Endocrine Drugs

ENDOCRINE AGENTS

Exam 2: 6 questions per class, 25 questions, no scantrons. Less testing on patho more on the drugs.

Hormones and the hypothalamus:

ADH: works on kidney

Oxytoxin

AcTH: act on adrenals, which release corticosteroids

TSH: effects thyroid gland

Prolactin

SH

LH

Growth hormone

THYROID DRUGS

A. Thyroid gland

1. Secretion of hormones T3 & T4 regulated by feedback mechanisms

feedback means: negative feedback, once a state is reached a chemical is released to prevent more stimulation.

2. Hypothyroidism: primary or secondary cause; myxedema: that’s severe hypothyroidism—odd syndrome. Hypothyroid: fatigue, obesity.

B. Thyroid Replacement:

Levothyroxine sodium (Synthroid)

Class; Thyroid Hormone

1. Indication for use: treat myxedema, hypothyroid conditions

2. Mode of action: increases T3 and T4, long acting drug. Increases metabolic rate, oxygen consumption, body growth

3. Adverse effects: tachycardia, HTN, thyroid crisis, angina, CV collapse

C. Hyperthyroidism: Grave’s disease. Hypertrophy of the thyroid, could be autoimmune. This is the big bulging eye thing

D. Nursing Process

assess: vital signs, metabolic rate, body weight

RN Dx: fatigue r/t hypothyroidism, malaise etc. Activity intolerance.

Education re: drugs, compliance

E. Mrs. X takes Synthroid 0.05 mg daily. Pharmacy sends Synthroid 25 mcg tablets. How many tablets should she receive?

A. Addison’s Disease: adrenal insufficiency

B. Cushing’s Syndrome: adrenal hypersecretion

ADRENAL DRUGS we’ll give them a lot, there are quite a few. NCLEX likes Cushing’s and Addison’s questions. There are lots of corticosteroids. They decrease inflammation, therefore they decrease the immune system; TBI patients with swelling in the brain, decrease the systemic inflammation and shock from sepsis with an infection.

Hydrocortisone cream:

Glucocorticoids are influenced by Acth, from the pituitary. Effect carb, fat, protein metabolism. They act like mineralocorticoids.

C. Glucocorticoid Prototype:

Prednisone

1. Indication for use: dermatologic disorders, immunosuppressant, decrease inflammatory occurrence.

2. Action: suppresses inflammation and adrenal function

3. Adverse reaction: HTN, tachycardia, (not in drug guide:)GI bleeding, pancreatitis, thrombophlebitis, hyperglycemia, Hypokalemia, loopiness, delayed wound healing, muscle wasting, osteoporosis,

Docs often order these to taper off to avoid side effects.

D. Other glucocorticoid Prototypes

1. Inhaled Steroid:

Beclomethasone (Vanceril)

Type: glucocorticoid, long acting

Use: for Rx of asthma, COPD, allergies

2. Action: suppresses inflammation and adrenal function

Adverse: Candidal infection of oropharynx, with excessive doses: symptoms of hypercorticism. Dry mouth, itchy nose, etc.

If ‘steroid dependent COPD’er,’ that’s a serious disease. If we see that, we have to make sure a steroid is ordered for them in order to keep their airways open. Don’t let them be abruptly stopped.

2. methylprednisolone (Solu-Medrol):

Class: adrenal corticosteroid; anti-inflammatory

Used for Rx of acute or chronic allergic reaction, cerebral edema, and for spinal cord injury, lupus nephritis, multiple sclerosis.

Action: Has antiinflammatory and immunosuppressive properties.

Adverse: hyperglycemia, Hypokalemia, loopiness, delayed wound healing, muscle wasting, osteoporosis,

E. Mineralocorticoids: secrete aldosterone; for Rx of adrenocortical insufficiency with Addison’s Disease. Aldosterone is a water/salt saver. We don’t give these that often.

F. Mr. P 68 had a severe allergic reaction to shellfish. He was taken to the ED and given dexamethasone 100 mg IV. Why? What patient education is needed before goes home? They gave this to reverse the inflammatory response. This patient needs to learn not to eat shellfish.

ANTIDIABETIC DRUGS

Hyperglycemia triggers insulin

Hypoglycemia triggers glucagon to release glycogen/glucose from the liver cells

A. Diabetes

1. Def: chronic disease from deficient glucose metabolism, resulting from insufficient insulin secretion from beta cells, causing hyperglycemia; Types 1 & 2, gestational, secondary from medications-such as?

Type 1: beta cells in the pancreas ain’t makin no insulin ever the end.

Type 2: insulin resistance

There’s an epidemic of both types of diabetes right now—we don’t know why, it’s our society probably.

Want to manage blood sugars b/c morbidity and mortality soar when sugars aren’t kept close to normal all the time

2. Sx: polyphagia, polyuria, polythirtya, blurred vision, frequent infections, poor wound healing, micro and macro vascular disease

3. Complications:

DKA [diabetic ketoacidosis; the body starts breaking down fats and proteins b/c the cells are hungry, you lose a lot of water so you’re hypovolemic, ketones in the blood create acidosis, and it smells like fruit, sometimes we think it’s alcohol] When this person comes into the er: you give them insulin stat, IV. They need blood sugar tests Q hour. IV fluids for dehydration, check electrolyte levels. We bring the blood sugar up slowly to prevent weird fluid shifts in the body/brain. There’s usually a DKA protocol for an ER.

