Endocrine Medications

PITUITARY MEDICATIONS
THE ANTERIOR PG secretes GH, TSH, ACTH, prolactin, MSH and gonadotropins The posterior PG secretes antidiuretic hormone and oxytocin

GROWTH HORMONES
Medication Somatrem Uses Growth Failure Side Effects Development of antibodies to GH

Somatropin

Growth failure

Headache, muscle pain, weakness, mild hyperglycemia, hypertension, allergic reaction, pain at injection site

Interventions:
Assess childs physical growth and compare growth with standards Recommend annual bone age determinations for children receiving growth hormones Monitor blood glucose levels and thyroid function test Teach the client and family about the clinical manifestations of hyperglycemia and the importance of follow up regarding periodic blood test

ANTIDIURETIC HORMONES
Enhance reabsorpton of water in the kidney, promoting an antidiuretic effect and regulating fluid balance Used in diabetes insipidus

Side effects:
Flushing Headache Nausea and abdominal cramps Water intoxication HPN with water intoxication Nasal congestion with nasal administration

Examples:
Desmopressin acetate Lypresin Vasopressin

Interventions:
Monitor weight Monitor I&O and urine osmolality Monitor electrolyte levels Monitor for signs of water intoxication Monitor for signs of DHN, indicating need to increase dosage Monitor BP Instruct client how to use intranasal meds Weigh daily

THYROID HORMONES
Control the metabolic rate of tissues and accelerate heat production and oxygen consumption Used to replace the thyroid hormone deficit in condition such as hypothyroidism and myexedema Enhance the action of oral anticoagulant, sympathomimetics and antidepressants and decrease the action of insulin, oral hypoglycemic and digitalis preparations Should be given at least 4 hours apart from multivitamins, aluminum hydroxide and magnesium hydroxide, simethicone, calcium carbonate, bile acid sequestrants, iron and sucralfate

Examples:
Levothyroxine sodium Liothyronine sodium Liotrix

Levothyroxine Sodium(Synthroid)
6th day 6th dose 4th day 4th dose 1st day 1st dose
Watch for: Irritability Palpations Tachycardia Diarrhea Arrhythmias

Missed dose 1st day Missed dose 4th day Missed dose 6th day

Dose is too low

Dose is too high

Side Effects:
Nausea and decreased appetite Abdominal cramps and diarrhea Weight loss Nervousness and tremors Insomnia Sweating and heat intolerance Tachycardia, dysrhythmias, palpitations, chestpain HPN Headache Toxicity: hyperthyroidism

Interventions:
Assess client for history of meds currently being taken Monitor VS Monitor weight Monitor triidothyronine, thyroxine and TSH levels Instruct client to take meds at the same time each day preferably in the morning without food Monitor pulse rate Report symptoms of hyperthyroidism Avoid foods that inhibit thyroid secretions Avoid OTC meds

ANTITHYROID HORMONES
Inhibit the synthesis of Thyroid hormones Used for hyperthyroidism or Graves disease

Examples:
Methimazole Propylthiouracil Potassium iodide Radioactive iodine

Methimazole (Tapazole)
Tapazole is 10 times more potent thatn propythiourical (PTU), the protype of this class.

Warning:
When in use, watch for: -Paresthesia -Dyspepsia -Hepatitis -GI mobility
This medication helps control hyperthyroidism and thyrotoxicosis (thyroid storm), especially prior to surgery or radioactive iodine treatment.

Side effects
N/V Diarrhea Drowsiness, headache, fever Hypersensitivity with skin rash Agranulocytosis with leucopenia and thrombocytopenia Alopecia and hyperpigmentation Toxicity: hypothyroidism Iodism: vomiting, abdominal pain, metallic or brassy taste in the mouth, rash and sore gums and salivary glands

Interventions
Monitor VS Monitor triidothyronine, thyroxine and TSH levels Monitor weight Take meds with meals Monitor pulse rate Report fever or sore throat Instruct the client regarding the importance of med compliance and that abruptly stopping could cause thyroid storm Monitor for signs of iodism Consult physician before eating iodize salt and iodine rich foods Avoid aspirin and meds containing iodine

