Transcript Drugs that affect the Endocrine System

Pharmacology 1950
Unit 8
1

1. define hormone
◦ Maintain homeostasis within the blood system
 Example:

2. List the endocrine glands
◦ Pineal
◦ Parathyroid
◦ Adrenal
hypothalmus
thyroid
pancreas
pituitary
thymus
gonad
2



ACTH

Prolactin

FSH

LH
TSH
GH
3

ADH

Oxytocin

5. Identify main thyroid hormones
◦ Calcitonin
◦ thyroid
4

Thyroid gland
◦ Regulates BMR
◦ Iodine is essential for synthesis of T3 and T4

Negative feedback mechanism to limit
secretion as needed.
◦ Thyroid hormone attaches to a carrier pro-TBG
◦ When it reaches the tissue level thyroxin converts to
T3 where it enters the cell level.
5
 Objective
7: identify the actions of
drugs used to treat
hyperthyroidism
◦ Interferes with synthesis of T3 T4
and prevents conversion to target
tissues
◦ Delayed action from several days to
weeks.
6
7

Objective 8: list the anti-thyroid
agents used to treat
hyperthyroidism (Graves Disease)
◦ S/S: increased BMR, tachycardia, wt
loss, 4-8x more common in women

Drugs are:
◦ Iodine-131 (131I)
◦ Propylthiuracil (PTU, Propacil)
 prototype
◦ Methimazole (Tapazole
8

Radioactive iodine
◦ Taken up by thyroid
◦ Destroys hyperactive thyroid tissue
 Essentially no other tissue is
affected
 Takes 3-6 months for fully
assess effect
 If more than one dose needed,
three months between doses is
needed
9
 Dosing is oral
 Add to water
 No color
 No taste
 Be very careful not to spill
(hazardous)
 Client can not be pregnant
 Becomes euthyroid state
 Avoid children/preg women
for 1 week..others for few days
10
 Side
effects
◦ Tenderness in thyroid gland
◦ Hyperthyroidism in 40%, second
dose needed
◦ Hypothyroidism
11
 Drug
interactions
◦ Lithium carbonate
 Hypothyroidism develops
12
 PTU
and Tapazole
◦ Block synthesis of T3 and T4
◦ Takes days to 3 weeks to see
effect
◦ Can use long term
◦ Can use short term pre subtotal
thyroidectomy
13
 Side
effects
◦ Purpuric, maculopapular rash
◦ Headaches, salivary and lymph
node enlargement
◦ Bone marrow suppression
◦ Hepatotoxicity
◦ Nephrotoxicity
14
 Hypothyroid
condition in adults
called myxedema
◦ General s/s
 Weakness, muscle cramping, slurred
speech, intolerance to cold
 Congenital
cretinism
hypothyroidism called
15
16
 Objective
agents
10: list the thyroid
◦ Levothyroxine replaces T3 and T4
 prototype
17
 Liothyronine
synthetic T3
◦ Onset of action more rapid than
levothyroxine
 Liotrix synthetic mixture
levothyroxine and liothyronine (4
to 1 ratio)
◦ Provides consistent levels of T3
and T4
18
 Thyroid
USP
◦ From beef, pork, or sheep
thyroid glands
◦ Oldest form available, cheapest
◦ Lacks purity, uniformity, stability
◦ Clients should avoid changing
agents
19
 Side
effects
◦ Hyperthryoidism
 Drug interactions
◦ Warfarin: larger doses needed
◦ Digitalis: smaller doses needed
◦ Hyperglycemia can occur early in
therapy
20
 Objective
11: describe the nursing
process associated with
administering thyroid or antithyroid preparations
21
 Assessment
important
◦ Clients sensitive to replacement
therapy, monitor for adverse
effects
◦ Levothyroxine started low and
dose increased over weeks
22
 Safe
handling, storage and
disposal of radioactive materials
via institution policy
 Blood levels need to be
monitored
 Clients need to be alert to side
effects and report
 Clients need to report if no
improvement
23
 Objective
12: name the parts of
the adrenal gland
◦ Medulla
◦ cortex
 Objective
13: list the types of
hormones secreted by the adrenal
glands
24
 Two
hormones from adrenal
gland
◦ Mineralcorticoids
◦ Glucocorticoids
25

