Wednesday, May 2, 2012

Endocrine System drugs


Endocrine System Drugs

THYROID HORMONE (T3&T4)

·         This agent increases serum T3 and T4 levels and suppresses TSH production.
·         Indication:
o    Treatment of hypothyroidism (myxedema)
o    Treatment for diffuse non-toxic goiter
o    Chronic lymphocyte thyroiditis (Hashimoto's)
o    Thyroid carcinoma
o    Are also used with antithyroid drug (e.g methimazole) to manage thyrotoxicosis.
·         Contraindication: contraindicated in untreated hyperthyroidism

Drugs

Levothyroxine sodium (Levothroid®, Synthroid®)
§  SyntheticT4
§  Increases the metabolic rate of all tissues in the body
§  Suppresses TSH production
Liothyronine (Cytomel®)

§  Synthetic T3
§  Frequently used as an initial therapy for treating myxedema
Liotrix (Euthroid®, Thyrolar®)

§  A combination of levothyroxine and liothyronine (4:1 ratio)

Side effects:

·         Tachycardia, palpitations
·         Angina pectoris
·         Hypertension
·         Cardiovascular collapse
·         Thyroid crisis


Nursing consideration:

ü  Monitor T3 ,T4,TSH, and radioactive-iodine uptake until stable
ü  Monitor for any adverse reactions e.g fever, arrhythmias, hypertension, heat intolerance.
ü  Monitor height,weight and psychomotor development  if given to a child
ü  Administer in morning if possible as a single dose to decrease sleeplessness
ü  Levothyroxine and liothyronine may decrease the effective of digitalis preparation.
ü  Estrogen can increase the effect of liothyronine
ü  Advise patient that thyroxine therapy is not a cure but a long term treatment to control symptoms.
ü  Caution patient to avoid drug preparation containing iodine, iodine-rich food, iodized salt, soybeans, tofu, turnips and high iodine seafoods.

ANTITHYROID DRUG

·         Reduces thyroid hormone by inhibiting thyroid secretion.
·         Indication:
o    Thyrotoxicosis (e.g Grave's disease)
o    thyrotoxic crisis
o    Preparation for thyroidectomy
·         Contraindication: Known hypersensitivity to methimazole and carbimazole, pregnant woman, hepatic disease, agarnulocytosis.

Example:
Drugs
Thioamides: Inhibits the synthesis of thyroid hormone
·         Methimazole (Tapazole®)
- More potent than PTU and has a longer half-life.
·         Propylthiouracil (PTU)

·         Iodide (Lugol's solution)
Used to reduce size & vascularity thyroid gland

Side effects:

§ Rash, hives
§ Headache
§ Hair loss
§ Nausea and vomiting
§ Muscle and joint pain
§ Agranulocytosis
§ Goiter (prolong drug use)
§ Hepatotoxicity
Nursing consideration:

ü  Monitor laboratory results
ü  Assess clinical response to medication after 3 weeks of therapy (e.g increased weight, ↓ pulse, ↓ T4 level)
ü  Check for any signs of hypothyroidism (e.g edema, cold intolerance, mental depression)
ü  Asses for bone marrow depression: infection, sore throat, fever, fatigue
ü  Monitor for signs of agranulocytosis. E.g fever or sore throat.
ü  Discontinue drug 3-4 weeks before radioactive iodine uptake (as indicated)
ü  Lithium and digoxin increase the action of the thyroid drug
ü  When used with oral anticoagulant (e.g warfarin), they can increase the potency of the anticoagulant.
ü  Inform patient that tachycardia, diarrhea, fever, and irritability are symptoms of inadequate dosage. Advise patient to report to physician when these symptoms occur.
ü  Advise patient to abstain from breast-feeding after delivery because drug appear in breast milk

VITAMIN D ANALOGUE

·         Increases serum calcium levels in the blood by promoting calcium absorption from the GI tract, reabsorption of calcium in the renal tubules and calcium release from bone to the bloodstream.
·         Indication:
o    Treatment of hypoparathyroidism; hypocalcemia
o    Renal osteodystrophy
o    Postmenopausal osteoporosis
o    Rickets
o    Psoriasis
·         Contraindication: hypersensitivity, hypercalcemia, hyperphosphatemia, hypervitaminosis D, malabsorption syndrome