PARATHYROID MEDICATIONS
Regulates serum calcium levels Low serum levels of calcium stimulate parathyroid hormone release Hyperparathyroidism results in high serum calcium level and bone demineralization; meds is used to lower the serum calcium levels Hypothyroidism results in low serum calcium level, which increases neuromuscular excitability; treatment includes calcium and vit D supplements Calcium salts administered with digoxin increase the risk of digoxin toxicity Oral calcium salts reduce the absorption of tetracycline hydrochloride

Examples:
Calcium carbonate Calcium citrate Dibasic calcium phosphate Calcium lactate Vit D supplements calcitriol, ergocalciferol Calcium regulators alendronate sodium, calcitonin salmon, etidronate disodium, risedronate sodium Antihypercalcemics cinacalcet hydrochloride, doxercalciferol

Interventions:
Monitor electrolyte and calcium levels Assess for S/Sx of hypocalcemia and hypercalcemia Assess for signs or tetany in client with hypocalcemia Assess for renal calculi in client with hypercalcemia Check OTC meds labels for the possibility of calcium content Instruct the client receiving oral calcium supplements to maintain adequate intake of Vit D Instruct the client receiving calcium regulators to swallow the tablet whole with water at least 30 mins before breakfast and not to lie down for at least 30 mins Clients using antihypercalcemic agents should avoid foods rich in calcium Not to take other meds within 1 hour of taking calcium salt Increase fluid and fiber in diet

CORTICOSTEROID MINERALOCORTITICOIDS
Mineralocorticoids are steroid hormones that enhance the reabsorption of sodium and chloride and promote the excretion of potassium and hydrogen from the renal tubules, thereby helping maintain fluid and electrolyte balance Used for replacement therapy in primary and secondary adrenal insufficiency in Addisons disease Ex. Fludrocortisone acetate

Side effects
Sodium and water retention

Interventions
Monitor VS Monitor I&O and weight and for edema Monitor electrolyte and calcium levels Take meds with food or milk Consume a high potassium diet Do not stop the med abruptly Report illness, severe diarrhea, vomiting, fever Notify physician if low BP, weakness, cramping, palpitation or changes in mental status occur

GLUCOCORTICOIDS
Affect glucose, protein, and bone metabolism, alter normal immune response and suppress inflammation and produce anti inflammatory, antiallergic and antistress effects May be used as replacement for adrenocortical insufficiency

Examples
Dexamethasone Hydrocortisone Methylprednisolone Prednisolone Prednisone Triamcinolone

Corticosteroids
Methylprednisolone Sodium Succinate (SoluMedrol) Dexamethasone (Decadron) Prednisone (Deltasone) The Good

These drugs stop, control, or reduce the inflammatory response (local or systemic) in any part of the body by suppressing the immune system.

The Bad

Although there is a slow internal and external deterioration of the body, the trade off is that the steroid in a chronic or autoimmune disorder will usually keep the body alive longer than if the inflammatory process was left unchecked.

The dose amount and duration of use dictate the extent of dependency and damage to the body. Watch for edema, peptic ulcers, delayed wound healing, osteoporosis & infections

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Side Effects
Hyperglycemia Hypokalemia Hypocalcemia, osteoporosis Sodium and fluid retention Weight gain Mood swings Moon face, buffalo hump, truncal obesity Increased susceptibility to infection and masking of the s/Sx of infection Cataracts Hirsutism, acne, fragile skin, bruising Growth retardation in children GI irritation, peptic ulcer pancreatitis Seizures, psychosis

Interventions:
Monitor VS Monitor serum electrolyte and blood glucose levels Monitor for hypokalemia and hyperglycemia Monitor I&O and weight and for edema Monitor for HPN Assess medical hx for glaucoma, cataracts, peptic ulcer, mental health disorder or DM Monitor older clients for S/Sx of increased osteoporosis Assess for changes in muscle strength

It is best to take med in the early morning Eat foods high in potassium Avoid individuals with respiratory infections Report S/Sx of medication overdose or Cushings Syndrome Client may need additional doses during periods of stress Do not stop the med abruptly

DIABETES MELLITUS
A CHRONIC DISORDER OF IMPAIRED GLUCOSE INTOLERANCE AND CARBOHYDRATE, PROTEIN &

LIPID METABOLISM; CAUSED BY A DEFIECIENCY

OF INSULIN

 Cause: Unknown Predisposing Factors

Stress Heredity Obesity Viral infection Autoimmune Disorder Women Multigravida with Large babies
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1. INSULIN-DEPENDENT DIABETES 2. NON-INSULIN DEPENDENT DIABETES