Mineralcorticoids
◦ Maintain fluid and electrolyte
balance
◦ Used to treat adrenal insufficiency
 Fludrocortisone (Florinef)
 Aldosterone(prototype)
 Act on distal tubules, causes
water and sodium retention
 Causes excretion of potassium
and hydrogen
26
 Objective
14: describe the
metabolic effects of the
glucocorticoids, and the
consequences of these effects
27





Increase blood sugar
Increase protein breakdown
Suppress immune responses
Increase sensitivity of smooth muscle to
norepinephrine
Affects mood and brain excitability
28
 Objective
15: describe how
glucocorticoids suppress
inflammation
◦ Corticosteroids secreted by adrenal
cortex of adrenal gland
Glucocorticoids
29
 Glucocorticoids
include
◦ Cortisone, hydrocortisone,
prednisone etc.
◦ Have antiinflammatory,
antiallergic activity
30
 Also affect glucose, protein
and fat metabolism
 Glucocorticoids secreted in
response to stressors
 Cause release of epinephrine
31
 Objective
16: identify therapeutic
uses of glucocorticoids
◦ Glucocorticoids used for
replacement therapy when
adrenal gland not functional
◦ High doses used for
inflammation, allergy, asthma
32

Use of corticosteroids
◦ Used with caution in those with
 Diabetes mellitus
 Heart failure
 Hypertension
 Peptic ulcer
 Mental disturbance
 Suspected infection
33
After one week, discontinue drug
slowly (wean off)
 Interacts with many drugs
 May need to administer every other
day
 Abrupt discontinuation
◦ Fever; Malaise; Fatigue
◦ Weakness; orthostatic dizziness,
hypotension
◦ Dyspnea; hypoglycemia

34
 Topical:
apply as directed, may
use occlusive dressing
 Alternate –day therapy: give
between 6 & 9 AM; give with
meals
35

Side Effects
◦ Electrolyte imbalance, fluid
accumulation
◦ Susceptibility to infection
◦ Behavioral changes
◦ Hyperglycemia
◦ Peptic ulcer formation
◦ Delayed wound healing
36
 Drug
interactions
◦ Loop diuretics: can enhance
electrolyte loss
◦ Warfarin: can have increased or
decreased effect
◦ Hyperglycemia: diabetics and
children need to be monitored
37
 Objective
17: list the
glucocorticoid preparations
38
 Various
drugs for topical, oral,
injection, inhalation
◦ Cortisone
◦ Dexamethasone (Decadron,
Dexone)
◦ Fludrocortisone (Florinef)-also
mineralcorticoid
39

Hydrocortisone (Cortef, SoluCortef)
◦ prototype
Methlprednisolone (Solu-Medrol,
Depo-Medrol)
 Prednisolone (Delta-Cortef)
 Prednisone (Deltasone, ApoPrednisone)

◦ prototype

Triamcinolone (Aristocort,
Kenalog)
40
 Objective
18: describe nursing
care responsibilities associated
with administering
glucocorticoids
◦ Provide education, VS, glucose levels,
long term use may lead to
osteoporosis, Cushing syndrome
41

Objective 19: identify the functions
of insulin in the body
◦ Glucose transport
◦ Affects carbohydrate, lipid and pro
metabolism

Objective 20: define diabetes
mellitus
◦ Group of metabolic diseases with
decreased insulin production or
decrease in receptor cells
42

Objective 21: identify the site of insulin
production in the body
◦ pancreas

Objective 22: list the types of diabetes
◦ Insulin dependent Type I
 10% of population; onset 11-13 years of age
◦ Insuline dependent Type 2
 Deficient amounts of insulin production or insulin
resistant cells
◦ Gestational
 Associated with pregnancy
43

Objective 23: explain the functions of
insulin
◦ Hormone from beta cells of the
pancreas (islets of Langerhans)
 Normally: 0.5 – 1 unit per hour
secreted
 Adult: 30-50 units per day
 Insulin transports glucose into
cells; helps metabolize protein
and fat.
 Diabetes is a metabolic
disorder: all body systems
affected
44
 Objective
24: identify the onset,
the peak, and the duration of
action for rapid, intermediate,
long acting and fixed
combinations of insulin
45