Example:
·         calcitriol (Rocaltrol®)
·         dihydrotachysterol (Hytakerol®)
·         ergocalciferol (Drisdol®)
·         calcifediol (Calderol®)

Side effects: occasional skin irritation

Nursing Consideration:

ü  Monitor for signs and symptoms of vitamin D intoxication: headache, somnolence, hypertension, arrhythmias, anorexia, photophobia, bone & muscle pain, hyperthermia
ü  Assess for signs of hypercalcemia and inform patient signs of hypercalcemia as well.
ü  Monitor laboratory results
ü  Educate patient about food rich in calcium

CALCITONIN

·         Decreases serum calcium by a direct effect on bone (calcium deposition) & kidney (calcium excretion) and by opposing to parathyroid hormone.
·         Indication:
o    Hypercalcemia
o    Postmenopausal and corticosteroid-induced osteoporosis
o    Paget's disease
·         Contraindication: hypersensitivity to drug, children



Examples:

·         Calcitonin [human] (Cibacalcin®)
·         Calcitonin [salmon] (Calcimar®) - more potent

Side effects:

·         Nausea & vomiting
·         GI disturbances
·         Hot flushes
·         Metallic taste on mouth
·         Loss of appetite

Nursing Consideration:

ü  Assess and monitor blood results when patient is under calcitonin medication
ü  Advise patient to report signs of hypercalcemia such as nausea, vomiting, muscle weakness, restlessness, and confusion.
ü  Educate patient that she needs to inform her health care provider about her pregnancy status before taking calcitonin
ü  Advise patient that warmth and flushing occurs and usually last 1 hour
ü  Educate the patient how to monitor nutritional status: e.g check diet for sources of vitamin D and calcium.

DIPHOSPHONATES (bisphosphonates)

·         Group of inorganic compounds that inhibits osteoclast activity by binding to bone hydroxyapatite thus preventing bone resorption.
·         Indication:
o    Prevention (high risk) and/or treatment of osteoporosis
o    Paget's disease
o    Heterotopic ossification
·         Contraindication: hypocalcemia, inability to stant or sit upright for at least 30 minutes, achalasia (esophagus), hypersensitivity

Examples:

·         alendronate (Fosamax®)
·         etidronate (Didronel®)
·         pamidronate (Aredia®)
·         risedronate (Actonel®)

Side effects:

·         Abdominal pain, constipation
·         Diarrhea, flatulence
·         Musculoskeletal pain
·         Headache
·         Esophageal ulcer; dysphagia


Nursing Consideration:

ü  Assess for signs of hypercalcemia such as nausea, vomiting, muscle weakness, restlessness, and confusion.
ü  Determine the result from bone density test
ü  Monitor alkaline phosphatase
ü  Best to take drug in the morning with plenty of water (not mineral water) and before meal and other medication.
ü  After swallowing, advise patient not to lie down. Remain fully upright or walking for at least 30 minutes. This prevent esophageal irritation
ü  Advise patient to perform weight-bearing exercises or activities to promote an increase in bone density.




GLUCOCORTICOID

·         This group of steroid drugs has various properties that provide a wide range of benefits to patients. These includes:
o    Anti-Inflammatory effect - Its ability to inhibit prostaglanding synthesis, migration of macrophages, phagocytosis and lysosomal release will result to the attenuation of heat, erythema, swelling and tenderness on the affected area.
o    Anti-Allerigic (Immunosuppresion)
·         Indication:
o    Cortisol replacement in adrenal cortical hypofunction (e.g Addison's disease, inadequate ACTH release)
o    Non-endocrine disorders:
Disorders (d/o)
Example
effect
Allergic d/o
Anaphylactic reaction, drug induced allergic reaction, severe hay fever
↓ inflammation
Collagen d/o
Dermatomyositis, lupus
Immunosuppression
Dermatologic d/o
Alopecia areata, psoriasis, dermatitis, pemphigus
↓ inflammation
Gastrointestinal d/o
Inflammatory bowel disease, Crohn's disease
↓ inflammation
Hematologic d/o
Autoimmune hemolytic anemia, thrombocytopenia
Immunosuppression
Nonrheumatic inflammation
Bursitis, tenosynovitis
↓ inflammation
Neoplastic disease
Leukemia, lymphomas, nasal polyps
Immunosuppression
Neurologic disease
Multiple sclerosis, myasthenia gravis, meningitis
↓ inflammation,
Immunosuppresion
Neurogenic trauma
Brain surgery, closed head injury
↓ edema
Ophthalmic d/o
Conjunctivitis, optic neuritis
↓ inflammation
Respiratory v
Bronchial asthma, P.tuberculosis
↓ inflammation
Rheumatic d/o
Ankylosing spondylitis, RA, DJD
↓ inflammation,
Immunosuppresion

