Endocrine Agents

1
Endocrine Agents

• Chapters 29, 30, 31 32

2
(No Transcript)
3
Pituitary gland(Hypophysis)

• The Pituitary gland is an endocrine gland the
  size of a pea located at the bse of the skull.
  Divided into 2 lobes
• Anterior pituitary (adenohypophysis)
• Oxytocin, ADH
• Posterior pituitary (neurohypophysis)
• Growth hormone, prolactin, FSH, Thyroid,
  endorphins

4
Figure 29-1 Pituitary hormones. (From L.M.
McKenry E. Salerno (2003). Mosbys pharmacology
in nursing revised and updated (21st ed.). St.
Louis, MO Mosby.)
5
Pituitary Agents

• Anterior pituitary agents
• cosyntropin
• somatotropin
• octreotide
• Posterior pituitary agents
• vasopressin
• desmopressin

6
Uses

• Replacement therapy to make up for hormone
  deficiency
• Drug therapy to produce a specific hormone
  response when a hormone deficiency is present
• Diagnostic aids to determine hypofunction or
  hyperfunction of a specific hormonal function

7
Mechanism of Action

• Differ depending on the agent
• Either augment or antagonize the natural effects
  of the pituitary hormones

8
Indications

• corticotropin
• Stimulation of release of cortisol from adrenal
  cortex
• Used to diagnose, but not treat, adrenocortical
  insufficiency
• Multiple sclerosis
• corticotropin insufficiency caused by long-term
  corticosteroid use
• (?inflammation ?histamine?edema)

9
Indications (contd)

• somatropin (mimics GH)
• Recombinantly made growth hormone (GH)
• Stimulate skeletal growth in clients with
  deficient GH, such as hypopituitary dwarfism
• Octreotide(inhibits GH release)
• Alleviates or eliminates certain symptoms of
  carcinoid tumours, acromegaly

10
Indications (contd)

• vasopressin and desmopress
• (mimic ADH)
• Used in the treatment of diabetes insipidus (not
  diabetes mellitus)
• Used in the treatment of various types of
  bleeding, especially GI bleeding
• desmopressin is useful for increasing factor VIII
  (anti-hemophilic factor)
• Hemophilia A
• Type I von Willebrands disease

11
Nursing Implications (contd)

• Agents should not be discontinued abruptly
• Do not take OTC products without checking with
  health care provider
• Parents of children who are receiving growth
  hormones should keep a journal reflecting the
  childs growth

12
Nursing Implications (contd)

• Monitor for therapeutic responses
• somatropin should increase growth in children
• desmopressin, vasopressin should reduce severe
  thirst and decrease urinary output, decrease GI
  bleeding

13
Thyroid Gland

• One of the largest endocrine glands
• Secretes three hormones essential for proper
  regulation of metabolism
• Thyroxine (T4)
• Triiodothyronine (T3)
• Calcitonin
• Located near the parathyroid gland
• Involved in many bodily processes, growth, body
  temperature regulation, cardiovascular, endocrine
  neuromuscular functions.

14

• Iode from diet is responsible for the synthesis
  thyroglobuline
• Hypothalamus secretes TSH that stimulates the
  thyroid to break down thyroglobulin into T3 T4
  and is released into the circulation

15
Hypothyroidism Deficiency in Thyroid Hormones

• Primary abnormality in the thyroid gland itself.
  Most common cause is hashimotos thyroiditis.
• Secondary results when the pituitary gland is
  dysfunctional and does not secrete TSH

16
Thyroid abnormalities

• Cretinism Hyposecretion of thyroid hormone
  during youth. Low metabolic rate, retarded growth
  and sexual development, possibly mental
  retardation
• Myxedema Hyposecretion of thyroid hormone as an
  adult. Decreased metabolic rate, loss of mental
  and physical stamina, weight gain, loss of hair,
  firm edema, yellow dullness of the skin
• Goiter Enlargement of the thyroid gland. Results
  from overstimulation by elevated levels of TSH.
  TSH is elevated because there is little or no
  thyroid hormone in circulation

17
Hypothyroidism pathologies

• Hashimotos thyroiditis
• Postoperative hypothyroidism
• Postpartum thyroiditis

18
Hypothyroidism

• Common symptoms
• Thickened skin
• Hair loss
• Constipation
• Lethargy
• Anorexia

19
Thyroid Preparations

• levothyroxine most common
• Synthetic thyroid hormone T4
• liothyronine
• Synthetic thyroid hormone T3

