caused by increased sodium-potassium-adenosine triphosphatase
(Na/K-ATPase) pump activity, which leads to potassium shifting mostly into the muscles and depleting circulating levels.^2,3 Hyperpolarisation of muscle membranes leads to reduced muscle excitability, causing paralysis.² The increase in Na/K-ATPase activity is driven by an increase in thyroid hormones and resulting beta-adrenergic response.^2,3

Attacks usually occur a few hours after ingesting a high carbohydrate meal or strenuous exercise. These precipitating factors stimulate Na/K-ATPase pump activity and increase potassium uptake by muscle from the circulation.^2,3

Prednisone can precipitate TPP

Prednisone may induce hypokalaemia that can precipitate TPP. Therefore, patients with hyperthyroidism who require treatment with prednisone are at risk of experiencing TPP.¹

Management

If TPP is suspected, monitor blood potassium and correct hypokalaemia.¹ Ensure adequate control of hyperthyroidism to prevent recurrence.^2,3 Because there is an enhanced beta-adrenergic response in thyrotoxicosis, non-selective beta-blockers (eg, propranolol) may be used as adjunctive management.^2,3,5,6

References

1. Clinect NZ Pty Limited. Prednisone (Clinect) New Zealand Data Sheet 23 February 2026. URL: www.medsafe.govt.nz/profs/Datasheet/a/Apoprednisonetab.pdf (accessed 15 July 2026).
2. Kung AWC. 2006. Clinical review: Thyrotoxic periodic paralysis: A diagnostic challenge. The Journal of Clinical Endocrinology & Metabolism 91(7): 2490-95. DOI: 10.1210/jc.2006-0356 (accessed 15 July 2026).
3. Lin SH. 2005. Thyrotoxic periodic paralysis. Mayo Clinic Proceedings 80(1): 99-105. DOI: 10.1016/S0025-6196(11)62965-0 (accessed 15 July 2026).
4. Elston MS, Orr-Walker BJ, Dissanayake AM, et al. 2007. Thyrotoxic, hypokalaemic periodic paralysis: Polynesians, an ethnic group at risk. Internal Medicine Journal 37(5): 303-07. DOI: 10.1111/j.1445-5994.2007.01313.x (accessed 15 July 2026).
5. Teva Pharma (New Zealand) Limited. Drofate New Zealand Data Sheet 26 March 2024. URL: www.medsafe.govt.nz/profs/Datasheet/d/drofatetab.pdf (accessed 15 July 2026).
6. Ipca Pharma (NZ) Pty Limited. Ipca-Propranolol New Zealand Data Sheet 1 June 2023. URL: www.medsafe.govt.nz/profs/Datasheet/I/IpcaPropranololtab.pdf (accessed 15 July 2026).