Lispro and Aspart
◦ Most rapid acting of insulins
◦ They are synthetic insulin analogs
 Give within 10-15 minutes of a
meal
 Onset: 10 minutes
 Peak: 30 to 60 min
 Duration: 5 hours
46

Regular insulin
◦ Human regular insulin available,
not just animal derivation
 Give within 30-60 minutes of
meals
 Onset: 30 minutes
 Peak: 2.5-5 hours
 Duration: 5-10 hours
 Administration: subcutaneous
or IV
47

Neutral protamine Hagedorn (NPH)
◦ Contains regular insulin and protamine
 Protamine binds to insulin: slow
release
 Onset: 1-4 hours (pork is 1-1.5 hrs)
 Peak: 8-12 hours (pork: 8-12 hrs)
 Duration: 18-24 hours (pork: 24 hrs)
48
 Lispro:
can be mixed with
protamine
◦ Humalog mix 75/25
 75% Lispro with protamine
 25% Lispro
 Rapid acting insulin with
intermediate duration of
action (12-24 hours)
49
50
 Humulin
Ultralente
◦ Crystalline form of Lente insulin
 Onset: 4-8 hours
 Peak: 12-18 hours
 Duration: 24-28 hours
51

Insulin-Glargine solution (Lantus)
◦ Biosynthetic
 Absorbed in a uniform manner-no
large fluctuations of insulin levels =
reduction in possible hypoglycemia
Onset: 5 hours
Peak: no pronounced peak activity
Duration: 24 hours
Do NOT mix with other insulins
52
53
54
55
56
57
58
 Objective
25: describe the local
tissue responses that can occur
with repeated insulin injections
59
 Two
problems can occur
◦ Allergic reactions
 From proteins in insulin,
alcohol, the insulin itself
 Switch types of insulin
 Use unscented alcohol
 Will resolve
60
◦ Lipodystrophies
 Atrophy or hypertrophy of
subcutaneous fat
 Use the area because of
anesthesia effect
61
62
◦ Use of the site decreases insulin
absorption
◦ Causes erratic absorption of
insulin
◦ Is cosmetic problem
63
 Objective
26: list the symptoms of
insulin shock
 Hypoglycemia
◦ Headache
◦ Nausea
◦ Weakness
◦ Hunger
64
 Lethargy
 Decreased coordination
 General apprehension
 Sweating
 Confusion
 Blurred or double vision
 Can progress to coma and
death
65
 Objective
27: discuss glucose
elevating drugs
◦ The drug used to raise blood
sugar
 Glucagon
 Glucose
66

Glucagon
◦ Hormone from alpha cells of
pancreas
 Breaks down stored glycogen to
glucose
 Aids in gluconeogenesis
 Must have glycogen available or
drug will not work
67
◦ May see 50% glucose
administered
◦ IV
◦ Raises blood sugar
 Use when no glycogen is
stored
68
 Objective
28: describe what is
meant by sliding scale insulin
administration
69
 Sliding
scale insulin
◦ Physician orders doses of insulin
based upon blood glucose level
◦ Regular insulin is used
 Sliding scale is “catch-up”
 Read the orders carefully
70
 Blood
sugar
 0-150
units
 151-200
units
 201-300
units
 Over 300, call physician
Insulin
0
2
5
71
 Objective
29: describe the
action of the oral antidiabetic
agents
◦ Some act on the cells to
decrease resistance
◦ Some act on the beta cells to
increase production
◦ Some inhibit glucose
absorption
72
 Objective
30: identify the
conditions under which an oral
antidiabetic agent would be used
◦ Type 2 diabetes
 No control with diet/exercise
73

Objective 31: list the oral antidiabetic agents
74
◦ Classifications are
 Biguanide oral hypoglycemic agents
 Sulfonylurea oral hypoglycemic
agents
 Meglitinide oral hypoglycemic
agents
 Thiazolidinedione oral
hypoglycemic agents
 Antihyperglycemic agents
75

Metformin (Glucophage)
◦ Does not stimulate insulin release
◦ Will not cause hypoglycemia
◦ Can be used in combination with
sulfonylureas
◦ Decreases serum triglycerides and
LDL
◦ Slightly increases HDL
76
 Initial
dose: 500 mg BID
◦ Can go up to 2500 mg daily
 Use divided doses
 If blood sugar not controlled,
add another agent
77