20
Mechanism of Action

• Thyroid preparations are given to replace what
  the thyroid gland cannot produce to achieve
  normal thyroid levels.
• Thyroid drugs work the same way as thyroid
  hormones

21
Indications

• To treat all three forms of hypothyroidism
• levothyroxine is the preferred agent because its
  hormonal content is standardized therefore, its
  effect is predictable
• Also used for thyroid replacement in clients
  whose thyroid glands have been surgically removed
  or destroyed by radioactive iodine in the
  treatment of thyroid cancer or hyperthyroidism

22
Side Effects

• Cardiac dysrhythmia is the most significant
  adverse effect
• May also cause
• Tachycardia, palpitations, angina, hypertension,
  insomnia, tremors, headache, anxiety, nausea,
  diarrhea, menstrual irregularities, weight loss,
  sweating, heat intolerance, others

23
Hyperthyroidism Excessive Thyroid Hormones
free T3 T4

• Caused by several diseases
• Graves disease
• Toxic nodular disease
• Multinodular disease
• Thyroid storm
• Thyroid cancer
• Pituitary hormones

24
Hyperthyroidism

• Affects multiple body systems, resulting in an
  overall increase in metabolism
• Wt loss
• Diarrhea Fatigue
• Flushing Palpitations
• Increased appetite Nervousness
• Muscle weakness Heat intolerance
• Sleep disorders Irritability
• Altered menstrual flow

25
Treatment of Hyperthyroidism

• Radioactive iodine (131I) works by destroying the
  thyroid gland
• Surgery to remove all or part of the thyroid
  gland
• Antithyroid drugs thioamide derivatives
• methimazole
• propylthiouracil (PTU)

26
Antithyroid Agents

• Used to palliate hyperthyroidism and to prevent
  the surge in thyroid hormones that occurs after
  the surgical treatment or during radioactive
  iodine treatment for hyperthyroidism
• May cause liver and bone marrow toxicity

27
Nursing Implications

• Assess for drug allergies, contraindications,
  potential drug interactions
• Obtain baseline vital signs, weight
• Cautious use advised for those with cardiac
  disease, hypertension, and pregnant women
• Teach client to take thyroid agents once daily in
  the morning to decrease the likelihood of
  insomnia if taken later in the day

28
Nursing Implications (contd)

• Teach client to take the medications at the same
  time every day Teach clients to report any
  unusual symptoms, chest pain, or heart
  palpitations
• Teach clients not to take OTC medications without
  physician approval
• Teach clients that therapeutic effects may take
  several months to occur

29
Nursing Implications (contd)

• Antithyroid medications
• Better tolerated when given with food
• Give at the same time each day to maintain
  consistent blood levels
• Never stop these medications abruptly
• Avoid eating foods high in iodine (seafood, soy
  sauce, tofu, and iodized salt)

30
Nursing Implications (contd)

• Monitor for therapeutic response
• Monitor for side/adverse effects
• Symptoms of overdose of thyroid hormones include
  cold intolerance, depression, edema

31
Adrenal Gland

• An endocrine gland that sits on tops of the
  kidneys
• It is composed of Adrenal cortex Adrenal
  medulla
• chiefly responsible for regulating the stress
  response through the synthesis of corticosteroids
  and catecholamines, including cortisol and
  adrenaline.
• Each portion has different functions and secretes
  different hormones

32

33
Table 32-1 Adrenal gland characteristics
34
Adrenal Gland (contd)

• Adrenal medulla secretes
• Epinephrine
• Norepinephrine
• Adrenal cortex secretes corticosteroids
• Glucocorticoids
• Mineralocorticoids (primarily aldosterone)
• All adrenal cortex hormones are steroid hormones

35
Box 32-1 Adrenal Cortex Hormones Biological
Functions
36
Adrenocortical Hormones

• Oversecretion leads to Cushings syndrome
• ? cortisol in the blood. Cushings disease is very
  similar to Cushings syndrome in that all
  physiologic manifestations of the conditions are
  the same.
• ?wt gain, moon face, ?sweating,thinning of
  skin,buffalo hump, histuism
• Undersecretion leads to Addisons disease
•  Addison's disease is an endocrine or hormonal
  disorder that occurs in all age groups and
  afflicts men and women equally. The disease is
  characterized by weight loss, muscle weakness,
  fatigue, low blood pressure, and sometimes
  darkening of the skin in both exposed and
  nonexposed parts of the body.

