Endocrine Agents

1. Endocrine Agents Chapters 29, 30, 31 & 32

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). Mosby�s 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 (cont�d) 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 (cont�d) 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 Willebrand�s disease

11. Nursing Implications (cont�d) 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 child�s growth

12. Nursing Implications (cont�d) 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 hashimoto�s 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 Hashimoto�s 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 (cont�d) 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 (cont�d) 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 (cont�d) 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

33. Table 32-1 Adrenal gland: characteristics

34. Adrenal Gland (cont�d) 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 Cushing�s 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 Addison�s 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 (cont�d) 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 (cont�d) Glucocorticoids betamethasone (several formulations) fluticasone propionate hydrocortisone (several formulations) cortisone methylprednisolone prednisone Many others

39. Adrenocortical Hormones (cont�d) Mineralocorticoid fludrocortisone acetate (Addison�s 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 (cont�d) Organ transplant (decrease immune response) Palliative management of leukemias and lymphomas Spinal cord injury

43. Indications (cont�d) 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 (cont�d) Antiadrenals (adrenal steroid inhibitors) Used in the treatment of Cushing�s 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, hypertension�all due to electrolyte imbalances CNS Convulsions, headache, vertigo, mood swings, nervousness, insomnia, others

47. Side Effects (cont�d) Potent effects on all body systems Endocrine Growth suppression, Cushing�s syndrome, menstrual irregularities, carbohydrate intolerance, hyperglycemia, others GI Peptic ulcers with possible perforation, pancreatitis, abdominal distention, others

48. Side Effects (cont�d) 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 (cont�d) 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 (cont�d) 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 (cont�d) 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 >7 mmol/L Hypoglycemia Blood glucose level <2.8 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 body�s defective insulin receptors.

58. Type 2 Diabetes Mellitus (cont�d) 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 (cont�d) 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 (cont�d) Alpha-glucosidase inhibitors acarbose Thiazolidinediones (Actos) pioglitazone, rosiglitazone Also known as �glitazones�

67. Oral Antihyperglycemic Agents:Mechanism 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 Agents:Mechanism of Action (cont�d) 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 Agents:Mechanism of Action (cont�d) 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 Agents:Mechanism of Action (cont�d) 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 Agents:Indications 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 (cont�d) Alpha-glucosidase inhibitors (arcabose) Flatulence, diarrhea, abdominal pain Thiazolidinediones (Actos) Moderate weight gain, edema, mild anemia, hepatic toxicity

74. Antihyperglycemic Agents:Nursing 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 client�s 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 (cont�d) 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 (cont�d) Thorough client education is essential regarding: Disease process Diet and exercise recommendations Self-administration of insulin or oral agents Potential complications

78. Nursing Implications (cont�d) 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 (cont�d) 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 (cont�d) Insulin (cont�d) 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 (cont�d) 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 (cont�d) 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 (cont�d) 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