Endocrine Agents
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Endocrine Agents

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Endocrine Agents Endocrine Agents Presentation Transcript

  • Endocrine Agents Chapters 29, 30, 31 & 32
  •  
  • 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
    View slide
  • Figure 29-1 Pituitary hormones. (From L.M. McKenry & E. Salerno (2003). Mosby’s pharmacology in nursing – revised and updated (21 st ed.). St. Louis, MO: Mosby.) View slide
  • Pituitary Agents
    • Anterior pituitary agents
      • cosyntropin
      • somatotropin
      • octreotide
    • Posterior pituitary agents
      • vasopressin
      • desmopressin
  • 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
  • Mechanism of Action
    • Differ depending on the agent
    • Either augment or antagonize the natural effects of the pituitary hormones
  • 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)
  • 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
  • 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
  • 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
  • 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
  • Thyroid Gland
    • One of the largest endocrine glands
    • Secretes three hormones essential for proper regulation of metabolism
      • Thyroxine (T 4 )
      • Triiodothyronine (T 3 )
      • Calcitonin
    • Located near the parathyroid gland
    • Involved in many bodily processes, growth, body temperature regulation, cardiovascular, endocrine & neuromuscular functions.
    • 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
  • 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
  • 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
  • Hypothyroidism: pathologies
    • Hashimoto’s thyroiditis
    • Postoperative hypothyroidism
    • Postpartum thyroiditis
  • Hypothyroidism
    • Common symptoms
      • Thickened skin
      • Hair loss
      • Constipation
      • Lethargy
      • Anorexia
  • Thyroid Preparations
    • levothyroxine * most common
      • Synthetic thyroid hormone T 4
    • liothyronine
      • Synthetic thyroid hormone T 3
  • 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
  • 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
  • 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
  • Hyperthyroidism: Excessive Thyroid Hormones: free T3 & T4
    • Caused by several diseases
      • Graves’ disease
      • Toxic nodular disease
      • Multinodular disease
      • Thyroid storm
      • Thyroid cancer
      • Pituitary hormones
  • 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
  • Treatment of Hyperthyroidism
    • Radioactive iodine ( 131 I) works by destroying the thyroid gland
    • Surgery to remove all or part of the thyroid gland
    • Antithyroid drugs: thioamide derivatives
      • methimazole
      • propylthiouracil (PTU)
  • 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
  • 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
  • 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
  • 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)
  • Nursing Implications (cont’d)
    • Monitor for therapeutic response
    • Monitor for side/adverse effects
      • Symptoms of overdose of thyroid hormones include cold intolerance, depression, edema
  • 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
  •  
  • Table 32-1 Adrenal gland: characteristics
  • Adrenal Gland (cont’d)
    • Adrenal medulla secretes:
      • Epinephrine
      • Norepinephrine
    • Adrenal cortex secretes corticosteroids
      • Glucocorticoids
      • Mineralocorticoids (primarily aldosterone)
      • All adrenal cortex hormones are steroid hormones
  • Box 32-1 Adrenal Cortex Hormones: Biological Functions
  • 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.
  • 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
  • Adrenocortical Hormones (cont’d)
    • Glucocorticoids
      • betamethasone (several formulations)
      • fluticasone propionate
      • hydrocortisone (several formulations)
      • cortisone
      • methylprednisolone
      • prednisone
      • Many others
  • 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)
  • 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
  • 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
  • Indications (cont’d)
      • Organ transplant (decrease immune response)
      • Palliative management of leukemias and lymphomas
      • Spinal cord injury
  • 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
  • Indications (cont’d)
    • Antiadrenals (adrenal steroid inhibitors)
      • Used in the treatment of Cushing’s syndrome
  • Contraindications
    • Drug allergies
    • Serious infections, including septicemia, systemic fungal infections, and varicella
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Signs & Symptoms of DM
    • Polydipsia
    • Polyuria
    • Polyphagia
    • Wt loss
    • Fatigue
    • Blurred vision
  • Table 31-1 Type 1 and type 2 diabetes: characteristics
  • Type 1 Diabetes Mellitus IDDM
    • 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
  • 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
  • Type 2 diabetes Metabolic 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.
  • 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
  • Types of Antidiabetic Agents
    • Insulins
    • Oral antihyperglycemic agents
    • Both aim to produce normal blood glucose states
  • 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
  • Types of insulin available in Canada
    • See diagram
  • 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
  • Table 31-3 Insulin mixing compatibilities
  • 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
  • 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
  • Oral Antidiabetic Agents (cont’d)
    • Alpha-glucosidase inhibitors
      • acarbose
    • Thiazolidinediones (Actos)
      • pioglitazone, rosiglitazone
      • Also known as “glitazones”
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Symptoms of hypoglycemia include :
    • hunger
    • nervousness and shakiness
    • perspiration
    • dizziness or light-headedness
    • sleepiness
    • confusion
    • difficulty speaking
    • feeling anxious or weak
  • 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
  • Nursing Implications (cont’d)
    • Monitor for therapeutic response
      • Decrease in blood glucose levels to the level prescribed by physician
      • Measure hemoglobin A 1c to monitor long-term compliance to diet and drug therapy
      • Watch for hypoglycemia and hyperglycemia
  • Lessening Fingertip Pain From Testing
    • D on't use rubbing alcohol. Re peated 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