37
Adrenocortical Hormones (contd)

• Can be either synthetic or natural
• Many different agents and forms
• Glucocorticoids
• Topical, systemic, inhaled, nasal
• Mineralocorticoid
• Systemic
• Adrenal steroid inhibitors
• Systemic

38
Adrenocortical Hormones (contd)

• Glucocorticoids
• betamethasone (several formulations)
• fluticasone propionate
• hydrocortisone (several formulations)
• cortisone
• methylprednisolone
• prednisone
• Many others

39
Adrenocortical Hormones (contd)

• Mineralocorticoid
• fludrocortisone acetate (Addisons disease)
• Adrenal steroid inhibitors
• Ketoconazole (Cushing's syndrome (high blood
  levels of cortisol)
• Mitotane (adrenocortical carcinoma)

40
Mechanism of Action

• Most exert their effects by modifying enzyme
  activity
• Different agents differ in their potency,
  duration of action, and the extent to which they
  cause salt and fluid retention
• Glucocorticoids inhibit or help control
  inflammatory and immune responses

41
Indications

• Wide variety of indications
• Adrenocortical deficiency
• Cerebral edema
• Collagen diseases
• Dermatological diseases
• GI diseases
• Exacerbations of chronic respiratory illnesses,
  such as asthma and COPD

42
Indications (contd)

• Organ transplant (decrease immune response)
• Palliative management of leukemias and lymphomas
• Spinal cord injury

43
Indications (contd)

• Glucocorticoids given
• By inhalation for control of steroid-responsive
  bronchospastic states
• Nasally for rhinitis and to prevent the
  recurrence of polyps after surgical removal
• Topically for inflammations of the eye, ear, and
  skin

44
Indications (contd)

• Antiadrenals (adrenal steroid inhibitors)
• Used in the treatment of Cushings syndrome

45
Contraindications

• Drug allergies
• Serious infections, including septicemia,
  systemic fungal infections, and varicella

46
Side Effects

• Potent effects on all body systems
• Cardiovascular
• Heart failure, cardiac edema, hypertensionall
  due to electrolyte imbalances
• CNS
• Convulsions, headache, vertigo, mood swings,
  nervousness, insomnia, others

47
Side Effects (contd)

• Potent effects on all body systems
• Endocrine
• Growth suppression, Cushings syndrome, menstrual
  irregularities, carbohydrate intolerance,
  hyperglycemia, others
• GI
• Peptic ulcers with possible perforation,
  pancreatitis, abdominal distention, others

48
Side Effects (contd)

• Potent effects on all body systems
• Integumentary
• Fragile skin, petechiae, ecchymosis, facial
  erythema, poor wound healing, hirsutism,
  urticaria
• Musculoskeletal
• Muscle weakness, loss of muscle mass,
  osteoporosis
• Other
• Weight gain

49
Nursing Implications (contd)

• Assess for contraindications to adrenal agents,
  especially the presence of peptic ulcer disease
• Assess for drug allergies and potential drug
  interactions (prescription and OTC)
• Systemic forms may be given by oral, IM, IV, or
  rectal routes (not SC)
• Oral forms should be given with food or milk to
  minimize GI upset

50
Nursing Implications (contd)

• After using an inhaled corticosteroid, instruct
  clients to rinse their mouths to prevent possible
  oral fungal infections
• Teach clients on corticosteroids to avoid contact
  with people with infections and to report any
  fever, increased weakness, lethargy, or sore
  throat

51
Nursing Implications (contd)

• Sudden discontinuation of these agents can
  precipitate an adrenal crisis caused by a sudden
  drop in serum levels of cortisone
• Doses are usually tapered before the agent is
  discontinued
• Clients should be taught to take all adrenal
  medications at the same time every day, usually
  in the morning, with meals or food

52
Diabetes Mellitus

• Two types
• Type 1
• Type 2
• Hyperglycemia
• Fasting plasma glucose gt7 mmol/L
• Hypoglycemia
• Blood glucose level lt2.8 mmol/L
• Gestational diabetes

53
Signs Symptoms of DM

• Polydipsia
• Polyuria
• Polyphagia
• Wt loss
• Fatigue
• Blurred vision

54
Table 31-1 Type 1 and type 2 diabetes
characteristics
55
Type 1 Diabetes MellitusIDDM

• characterized by loss of the insulin-producing
  beta cells of the islets of Langerhans of the
  pancreas leading to a deficiency of insulin.
• Affected clients need exogenous insulin
• Complications
• Retinopathy, nephropathy, neuropathy
• Diabetic ketoacidosis (DKA)
• Oral antihyperglycemic agents not effective

56
Type 2 Diabetes Mellitus

• Most common type
• Caused by insulin deficiency and insulin
  resistance, but there is not an absolute of
  insulin production
• Many tissues are resistant to insulin
• Reduced number insulin receptors
• Insulin receptors less responsive
• ?Obesity among children and adolescent is
  increasing the incidence

57
Type 2 diabetesMetabolic syndrome

• The cluster of co-occurring conditions of
• ? Abdominal obesity, ?triglycerides, ?BP
• Are strongly associated with the development of
  type 2 diabetes.
• Obesity worsens insulin resistence because
  adipose tissue is the site of large porportions
  of the bodys defective insulin receptors.

