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NurseReview.Org Pharmacology  Endocrine Drugs NurseReview.Org Pharmacology Endocrine Drugs Presentation Transcript

  • Pharmacology of the Selected Endocrine Drugs
  • Fig. 10.9
  • Fig. 10.10
  • Fig. 10.11a
  •  
  • Fig. 10.12a
  • Fig. 10.12b
  •  
  • Fig. 10.14
  • Fig. 10.17
  • Fig. 10.18
  • Fig. 10.19
  • Endocrine Medications
    • Hormonal replacement
  • ADH
  • Endocrine Medications
    • Anti-diuretic hormones
    • Enhance re-absorption of water in the kidneys
    • Increases water permeability in the renal collecting ducts
    • Also stimulates VASOCONSTRICTION and increases the blood pressure
  • Endocrine Medications
    • Therapeutic Indications
    • Hormonal replacement
    • Used in diagnostic procedure
    • Used to control the hemorrhage in variceal bleeding
    • Treatment of enuresis
  • Endocrine Medications
    • Used in DI
    • 1. Desmopressin and Lypressin intranasally
    • 2. Pitressin IntraMuscularly
  • Endocrine Medications
    • Anti-diuretic hormones
    • SIDE-effects
    • Flushing and headache
    • Water intoxication
    • CVS: heart block, MI
    • Renal: hyponatremia
    • Gangrene due to vasoconstriction
  • Thyroid Medications
  • Thyroid Medications
    • Thyroid hormones
    • These products are used to treat the manifestations of hypothyroidism
    • Replace hormonal deficit in the treatment of HYPOTHYROIDSM
  • Thyroid Medications
    • Thyroid hormones
    • Levothyroxine (Synthroid)
    • Liothyroxine (Cytomel)
    • Thyroid dessicated
    • Liotrix (Thyrolar)
  • Thyroid Medications
    • Thyroid hormones: Actions
    • Replaces both T3 and T4
    • Increases metabolic rate
  • Thyroid Medications
    • Thyroid hormones: Actions
    • Increase the metabolic rate
    • Increase O2 consumption
    • Increase HR, RR, BP
  • Thyroid Medications
    • Thyroid hormones: Indications
    • Hypothyroidism
    • Diagnostic suppression test
  • Thyroid Medications
    • Thyroid hormones
    • Side-effects
    • Nausea and Vomiting
    • Signs of increased metabolism= tachycardia, hypertension, cardiac arrhythmias, anxiety, headache, tremors, palpitations
  • Thyroid Medications
    • Thyroid hormones : Nursing responsibility
    • 1. Monitor weight, VS
    • 2. Instruct client to take daily medication the same time each morning WITHOUT FOOD
    • Monitor blood tests to check the activity of thyroid
  • Thyroid Medications
    • Thyroid hormones: Nursing responsibility
    • 3. Advise to report palpitation, tachycardia, and chest pain
    • 4. Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications
    • The thyroid becomes oversaturated with iodine and stop producing thyroid hormone
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications
    • Drugs used to BLOCK the thyroid hormones and treat hyperthyroidism
    • Inhibit the synthesis of thyroid hormones
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications
    • 1. Methimazole (Tapazole)
    • 2. PTU (prophylthiouracil)
    • 3. Iodine solution- SSKI and Lugol’s solution
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications: Indications
    • Grave’s dosease
    • Thyrotoxicosis
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications:
    • Absorption is good orally
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications
    • Side-effects of thionamides
      • N/V, drowsiness, lethargy, bradycardia, skin rash
      • GI complaints
      • Arthralgia, myalgia
      • AGRANULOCYTOSIS
        • Most important to monitor
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications
    • Side-effects of Iodine solutions Lugol’s
      • Most common adverse effects is HYPOTHYROIDISM
      • Iodism= metallic taste, burning in the mouth, sore teeth and gums, diarrhea, stomach upset
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications
    • Nursing responsibilities
    • 1. Monitor VS, T3 and T4, weight
    • 2. The medications WITH MEALS to avoid gastric upset
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications Nursing responsibilities
    • 3. Instruct to report SORE THROAT or unexplained FEVER
    • 4. Monitor for signs of hypothyroidism.