Side effects to expect
◦ N/V
◦ Anorexia
◦ Abdominal cramps
◦ Flatulence
 Will resolve
 Take with meals to decrease SE
78
 SE
to report
◦ Malaise
◦ Myalgias
◦ Respiratory distress
◦ Hypotension
 Lactic acidosis can occur
 More if renal failure or
excess alcohol intake
79
 Drug
interactions
◦ Drugs that depend upon kidney
for excretion can block
metformin excretion
 Can have lactic acidosis
develop
80
 Drugs
that cause hyperglycemia
with metformin
◦ OBC
◦ Corticosteroids
◦ Phenothiazines
◦ Diuretics
◦ Thyroid replacement
81
 Stimulate
release of insulin
 Use when pancreas can still
secrete insulin
82
 Two
generations
◦ First generation
 Example: Dymelor (500 mg
daily)
◦ Second generation
 Example: Glucotrol (2.5-5 mg
daily) Prototype
83
 Allergy:
if allergic to
sulfonamides, probably allergic to
sulfonylureas
◦ Do not administer
84
 SE
to expect
◦ N/V
◦ Anorexia
◦ Abdominal cramps
 Usually mild
 Decrease with continued
therapy
85
 SE
to report
◦ Hypoglycemia
 Monitor blood sugar
 Treat with glucose source
◦ Hepatotoxicity
 Anorexia, N/V, jaundice,
increased liver function tests
86
◦ Blood dyscrasias
 RBC, WBC
 Monitor for sore throat,
fever, purpura, jaundice
◦ Dermatologic reactions
 Rash or pruritus
 If occurs: hold drug, call MD
87
 Drug
interactions
◦ Various drugs can cause
hypoglycemia such as Warfarin,
ethanol
88
◦ Hyperglycemia with
corticosteroids, phenothiazines
and others
◦ Beta-adrenergic blockers: cause
hypoglycemia or mask the
symptoms
◦ Alcohol: Antabuse-like reaction
89
 Stimulate
release of insulin from
pancreas
 Can be used alone or in
combination
◦ Have short duration of action
◦ Must take up to QID
90
 Examples
of drugs
◦ Repaglinide (Prandin)
◦ Nateglinide (Starlix)
91
 Dosing
◦ Can take 1-30 minutes before a
meal
◦ Must take up to QID: compliance
◦ If skip meal, skip dose
92
 SE
to expect and report
◦ Hypoglycemia
 Dose adjustments may be
needed
 Monitoring of blood glucose
important
93
 Drug
interactions
◦ Hypoglycemia
 Ethanol, NSAIDs, Warfarin,
MAOIs
◦ Hyperglycemia
 Corticosteroids,
phenothiazines, estrogens
94
 B-blockers:
cause hypoglycemia
or mask symptoms
 Tegretol and others: increase
repaglinide metabolism
 Some macrolides and antifungals
can inhibit repaglinide
metabolism
95
 Increase
sensitivity of muscle and
fat tissue to insulin
◦ Allows more glucose to enter
cells
◦ Inhibit gluconeogenesis
 Decreases hepatic output of
glucose
◦ Do not increase insulin output
96
 Can
be used alone or in
combination with other OHA’s or
insulin
 Examples
◦ Pioglitazone (Actos)
◦ Rosiglitazone (Avandia)
97
 Baseline
labs: liver function and
alkaline phosphatase, CBC, WBC,
HDL, LDL, triglycerides
 Premenopausal, anovulatory
females
◦ Ovulation may resume
98
 SE
to expect
◦ N/V
◦ Anorexia
◦ Abdominal cramps
 Mild
 Resolve with continued therapy
99
 SE
to report
◦ Hypoglycemia
◦ Hepatotoxicity
◦ Weight gain
10
0
 Drug
interactions
◦ Various drugs can cause an
increase in hypoglycemia or
hyperglycemia
◦ B-adrenergics can mask
hypoglycemia or cause it
◦ Pioglitazone can enhance
metabolism of ethinyl estradiol
and norethindrone
 Ovulate, become pregnant
10
1