Contraindication: Systemic fungal infections, administration of live virus vaccines, varicella, ocular tuberculosis

Example:
Glucocorticoids

·   cortisone (Cortone acetate®)
Short  acting
·   hydrocortisone (Cortef®)
·   prednisolone (Delta-Cortef®)

Intermediate Acting
·   prednisone (Aristocort®)
·   methyprednisolone (Medrol®)
·   betamethasone (Celestone®)

Long Acting
·   beclomethasone (Vanceril®)
·   dexamethasone (Decadron®)

Side effects:

·    Hyperglycemia
·    Hypertension
·    Euphoria or psychosis
·    Growth retardation
·    Peptic ulcers
·    Osteoporosis

·    Edema
·    Sodium & water retention
·    Increased intraocular pressure (glaucoma)
·    ↓ extremity size/muscle wasting
·    Thinned skin with purpura
·    Abnormal fat deposits
Nursing consideration:

ü  Monitor vitals signs and blood results to detect early signs of adverse effects.
ü  Instruct patient to avoid persons with infection (e.g upper respiratory tract infection/ URTI). These drugs suppress the immune system
ü  Instruct patient to report signs and symptoms of a medication overdose or Cushing's Syndrome.
ü  Barbiturates, phenytoin and rifampin decreases the effect of glucocorticoids.
ü  Glucocorticoids increase the potency of NSAIDs thus greater risk of gastric bleeding & ulceration.
ü  Glucocorticoids will decrease the effect of oral anticoagulant (e.g warfarin).
ü  Potassium-wasting diuretics combined with glucocorticoids will have a greater loss in serum potassium, resulting in hypokalemia.
ü  High protein diet should be given to patients who are also administered with Florinef®. This drug causes a negative nitrogen balance.
ü  There may be a need to adjust insulin dosage among patients with diabetes. Glucocorticoids are hyperglycemic agents.
ü  Discontinuation of the drug should be tapered to avoid severe adrenocortical insufficiency.


MINERALOCORTICOID

·         Steroid hormone (aldosterone analogue) that enhances the reabsorption of sodium and chloride and further induces the excretion of potassium and hydrogen from the renal tubules thus helping to maintain fluid and electrolyte balance.
·         Indication: Usually combined with glucocorticoids in Corticosteroid replacement therapy for the treatment of Adrenal Cortical Insufficiency (Addison's disease)
·         Contraindication: Systemic fungal infections or known sensitivity to the medication

·         Example: fludrocortisone (Florinef®)

Side effects:
·          Hypokalemia
·          Hypocalcemia
·          Sodium & water retention


·          GI disturbances
·          Insomnia; mood swing
·          Increased susceptibility to infection
·          Delayed wound healing
·          Increased appetite & weight gain
Nursing Consideration:

ü  Monitor VS and blood work.
ü  Instruct the patient to take the drug with food or milk.
ü  Encourage the patient to have a potassium-rich diet.
ü  Inform patient to avoid crowded areas or person with infection.
ü  To avoid adrenal insufficiency, supportive may be required in times of stress (e.g surgery, severe illness) - as indicated.

ORAL HYPOGLYCEMIC DRUGS

Sulfonylureas

·         This group of drugs has the ability to stimulate the beta cells to further produce insulin thus lowering serum glucose level.

Non-Sulfonylureas

·         This group of drugs has a different mechanism in lowering serum glucose level as compared to the action of sulfonylureas. They do not induce hypoglycemia with the exception of meglitinides.
·         Biguanides:
o    It decreases hepatic production of glucose from stored glycogen following a meal and blunts the degree of postprandial hyperglycemia.
o    It is also decreased the absorption of glucose in the small intestine.