      • Instruct not to stop abrupt medication
  • ANTI-Thyroid Medications
    • ANTI-THYROID medications
    • Lugol’s Solution
    • Used to decrease the vascularity and size of the thyroid (in preparation for thyroid surgery)
    • T3 and T4 production diminishes
    • Given per orem, can be diluted with juice, administered WITH foods
    • Use straw to decrease staining
    • Monitor iodism
  • Steroids
  • STEROIDS
    • Replaces the steroids in the body
    • Cortisol, cortisone, betamethasone, and hydrocortisone
  • STEROIDS
    • These drugs enter the cells and bind to receptors
    • They inhibit the enzyme phospholipase
  • STEROIDS
    • Corticosteroids are used topically and locally to achieve the desired anti-inflammatory effects at a particular site
    • Examples:
    • Prednisone
    • Bethamethasone
    • Prednisolone
    • Fludrocortisone
  • STEROIDS
    • Side-effects
      • HYPERglycemia
      • Increased susceptibility to infection (immunosuppression)
      • Hypokalemia
      • Edema
      • Peptic ulceration
  • STEROIDS
    • Side-effects
      • If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension, cataract, mood changes, hirsutism, and fragile skin
  • STEROIDS
    • Nursing responsibilities
    • 1. Monitor VS, electrolytes, glucose
    • 2. Monitor weight edema and I/O
  • STEROIDS
    • Nursing responsibilities
    • 3. Protect patient from infection
    • 4. Handle patient gently
    • 5. Instruct to take meds WITH MEALS to prevent gastric ulcer formation
  • STEROIDS
    • Nursing responsibilities
    • 6. Caution the patient NOT to abruptly stop the drug
    • 7. Drug is tapered to allow the adrenal gland to secrete endogenous hormones
  • STEROIDS
    • Evaluation:
    • The drugs are effective if there is:
    • Relief of signs and symptoms of inflammation
    • Return of adrenal function to normal
  • DM Drug therapy
  • DRUG THERAPY and MANAGEMENT
    • Usually, this type of management is employed if diet modification and exercise cannot control the blood glucose level.
  • DRUG THERAPY and MANAGEMENT
    • These agents are employed to control the blood glucose level
    • They can be insulin and oral agents
    • These are given to replace the hormone in the body
    • If hormone is still present BUT decreased, Oral agents are given
  • Diabetes Mellitus
    • DRUG THERAPY and MANAGEMENT
    • Because the patient with TYPE 1 DM cannot produce insulin, exogenous insulin must be administered for life.
  • Diabetes Mellitus
    • DRUG THERAPY and MANAGEMENT
    • TYPE 2 DM may have decreased insulin production, ORAL agents that stimulate insulin production are usually employed.
  • Diabetes Mellitus
    • PHARMACOLOGIC INSULIN
    • This may be grouped into several categories according to:
    • 1. Source- Human, pig, or cow
    • 2. Onset of action- Rapid-acting, short-acting, intermediate-acting, long-acting and very long acting
  • Diabetes Mellitus
    • PHARMACOLOGIC INSULIN
    • This may be grouped into several categories according to:
    • 3. Pure or mixed concentration
    • 4. Manufacturer of drug
  • Diabetes Mellitus
    • GENERALITIES
    • 1. Human insulin preparations have a shorter duration of action than animal source
  • Diabetes Mellitus
    • GENERALITIES
    • 2. Animal sources of insulin have animal proteins that may trigger allergic reaction and they may stimulate antibody production that may bind the insulin, slowing the action
  • Diabetes Mellitus
    • 3. ONLY Regular insulin can be used INTRAVENOUSLY!