Characteristics of Type 1 and Type 2 Diabetes

Type 1 Type 2

Fast onset of disease Prevalence 0.5% young

Slow development
Prevalence 5-10% adult

Type I
IDDM Juvenile onset Unstable DM 30 yrs. Absolute Insulin deficiency Thin Prone to DKA

Type II
NIDDM Maturity onset Stable DM 40 yrs. With insulin sec., demands Obesed Prone to HHNC (Ketosis resistant)

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Pathophysiology of Type 2 Diabetes: 2 Defects

Genes Genes

Impaired Insulin Secretion

Insulin Resistance

Environment
IGT

Environmen t IGT Type 2 Diabetes

IGT = Impaired Glucose Tolerance

Main Problem

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Triad of Manifestations:

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Deficient insulin production Hyperglycemia

Inc. concemtration of blood glucose Glucosuria Excess glucose excreted in urine

Excess fluid loss

Polyuria / Polydipsia

Insulin deficiency Impaired metabolism of CHON and fats Weight loss Decreased storage of calories

Polyphagia

ASSESSMENT
POLYPHAGIA POLYDIPSIA POLYURIA HYPERGLYCEMIA WEIGHT LOSS BLURRED VISION

SLOW WOUND HEALING

VAGINAL INFECTIONS WEAKNESS & PARESTHESIAS

SIGNS OF INADEQUATE FEET CIRCULATION

MEDICATIONS FOR DM

INSULIN AND ORAL HYPOGLYCEMIC MEDICATIONS

Insulin increases glucose transport into cells and promotes conversion of glucose to glycogen, decreasing serum glucose levels Oral hypoglycemic agents stimulate the pancreas to produce more insulin, increase the sensitivity of peripheral receptors to insulin, decrease hepatic glucose output, or delay intestinal absorption of glucose, thus decreasing serum glucose levels

ORAL HYPOGLYCEMIC MEDICATIONS

Prescribed for clients with type 2 DM

Adverse effects
Hypoglycemia Diarrhea, jaundice, nausea and heartburn Anemia , photosensitivity

Sulfonylureas
Stimulate the beta cells to produce more insulin Ex: acetohexamide, chlorpropamide, glimepiridine

Glipizide (Glucotrol)
Watch for:
Epigastric fullness Diarrhea

Constipation
hypoglycemia Heartburn

priritus

Biguanides
Suppress hepatic production of glucose and increases insulin sensitivity Side effects: diarrhea, lactic acidosis Ex: metformin

Nursing Considerations Chlorpropamide has a long duration of action and 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.

Alpha-glucosidase inhibitors
Delay absorption of ingested carbohydrates, resulting in smaller increase in blood glucose level after meals Do not increase insulin production Can be given alone or in combination with sulfonylureas Will not cause hypoglycemia when given alone Given with first bite of meal Ex.: acarbose, migitol

Acarbose (precose)
I am acarbose (precose). I can work with insulin, metformin or a sulfonylurea, or I can work on my own. I go in with the first bites of each meal, so I can interfere with absorption of carbohydrates.

Watch for: diarrhea Flatulence Abdominal distention

Thiazolidinediones
Insulin sensitizing agents that lower blood glucose by decreasing hepatic glucose production and improving target cell response to insulin May cause liver toxicity Ex.: ploglitazone, rosiglitazone

Meglitinides
Stimulate pancreatic insulin secretion Quicker and shorter duration of action therefore, less chance of hypoglycemia Very fast onset of action allows client to take the med with meals and skip a dose when meal is skipped Ex: Nateglinide, Repaglinide

Interventions:
Assess the clients knowledge of DM and the use of oral antidiabetic agents Obtain a med hx regarding the meds that the client is taking currently Assess VS and blood glucose levels Avoid OTC meds Do not ingest alcohol with sulfonylureas Insulin maybe needed during stress, sugery or infection

INSULIN
Primarily acts on the liver, muscle and adipose tissue by attaching to receptors on cellular membranes and facilitating the passage of glucose, potassium and magnesium Prescribed for clients with type 1 DM and type 2 DM in client whose blood glucose level is not controlled with oral hypoglycemic agents The onset, peak and duration of action depends on the insulin type The main areas for injections are the abdomen, arms, thighs and hips Insulin injected into the abdomen may absorb more evenly and rapidly than other sites Heat, massage and exercise of the injected area can increase absorption rates and may result in hypoglycemia