Generic name
Brand name
Consideration
Sulfonylureas                                                                                            
·      Stimulate beta cells to produce more insulin.
·      May induce hypoglycemia. 
·      These drugs may be combined with nonsulfonylurease or insulin.                                                                                                        

Indication: Type 2 diabetes mellitus
Contraindication:
o    Liver and kidney dysfunctions
o    Type 1 DM
o    Pregnancy and breastfeeding
o    During stress, surgery or severe infection

Common Side Effects:

·      GI disturabances (nausea, vomiting, diarrhea, abdominal pain)
·      Visual disturbances
·      Drowsiness, confusion
·      Headache
First Generation: Short Acting
tolbutamide
Orinase®

First Generation: Intermediate Acting
acetohexamide
Dymolar®
tolazamide
Tolinase®

First Generation: Long Acting
chlorpropamide
Diabinese®

Second Generation
glipizide
Glucotrol®
glyburide nonmicronized
DiaBeta®, Micronase®
glyburide micronized
Glynase®
glimepiride
Amaryl®

Nonsulfonylurease
·      These drugs may be combined with sulfonylureas/insulin or monotherapy.


Indication: Type 2 diabetes mellits
Contraindication:
o   Hypersensitivity
o   Concurrent infection
o   Hepatic or renal dysfunction
o   Cardiopulmonary insufficiency
o   Alcoholism

Common side effects:

·         Bitter or metallic taste
·         Dizziness, nausea, vomiting
·         Flatulence, diarrhea
·         Lactic acidosis
·         Malabsorption of amino acids, vitamin B12 & folic acid
Biguanides
Metformin
Glucophage®

Alpha-Glucosidase Inhibitors
Acarbose
Precose®
Miglitol
Glyset®

Thiazolidinediones
Pioglitazone HCl
Actos®
Rosiglitazone maleate
Avandia®

Meglitinides
Repaglinide
Prandin®
Neteglinide
Starlix®

Fixed Combination
glyburide + metformin
Glucovane®


INSULIN

·         Insulin lowers serum glucose levels by exerting its effects by first binding to a receptor located on the surface membrane of target cells. It then stimulates glucose carriers that promote facilitation of glucose diffusion into the target cells.
·         Insulin is administered subcutaneously, at 45 o - 90 o angle.  A 90 o angle is for patient with adequate fatty tissue while the 45 o -60o angle is for patients with little fatty tissue. Regular insulin is the only type that can be administered IV. Insulin can not be administered orally because GI secretions destroy insulin.
·         Insulin absorption is greater when injected in the deltoid and abdominal areas than when given in the thigh and buttock areas.

·         Indication: Type 1 diabetes mellitus, Type 2 DM which cannot be controlled by diet, exercise and oral antidiabetics.

·         Contraindication:

o    Hypoglycemia
o    Insulinoma
o    Diabetic coma
o    Hypersensitivity reaction

·         Characteristics of Insulin:
o    Onset: length of time before insulin reaches the bloodstream and begins lowering blood glucose.
o    Peak: time during which insulin is at maximum strength in terms of lowering blood glucose.
o    Duration:  how long insulin continues to lower blood glucose.

·         Types of Insulin:

Type
Characteristics
Rapid-acting insulin
insulin lispro (Humalog®)
Onset
Peak
Duration
: 5-12 mins
: 0.5-2 hrs
: 3-4 hrs
insulin aspart  (Novolog®)
insulin glulisine (Apidra®)

Short-acting insulin (human)
Regular
Onset
Peak
Duration
: 20-30 mins
: 2-4 hrs
: 6-8 hrs
Humulin R®


Intermediate Acting
*NPH insulin

Onset
Peak
Duration

: 1-4 hrs
: 6-10 hrs
: 12-20 hrs
Humulin N insulin
Lente insulin
Humulin L insulin

Long-Acting  insulin
Ultralente  insulin
Onset
Peak
Duration
: 3-6 hrs
: 10-16 hrs
: 18-24 hrs
insulin glargine (Lantus®)
Onset
Peak
Duration
: 6-10 hrs
: unknown
: 20-24 hrs
insulin detemir (Levemir®)

Combination
Humulin 70/30
(isophane 70%, regular 30%)
Onset
Peak
Duration
: 0.5 hr
: 4-8 hrs
: 22-24 hrs
Humulin 50/50
(isophane 50%, regular 50%)
Onset
Peak
Duration
: 0.5 hr
: 4-8 hrs
: 24 hrs
Humulin 75/25
(lispro protamine 75%, lispro 25%)
Onset
Peak
Duration
: 15 min
: 0.5-6 hrs
: 20-24 hrs
*NPH - neutral protamine Hagedorn

Alternative Devices for Taking Insulin:

Injection aids
·         Devices that help users give injections with needles and syringes through the use of spring-loaded syringe holders or stabilizing guides.
Insulin jet injectors
·         It sends a fine spray of insulin through the skin by a high-pressure air mechanism instead of needles.