  • Diabetes Mellitus
    • 4. Insulin are measured in INTERNATIONAL UNITS or “iu”
    • 5. There is a specified insulin injection calibrated in units
  • Diabetes Mellitus
    • Mixed insulin are also available
    • The msot common of which is the 70-30 insulin
    • Made up of :70% NPH and 30% regular insulin in the vial
  • Comparison of Insulin Peak action 10-20 hrs 4-8 hrs Ultra-lente Long Acting 6-8 hrs to 12 hrs 1 ½ to 2 hrs NPH and Lente Intermediate acting 2-4 hrs 1 hour Regular Insulin RAPID acting 1 hour 15 minutes Lispro ULTRA-acting PEAK Onset Example Insulin Type
  • Diabetes Mellitus
    • RAPID ACTING INSULIN
    • Lispro (Humalog) and Insulin Aspart (Novolog)
    • Produces a more rapid effect and with a shorter duration than any other insulin preparation
  • Diabetes Mellitus
    • RAPID ACTING INSULIN
    • ONSET- 5-15 minutes
    • PEAK- 1 hour
    • DURATION- 3 hours
    • Instruct patient to eat within 5 to 15 minutes after injection
  • Diabetes Mellitus
    • REGULAR INSULIN
    • Also called Short-acting insulin
    • “ R”
    • Usually Clear solution administered 30 minutes before a meal
  • Diabetes Mellitus
    • REGULAR INSULIN
    • ONSET- 30 minutes to 1 hour
    • PEAK- 2 to 4 hours
    • DURATION- 4 to 6 hours
  • Diabetes Mellitus
    • INTERMEDIATE ACTING INSULIN
    • Called “NPH” or “LENTE”
    • Appears white and cloudy
  • Diabetes Mellitus
    • INTERMEDIATE ACTING INSULIN
    • ONSET- 2-4 hours
    • PEAK- 4 to 6-12 hours
    • DURATION- 16-20 hours
  • Diabetes Mellitus
    • LONG- ACTING INSULIN
    • “ UltraLENTE”
    • Referred to as “peakless” insulin
  • Diabetes Mellitus
    • LONG- ACTING INSULIN
    • ONSET- 6-8 hours
    • PEAK- 12-16 hours
    • DURATION- 20-30 hours
  • Diabetes Mellitus
    • HEALTH TEACHING
    • Regarding Insulin SELF- Administration
    • 1. Insulin is administered at home subcutaneously
  • Diabetes Mellitus
    • HEALTH TEACHING Regarding Insulin SELF- Administration
    • 2. Cloudy insulin should be thoroughly mixed by gently inverting the vial or ROLLING between the hands
  • Diabetes Mellitus
    • HEALTH TEACHING Regarding Insulin SELF- Administration
    • 3. Insulin NOT IN USE should be stored in the refrigerator, BUT avoid freezing/extreme temperature
  • Diabetes Mellitus
    • 4. Insulin IN USE should be kept at room temperature to reduce local irritation at the injection site
  • Diabetes Mellitus
    • 5. INSULIN may be kept at room temperature up to 1 month
  • Diabetes Mellitus
    • 6. Select syringes that match the insulin concentration.
      • U-100 means 100 units per mL
  • Diabetes Mellitus
    • 7. Instruct the client to draw up the REGULAR (clear) Insulin FIRST before drawing the intermediate acting (cloudy) insulin
  • Diabetes Mellitus
    • 8. Pre-filled syringes can be prepared and should be kept in the refrigerator with the needle in the UPRIGHT position to avoid clogging the needle
  • Diabetes Mellitus
    • 9. The four main areas for insulin injection are- ABDOMEN, UPPER ARMS, THIGHS and HIPS
  •  
  • Diabetes Mellitus
    • Insulin is absorbed fastest in the abdomen and slowest in the hips
    • Instruct the client to rotate the areas of injection, but exhaust all available sites in one area first before moving into another area.
  • Diabetes Mellitus
    • 10. Alcohol may not be used to cleanse the skin
    • 11. Utilize the subcutaneous injection technique- commonly, a 45-90 degree angle.
  • Diabetes Mellitus
    • 12. No need to instruct for aspirating the needle
    • 13. Properly discard the syringe after use.
  • Diabetes Mellitus
    • T-I-E
    • T est blood  I nject insulin  E at food
  • Diabetes Mellitus
    • ORAL HYPOGLYCEMIC AGENTS
    • These may be effective when used in TYPE 2 DM that cannot be treated with diet and exercise
    • These are NEVER used in pregnancy!