ANTI-DIABETIC DRUGS
Insulin Type Example Onset
15 minutes
1 hour

PEAK
1 hour
2-4 hrs

ULTRA-acting
RAPID-acting
INTERMEDIATE acting

Lispro
Regular Insulin NPH and Lente

1 to 2 hrs

LONG-Acting

Ultra-lente 4-8 hrs

6-8 hrs Up to 12 hrs 10-20 hrs

Insulin Peaks

I
S P R O

S
H O Regular T

L
E N

I
N T

= R = Rapid E

T
R M E D I A T E

The slower acting insulins are closest to the needle. The fastest acting insulin (lispro) is closest to the plunger.

Nursing Considerations

Insulin is administered at home subcutaneously ( only Regular insulin can be used INTRAVENOUSLY) Instruct the client to rotate the areas of injection, but exhaust all available sites in one area first before moving into another area

Route : SC
slow absorption less painful Angle: 90 Needle:
thin: 3/8 obesed: , 5/8

IV DKA Dont massage site of injection

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 Refrigerate unused insulin Never shake the vial Prevent lipodystrophy

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Side effects:
Localized

Induration or Redness Swelling Lesion at the site Lipodystrophy

Generalized

Edema Hypoglycemia Somogyi phenomenon

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Diabetes Mellitus
The four main areas for insulin injection areABDOMEN, UPPER ARMS, THIGHS and HIPS

Exubera
Short acting inhaled insulin indicated for treatment of types 1 and 2 DM Consists of fine dry powder insulin that enters the bloodstream more rapidly than the SQ injection Inhaled 10 mins before meals Causes a decrease in pulmonary function Contraindicated in clients who smokes, starts smoking or quits smoking less than 6 mos prior to initiation of treatment Side effects include cough, dry mouth, chest discomfort, hypoglycemia

Exanatide
A synthetic hormone classified as an incretin mimetic that is administered SQ Use for type 2 DM Restores first phase insulin response, lowers the production of glucagons after meals, slows gastric emptying, reduces fasting and postprandial blood glucose levels and reduces caloric intake, resulting in weight loss Administered as SQ injection in the thigh, abdomen or upper arm within 60 min before morning and evening meals, not taken after meals Can cause mild to moderate nausea that abates with use

Pramlintide
Synthetic form of amylin, a naturally occurring hormone secreted by the pancreas Used for clients with types 1 and 2 DM who use insulin Given before meals Associated with increased risk on insulin induced severe hypoglycemia,particularly in clients with type 1 DM GI side effects including nausea can occur

Glucagon
Hormone secreted by alpha cells of the islet of Langerhans in the pancreas Increases blood glucose level by stimulating glycogenolysis in the liver Can be administered SQ or IV Used to treat insulin induced hypoglycemia when the client is semiconscious or unconscious and is unable to ingest liquids The blood glucose level begins to increase within 5 to 20 mins after administration

Diazoxide
Increase blood glucose level by inhibiting insulin release from the beta cells and stimulating the release of epinephrine from the adrenal medulla Used to treat chronic hypoglycemia cause by hyperinsulinism resulting from islet cell cancer or hyperplasia

REPRODUCTIVE HORMONES
Female hormones include ESTROGENS, PROGESTINS and ovarian hormones Male hormones include ANDROGENS and anabolic steroids

Therapeutic Uses
FEMALE: Hormonal replacement therapy, oral contraception, treatment of infertility and management of some tumors

Eg: Conjugated estrogen, Estradiol, Ethinyl

estradiol, Diethylstilbesterol (DES), Clomiphene Progestins-Medroxyprogesterone (Provera), Norethindrone, Levonorgestrel (Norplant), Norgestrel

MALE: replacement therapy, metabolic stimulators and treatment of some tumors Eg: Testosterone cypionate, Methyltestosterone, Fluoxymesterone, Aqueous testosterone

Nursing Considerations
Not to be used in patients with history of, hypertension, thromboemoblic or CVA disease Contraindicated in pregnancy
WARN the client to avoid smoking because this will increase the risk for embolic episodes.