HHNS: Hyperosmolar something something.
hypoglycemic shock:

MI

Amputation

Blindness

Complications: High sugar is bad for nephrons, eyes, peripheral neuropathy, O2 delivery, MI’s, coronary syndrome [b/c insulin is also about fat metabolism.] Lose feet, lose kidneys, have an MI. If you keep blood sugars in rein, these complications are decreased 60-70%.

Normal fasting: 80-120

After a meal: 120-140

Prevent diabetes: we can redirect patients when filling out their menus.

Indicators: frequent vaginal infections/yeast infections, poor wound healing, blurred vision

Stuff that controls insulin levels: insulin, glucagon, adrenalines [they want the cells to have more sugar in the blood], cortisol/steroids, growth hormone

Sliding scale means Type 2.

B. Insulin

1. Types: Know onset of action, peak effect, duration of action

• Humalog (Lispro): rapid acting, shortest acting. Onset: 5 min, subQ. This is being given more and more for sliding scales. You really want to make sure that breakfast gets to the patient once you deliver this med!

• Regular Humulin R: short-acting (only insulin that can be given IV): can be given IV.

• Humulin N: NPH, intermediate acting

• Glargine (lantus): long acting : once a day, lasts 24 hours, we don’t actually know when it peaks. Can’t be mixed w/ anything else in the same syringe.

Insulin pump: has a line into the subQ tissue near the stomach, it puts a low and slow dose into the body and you can step up the dose before meals. This helps people be active diabetics. Complication: lipodystrophy

2. Interactions:

• increased hypoglycemic effect with aspirin, oral anticoagulants, alcohol, oral hypoglycemic agents, TCAs,;

• decreased hypoglycemic effect with thiazides, glucocorticoids, oral contraceptives, smoking, thyroid drugs

3.Action: promote use of glucose by body cells

4. Adverse effects: shock, tachycardia, hypoglycemic reaction, rebound hyperglycemia (somogyi effect-happens when insulin peaks, esp overnight, blood sugar goes down, than the body reacts and releases sugar, and they wake up w/ high blood sugar. They need less HS insulin or an HS snack)

5. Administration: Sub cut, or inhaled

6. Sliding Scale coverage: Regular or Humalog prn blood glucose values q6h or ac & hs

7. Client education

8. Insulin pump

9. Herbal antidiabetic agents

C. Oral hypoglycemic agents: know action, adverse effects

1. Sulfonylureas: glipizide (Glucotrol) stimulate beta cells.

Action: Directly stimulates functioning pancreatic beta cells to secrete insulin, leading to an acute drop in blood glucose. Indirect action leads to altered numbers and sensitivity of peripheral insulin receptors, resulting in increased insulin binding. It also causes inhibition of hepatic glucose production and reduction in serum glucagon levels.

Adverse: life threat: coma, hypoglycemia, seizures, resp depress

2. Biguanides: metformin (Glucophage)

Action: decreases liver breakdown of glycogen when blood sugar is high, decreases cell resistance. thought to be due to both increasing the binding of insulin to its receptors and potentiating insulin action

Adverse: lactic acidosis, dizzy, nausea, vomiting.

3. Alpha-glucosidase inhibitors: acarbose (Precose)

Action: Acarbose reduces blood sugar by interfering with carbohydrate absorption from the GI tract; inhibits enzymes: glucoamylase, sucrase, maltase, and isomaltase. Lactase is not affected by acarbose.

Adverse: Hypoglycemia, Anemia, Diarrhea,

4. Glitizones: piogliatazone (Actos) these are new and cool; the original had people dying of liver failure.

Class: thiazolidinedione

Action: Decrease cell resistance by affecting insulin receptors

Adverse: hypoglycemia, mild anemia, exacerbation of heart failure

5. Meglitinides: repaglinide (Prandin)

Action: stimulating release of insulin from the pancreatic islets.

Adverse: Hypoglycemia, angina

6. Fixed combinations: glyburide-metformin (Glucovance) this is a combo of two of the above: Prandin and Actos:

Actos: Decrease cell resistance by affecting insulin receptors

Prandin: stimulating release of insulin from the pancreatic islets.

First protocol for managing T2 DM: diet and exercise.

Next step: 1 oral agent

Next: 2^nd oral agent or higher dose

Next: insulin

D. Nursing Process

1. Assessment: Hemoglobin A1C [every three months to check hemoglobin to see how much sugar is attached to it], daily blood glucose values and trends [before and after meals], trends, patient education, complications

2. Nursing diagnoses: altered nutrition, knowledge deficit, risk for impaired tissue integrity

3. Planning: check blood sugars, vision, Hx, chest pain if Hx of MI or coronary disease.

4. Implementation

5. Evaluation

E. Case Scenarios

1. Your patient is a 78 yo admitted with CHF and DM. What nursing interventions are indicated?

Check AC and HS blood sugars. Education: see what they know. Help w/ menu. Offer the new pamphlets w/ the newest research. Check their meds, get them ontime. If NPO for a procedure, make sure their blood sugar is ok. For the CHF: check vitals, lung sounds, listen for crackles in the bases.

2. Your patient is a 24 yo male admitted with DKA. His admit BS was 880. What interventions are indicated?

So this is lifethreatening: DKA protocol, IV insulin, IV fluids, get baseline lab values, O2 to get his metabolic O2 availability up. Education, prevention.

Objectives: Upon completion of this class, the student will be able to:

Describe thyroid replacement drugs in terms of action and adverse effects;

Describe the use of specific glucocorticoids in terms of action and adverse effects;

Discuss the pathology of Types 1 & 2 diabetes;

Describe pharmacological management of diabetes including insulin and oral agents;

Discuss patient education regarding effective management of diabetes.