Two drugs
◦ Acarbose (Precose)
◦ Miglitol (Glyset)
◦ They inhibit pancreatic and GI
enzymes from digesting sugars
 This delays glucose absorption and
decreases postprandial
hyperglycemia
10
2
 Acarbose
◦ Does not cause hypoglycemia
◦ Can be used with sulfonylureas
or metformin
◦ Dosing
 TID at start of main meals
10
3
 SE
to expect
◦ Abdominal cramps
◦ Diarrhea
◦ Flatulence
 Caused by metabolism of
carbohydrates in gut
 Usually mild, resolve
10
4
 SE
to report
◦ Hypoglycemia
◦ Hepatotoxicity
 Can cause increased AST, ALT
 Has caused hyperbilirubinemia
10
5
 Hyperglycemia
can occur with
some drugs such as
corticosteroids, phenothiazines,
OBC, thyroid
 Digestive enzymes and
intestinal adsorbents reduce
effect of acarbose
 Acarbose can decrease
absorption of digoxin
10
6
 Miglitol
(Glyset)
◦ Used alone or with sulfonylureas
◦ Check liver function before
treatment
◦ Assess for malabsorption
syndrome or obstruction in gut
10
7
 Dosing
◦ Take with first bite of food
◦ Start with 25 mg TID
10
8
 SE
to expect
◦ Abdominal cramps
◦ Diarrhea
◦ Flatulence
10
9
 SE
to report
◦ Hypoglycemia
11
0

Drug interactions
◦ Hyperglycemia with various agents
such as cortisone, phenothiazines
◦ Propranolol, Ranitidine not
absorbed with concurrent miglitol
◦ Digestive enzymes, intestinal
adsorbents reduce effect of miglitol
11
1
 Objective
32: describe the nursing
interventions associated with
teaching the diabetic about the
treatment
11
2

Objective 33: list the therapeutic uses of
estrogen and progesterone
◦ Stimulate maturation of female sex
organs
◦ Responsible for menstrual cycle
◦ Drugs used for replacement, birth
control, control of prostate cancer,
breast cancer, osteoporosis
(controversial use)
11
3

Objective 34: name the estrogen preparations
◦ Various estrogens
 Conjugated estrogen (Premarin)
 Esterified estrogens (Estratab)
 Estradiol (Estrace)
 Estropipate (Ogen)
 Ethinyl estradiol (Estinyl)
11
4
 Objective
35: name the
progesterone preparations
◦ Progestins inhibit ovulation
 Norethindrone
 Ethynodiol diacetate
 Desogestrel
 Levonorgestrel
11
5


Objective 36: identify the most commonly
used ovulatory agents
Clomiphene citrate (Clomid)
◦ Structurally similar to natural
estrogens
 Stimulates ovaries to release ova
 Used for women with reduced
circulating estrogen
11
6

Objective 37: describe the actions of the
oral contraceptives
◦ Estrogens and progestins induce
contraception by inhibiting
ovulation
 Estrogen blocks pituitary release
of FSH
 Progestin inhibits LH
 Both alter cervical mucus
 May change endometrial wall
11
7
 Minipill
is progestin-only
◦ Must take every day
 Combination pill
◦ Take in 21 day cycle
11
8
 Complete
physical needed before
therapy
 SE expected: nausea, weight gain,
spotting, changed menstrual flow,
missed periods, depression, mood
changes, chloasma, headaches
11
9
 SE
to report: vaginal discharge,
breakthrough bleeding, yeast
infections
 Blurred vision, severe headaches,
dizziness, leg pain, chest pain,
shortness of breath, acute
abdominal pain
12
0

Various drugs can decrease effect of OBC
◦ Barbiturates, Tegretol, St. John’s
Wort, antibacterial agents

Drugs enhance effect and toxic effects
◦ Some antifungals, Warfain,
phenytoin, thyroid hormones,
benzodiazepines
12
1


< 72 hours after unprotected intercourse
Previn
◦ Action: prevents implantation or ovulation
12
2
 Objective
38: identify the nursing
process for clients with conditions
for which female hormones are
used
◦ Knowledge deficeit
◦ Nausea
◦ Noncompliance
12
3

Blood pressure increase

DVT

Smoking contributing factor
12
4