  • Diabetes Mellitus
    • ORAL HYPOGLYCEMIC AGENTS
    • There are several agents:
      • Sulfonylureas
      • Biguanides
      • Alpha-glucosidase inhibitors
      • Thiazolidinediones
      • Meglitinides
  • Diabetes Mellitus
    • ORAL HYPOGLYCEMIC AGENTS
    • These drugs are given per orem and are effective only in type 2 DM
    • Common adverse effects include:
      • Hypoglycemia
      • Diarrhea, jaundice, nausea and heartburn
      • Anemia , photosensitivity
  • Diabetes Mellitus
    • ORAL HYPOGLYCEMIC AGENTS
    • General Nursing Consideration
    • Observe for manifestations of hypoglycemia
    • Assess for allergic reaction
    • Instruct to take the medication at the same time each day
    • Caution to avoid taking other drugs without consultation with physician
  • Diabetes Mellitus
    • ORAL HYPOGLYCEMIC AGENTS
    • General Nursing Consideration
    • 5. THESE medications SHOULD NEVER be given to pregnant women, so rule out pregnancy
    • 6. Instruct to wear sunscreen
    • 7. Advise to bring simple sugar to be taken when hypoglycemic episodes occur
  • Diabetes Mellitus
    • SULFONYLUREAS
    • MOA- stimulates the beta cells of the pancreas to secrete insulin
    • Classified as to generations- first and second generations
  • Diabetes Mellitus
    • SULFONYLUREAS
    • FIRST GENERATION- Acetoheximide, Chlorpropamide, Tolazamide and Tolbutamide
    • SECOND GENERATION- Glipizide, Glyburide, Glibenclamide, Glimepiride
  • Diabetes Mellitus: Sulfonylureas
    • The most common side –effects of these medications are Gastro-intestinal upset and dermatologic reactions.
    • HYPOGLYCEMIA is also a very important side-effect
    • Given 30 minutes before meals- breakfast
  • Diabetes Mellitus: Sulfonylureas
    • Chlorpropamide has a very long duration of action. This also produces a disulfiram-like reaction when taken with alcohol
    • Second generation drugs have shorter duration with metabolism in the kidney and liver and are the choice for elderly patients
  • Diabetes Mellitus
    • BIGUANIDES
    • MOA- Facilitate the action of insulin on the peripheral receptors
    • These can only be used in the presence of insulin
  • Diabetes Mellitus
    • BIGUANIDES= “ formin”
    • They have no effect on the beta cells of the pancreas
    • Metformin (Glucophage) and Phenformin are examples
  • Diabetes Mellitus: Biguanides
    • The most important side effect is LACTIC ACIDOSIS!
    • These are not given to patient with renal impairment
  • Diabetes Mellitus: Biguanides
    • These drugs are usually given with a sulfonylurea to enhance the glucose-lowering effect more than the use of each drug individually
  • Diabetes Mellitus
    • ALPHA-GLUCOSIDASE INHIBITORS
    • MOA- Delay the absorption of glucose in the GIT
    • Result is a lower post-prandial blood glucose level
    • They do not affect insulin secretion or action!
    • Side-effect: DIARRHEA and FLATULENCE
  • Diabetes Mellitus
    • Examples of AGI are Acarbose and Miglitol
    • They are not absorbed systemically and are very safe
    • They can be used alone or in combination with other OHA
  • Diabetes Mellitus
    • Side-effect if used with other drug is HYPOGLYCEMIA
    • Note that sucrose absorption is impaired and IV glucose is the therapy for the hypoglycemia
  • Diabetes Mellitus
    • THIAZOLIDINEDIONES
    • MOA- Enhance insulin action at the receptor site
    • They do not stimulate insulin secretion
  • Diabetes Mellitus
    • THIAZOLIDINEDIONES
    • Examples- Rosiglitazone, Pioglitazone
    • These drugs affect LIVER FUNCTION
    • Can cause resumption of OVULATION in peri-menopausal anovulatory women
  • Diabetes Mellitus
    • MEGLITINIDES
    • MOA- Stimulate the secretion of insulin by the beta cells
    • Examples- Repaglinide and Nateglinide
  • Diabetes Mellitus
    • MEGLITINIDES
    • They have a shorter duration and fast action
    • Should be taken BEFORE meals to stimulate the release of insulin from the pancreas
  • Diabetes Mellitus
    • MEGLITINIDES
    • Principal side-effect of meglitinides- hypoglycemia
    • Can be used alone or in combination
  • Reproductive Hormones
    • Gonadal hormones include agents that affect the female and male reproductive cycle
    • Female hormones include ESTROGENS, PROGESTINS and ovarian hormones
    • Male hormones include ANDROGENS and anabolic steroids