58
Type 2 Diabetes Mellitus (contd)

• Several comorbid conditions
• Glucose intolerance
• Obesity
• Dyslipidemia
• Hypertension
• Insulin resistance
• Hyperinsulinemia
• Microalbuminemia (protein in the urine)
• Enhanced conditions for embolic events (blood
  clots)
• Heart disease

59
Types of Antidiabetic Agents

• Insulins
• Oral antihyperglycemic agents
• Both aim to produce normal blood glucose states

60
Human-Based Insulins

• Rapid acting,(aspart, lispro)
• Short acting (regular, humulinR, Toronto)
• Intermediate acting (Humulin N, NPH)
• Long acting (glargine, detemir)
• Combination Insulin products (humulog, humulin
  30/70 20/80)
• Regular insulin
• The only insulin product that can be given by IV
  bolus, IV infusion, or even IM

61
Types of insulin available in Canada

• See diagram

62
Sliding-Scale Insulin Dosing

• SC regular insulin doses adjusted according to
  blood glucose test results
• Typically used in hospitalized diabetic clients
• Subcutaneous regular insulin is ordered in an
  amount that increases as the blood glucose
  increases

63
Table 31-3 Insulin mixing compatibilities
64
Oral Antidiabetic Agents

• Used for type 2 diabetes
• Treatment for type 2 diabetes includes lifestyle
  modifications
• Diet, exercise, smoking cessation, weight loss
• Oral antihyperglcemic agents may not be effective
  unless the client also makes behavioural or
  lifestyle changes

65
Oral Antidiabetic Agents (contd)

• Insulin secretagogues 2 classes of drugs able
  to stimulate insulin secretion
• Sulfonylureas
• chlorpropamide, tolbutamide
• glimepiride, gliclazide, glyburide
• Nonsulfonureas
• repaglinide, nateglinide
• Biguanides
• metformin

66
Oral Antidiabetic Agents (contd)

• Alpha-glucosidase inhibitors
• acarbose
• Thiazolidinediones (Actos)
• pioglitazone, rosiglitazone
• Also known as glitazones

67
Oral Antihyperglycemic AgentsMechanism of Action

• Sulfonylureas (Glyburide)
• Stimulate insulin secretion from the beta cells
  of the pancreas, thus increasing insulin levels
• Forces the extra glucose out of the blood into
  the cells where it can be stored and used for
  energy.
• Beta cell function must be present
• Improve sensitivity to insulin in tissues
• Result lower blood glucose levels

68
Oral Antihypoglycemic AgentsMechanism of Action
(contd)

• Biguanides (metformin)
• Decrease production of glucose by the liver
• Increase uptake of glucose by tissues
• Do not increase insulin secretion from the
  pancreas therefore does not cause hypoglycemia

69
Oral Antihyperglycemic AgentsMechanism of
Action (contd)

• Alpha-glucosidase (New drug category!)
  inhibitors Acarbose (Precose)
• Reversibly inhibit the enzyme alpha-glucosidase
  in the small intestine
• Result delayed absorption of glucose
• Must be taken with meals to prevent excessive
  postprandial blood glucose elevations

70
Oral Antihyperglycemic AgentsMechanism of
Action (contd)

• Thiazolidinediones (Actos) (New drug category!)
• Decrease insulin resistance
• Insulin sensitizing agents
• Increase glucose uptake and use in skeletal
  muscle
• Inhibit glucose and triglyceride production in
  the liver

71
Oral Antihyperglycemic AgentsIndications

• Used alone or in combination with other agents
  and/or diet and lifestyle changes to lower the
  blood glucose levels in clients with type 2
  diabetes

72
Oral Antihypoglcemic Agents Side Effects

• Sulfonylureas (Glyburide)
• Hypoglycemia, hematological effects, nausea,
  epigastric fullness, heartburn, many others
• Biguanides (Metformin)
• Abdominal bloating, nausea, cramping, diarrhea,
  metallic taste, reduced vitamin B12 levels