External insulin pumps
·         Devices that deliver insulin through narrow, flexible plastic tubing that ends with a needle inserted just under the skin near the abdomen

Side effects:

·         Allergic reaction (e.g redness, hives)
·         Hypoglycemia
·         Temporary visual impairment
·         Lipodystrophy

Nursing Consideration:

ü  Determine the type of insulin prescribed and educate patient about insulin storage, preparation, administration and action .
o The nurse or patient must roll, not shake, the cloudy insulin bottles before use in order to ensure that the insulin and other components are well mixed.
o When preparing a mixture of regular insulin with another insulin preparation, draw the Regular insulin into the syringe first before NPH/Lente
o Lente & Ultra Lente are not stable if mixed with NPH
o Administer a mixed dose of insulin within 5 to 15 minutes of preparation to avoid decrease potency of the drug
o To prevent dosage error, be certain that calibration of units of the insulin syringe match with the insulin concentration.
o Teach parents/child to adjust insulin administration based on blood-glucose testing and glycosuria, during an illness or after changes in food intake or activities
ü  Instruct the patient about the need to develop a "site rotation pattern" for insulin administration to avoid lipoatrophy or lipohypertrophy. Injection should be 1 1/2 inches apart within the anatomical area
ü  Advise patient to administer insulin and take prescribed diet on a consistent schedule
ü  Observe for signs of insulin shock/hypoglycemia (see chapter 8); if present administer 10-15 g of fast acting carbohydrates. In severe hypoglycemia, administer glucagon as prescribed.
ü  Teach patient how to monitor blood glucose using Home Blood Glucose Monitoring (HBGM)
ü  There is a need to decrease insulin dosage with increased exercise and increase insulin dosage in stressful times (e.g severe infection)
ü  Advise parents to obtain a medical alert bracelet with information regarding insulin dosage prescription

GLUCAGON

·         Endogenous glucagon, a hyperglycemic hormone, is secreted by the alpha cells of the pancreatic islets.
·         Exogenous glucagon is administered to patients in order to stimulate glycogenesis in the liver thus increasing serum glucose level.
·         It is administered subcutaneously, intramuscularly or IV
·         Indication:
·         Insulin-induced severe hypoglycemia, especially in patients who are unable to ingest glucose due to loss of consciousness
·         Contraindication: hyperglycemia, known hypersensitivity

Example:
·         GlucaGen®; Glucagon Emergency Kit

Side effects:

·         Nausea & vomiting
·         Trainsient increase in blood pressure
·         Tachycardia
·         Gastric hypotonicity

Nursing Consideration:

ü  Do not administer glucagon if particulate matter, cloudiness or discoloration is noted or if the solution shows signs of gel formation
ü  Determine if the patient is taking anticoagulants. May increase hypoprothrombinemic effects resulting in bleeding.
ü  Monitor serum glucose level. Blood glucose begins to rise after 5 to 20 after administration.

DIAZOXIDE

·         A hyperglycemic drug that inhibits insulin release from the beta cells and stimulating release of epinephrine from the adrenal medulla.
·         Indication: Chronic hypoglycemia caused by hyperinsulinism (e.g islet cell cancer); Malignant hypertension
·         Contraindication: hypersensitivity to thiazides, diazoxide and other sulfonamide-derived drugs

Example: Proglycem® - oral; Hyperstat® - IV

Side effects:

·         Nausea
·         Mild itchiness
·         Decreased sense of taste
·         Headache, dizziness, anxiety
·         Tachycardia

Nursing consideration:

ü  Monitor blood pressure especially for patients administered with parenteral form of diazoxide. Severe hypotension may occur
ü  Check blood sugar. Onset of action is 1 hour after administration


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