  • Reproductive Hormones
    • The GENERAL Mechanism of Action
    • These hormones interfere with the normal cycle of hormone balance
  • Reproductive Hormones
    • INDICATIONS
    • FEMALE: Hormonal replacement therapy, oral contraception, treatment of infertility and management of some tumors
    • MALE: replacement therapy, metabolic stimulators and treatment of some tumors
  • Reproductive Hormones
    • Estrogens
    • Conjugated estrogen
    • Estradiol
    • Ethinyl estradiol
    • Diethylstilbesterol (DES)
    • Clomiphene
  • Reproductive Hormones
    • Progestins
    • Medroxyprogesterone acetate (Provera)
    • Megestrol
    • Norethindrone
    • Levonorgestrel (Norplant)
    • Norgestrel
    • Norethindrone acetate
  • Reproductive Hormones
    • Androgens
    • Testosterone cypionate
    • Methyltestosterone
    • Fluoxymesterone
    • Aqueous testosterone
  • Reproductive Hormones
    • Oral Contraceptive Pills
    • Two types are available: Combination estrogen and progesterone AND progestins only
  • Reproductive Hormones
    • Oral Contraceptive Pills: DYNAMICS
    • Inhibits OVULATION by altering the hypothalamus and gonadotropin axis
    • Alters the MUCUS to prevent sperm entry
    • Alters the uterine endometrium to prevent implantation
    • Suppresses the ovaries
  • Reproductive Hormones
    • Oral Contraceptive Pills: Indicators
    • Suppression of ovulation for prevention of pregnancy
    • Regulation of menstrual cycle and management of dysfunctional bleeding
    • Treatment of endometriosis
  • Reproductive Hormones
    • Oral Contraceptive Pills: Kinetics
    • Easily absorbed orally
    • NORPLANT provides 5 years of contraception
    • Provera provides 3 months of protection
    • Metabolized and excreted in liver
  • Reproductive Hormones
    • Oral Contraceptive Pills:
    • Not to be used in patients with history of, hypertension, thromboemoblic or CVA disease
    • Not given in certain cancers
    • Contraindicates in pregnancy
    • SMOKING should be avoided when under therapy
  • Reproductive Hormones
    • Oral Contraceptive Pills: Drug Interaction
    • Rifampicin, penicillin and tetracycline REDUCE effectiveness of contraception
    • Benzodiazepines decrease the levels of OCP
  • Reproductive Hormones
    • Oral Contraceptive Pills:
    • Side effects
    • CNS: headache
    • CV: Thromboembolic disease, MI, hypertension and pulmonary edema
    • NAUSEA and cholestatic JAUNDICE
    • Breast tenderness, weight gain, edema, breakthrough bleeding, acne
  • Reproductive hormones
    • Nursing Considerations
    • Assess for risk factors and the ability to comply with medications
    • Determine the type of OCP used
    • Monophasic pills provide constant dosing of BOTH estrogen and progestin
    • Biphasic pills provide constant estrogen but varying progestin doses
    • Triphasic pills provide varying Estrogen and Progesterone
  • Reproductive hormones
    • Nursing Considerations
    • 3. Teach the common side-effects and re-assure that these will decrease in time
    • 4. Instruct to use other means of contraception if antibiotics and anticonvulsants are also taken
    • 5. WARNT the client to avoid smoking because this will increase the risk for embolic episodes
  • Clomiphene
    • A synthetic, non-steroidal estrogen
    • Increases the secretion of gonadotropins and initiates the secretion of FSH and LH
    • OVULATION will occur
    • Used in the treatment of infertility
    • Readily absorbed orally
  • Clomiphene
    • Side effects can be:
    • Risk for Multiple pregnancy
    • Nausea, breast discomfort, headache and GI disturbances
    • Visual disturbances
    • Enlargement of the ovaries
  • Viagra (Sildenafil)
    • A medication used for penile erectile dysfunction
    • Selectively inhibits receptors and enzyme Phosphodiesterase E
    • This increases the nitrous oxide levels allowing blood flow into the corpus cavernosum
  • Viagra (Sildenafil)
    • Contraindicated in patients with bleeding disorders and with penile implants
    • Caution: Coronary Artery Disease and concomitant use of nitrates
    • Side-effects: PRIAPISM, headache, flushing, dyspepsia, UTI, diarrhea and dizziness
  • Viagra (Sildenafil)
    • Nursing consideration
    • Assess for risk factors
    • Instruct to take the drug ONE hour before sexual act
    • Drug is taken orally