73
Oral Antihyperglycemic Agents Side Effects
(contd)

• Alpha-glucosidase inhibitors (arcabose)
• Flatulence, diarrhea, abdominal pain
• Thiazolidinediones (Actos)
• Moderate weight gain, edema, mild anemia, hepatic
  toxicity

74
Antihyperglycemic AgentsNursing Implications

• Before giving any drugs that alter glucose
  levels, obtain and document
• A thorough history
• Vital signs
• Blood glucose level
• Potential complications and drug interactions

75
Nursing Implications

• Before giving any drugs that alter glucose
  levels
• Assess the clients ability to consume food
• Assess for nausea or vomiting
• Hypoglycemia may be a problem if
  antihyperglycemic agents are given and the client
  does not eat
• If a client is NPO for a test or procedure,
  consult physician to clarify orders for
  antihyperglycemic drug therapy

76
Nursing Implications (contd)

• Keep in mind that overall concerns for any
  diabetic client increase when the client
• Is under stress
• Has an infection
• Has an illness or trauma
• Is pregnant

77
Nursing Implications (contd)

• Thorough client education is essential regarding
• Disease process
• Diet and exercise recommendations
• Self-administration of insulin or oral agents
• Potential complications

78
Nursing Implications (contd)

• When insulin is ordered, ensure
• Correct route
• Correct type of insulin
• Timing of the dose
• Correct dosage
• Insulin order should be prepared dosages are
  second-checked with another nurse

79
Nursing Implications (contd)

• Insulin
• Check blood glucose level before giving insulin
• Roll vials between hands instead of shaking them
  to mix suspensions
• Ensure correct storage of insulin vials
• ONLY insulin syringes, calibrated in units, are
  to be used to measure and give insulin
• Ensure correct timing of insulin dose with meals

80
Nursing Implications (contd)

• Insulin (contd)
• When drawing up two types of insulin in one
  syringe, always withdraw the regular insulin
  first
• Provide thorough client education regarding
  self-administration of insulin injections,
  including timing of doses, monitoring blood
  glucoses, and injection site rotations

81
Nursing Implications (contd)

• Oral antihyperglycemic agents
• Always check blood glucose levels before giving
• Usually given 30 minutes before meals
• Alpha-glucosidase inhibitors are given with the
  first bite of each main meal
• metformin is taken with meals to reduce GI effects

82
Symptoms of hypoglycemia include

• hunger
• nervousness and shakiness
• perspiration
• dizziness or light-headedness
• sleepiness
• confusion
• difficulty speaking
• feeling anxious or weak

83
Nursing Implications (contd)

• Assess for signs of hypoglycemia
• If hypoglycemia occurs
• Give glucagon
• Have the client eat glucose tablets or gel, corn
  syrup, honey, fruit juice or nondiet soft drink
• Or have the client eat a small snack such as
  crackers or half a sandwich
• Monitor blood glucose levels

84
Nursing Implications (contd)

• Monitor for therapeutic response
• Decrease in blood glucose levels to the level
  prescribed by physician
• Measure hemoglobin A1c to monitor long-term
  compliance to diet and drug therapy
• Watch for hypoglycemia and hyperglycemia

85
Lessening Fingertip Pain From Testing

• Don't use rubbing alcohol. Repeated use will
  thicken the skin.  Instead, wash your hands in
  warm, soapy water prior to your fingerstick. 
  Warm water will help you produce a better drop of
  blood.  Once your finger is pricked, do not
  squeeze immediately.  Instead, hang your hand
  down and let gravity do the work for you.  Try
  'milking' your finger prior to lancing. 
  Excessive squeezing to get the blood to flow
  could cause bruising.
• Try a shallower puncture. The deeper you lance,
  the more tissue you damage. 
• Try different lancets.Many lancets on the market
  are interchangeable with different lancing
  devices.  Look for shorter and finer products and
  talk to your diabetes educator.  It's better to
  'spread the damage' over as many sites as
  possible instead of abusing that favourite spot. 
  Target the sides of your fingers instead of the
  soft centre area where there are more nerve
  endings. 
• suggest clients go in a 'horseshoe' pattern
  around their fingertips.
• Apply firm pressure at the site of the finger
  prick using a tissue, for several seconds or
  until you have no more leakage.  You want to make
  sure that the bleeding has completely stopped at
  the site to prevent bruising and further pain.
• Canadian diabetes Association