7_26 內分泌 part 2.docx

**Week 7 : Drugs for Endocrine Disorders II** 考試重點: 各種內分泌太多、太少的結果，以及個別如何治療，副作用又為何。 **Part 1**: **Thyroid** hormones and thyroid gland, +-----------------------+-----------------------+-----------------------+ | | Thyroid and thyroid |...

**Week 7 : Drugs for Endocrine Disorders II** 考試重點: 各種內分泌太多、太少的結果，以及個別如何治療，副作用又為何。 **Part 1**: **Thyroid** hormones and thyroid gland, +-----------------------+-----------------------+-----------------------+ | | Thyroid and thyroid | | | | gland | | +-----------------------+-----------------------+-----------------------+ | | Hyperthyroidism | Hypothyroidism | | | | | | | (too much thyroid | (too little thyroid | | | hormone) | hormone) | | | | | | | Metabolic processes | Metabolic processes | | | speed up (🐇). | slow down (🐢). | +-----------------------+-----------------------+-----------------------+ | | 這兩個都是自體免疫疾病(大家是因為遺傳) | 這兩個都是autoimmune疾病(大家是 | | | | 因為遺傳) | +-----------------------+-----------------------+-----------------------+ | 最常見成因 | Graves Disease | Hashimoto's Disease | | | 它會導致甲狀腺亢進 | 它會導致甲狀腺低落的其中一的疾病，因為遺傳 | | | | | | | (too much thyroid | | | | hormone) | 會把甲狀腺變成fiborotic | | | | | | | 自體免疫刺激甲狀腺受體，導致甲狀腺素變多 | tissue把它纖維化。使它沒用。 | +-----------------------+-----------------------+-----------------------+ | S/sx | 1. Weight loss | 1. Weight | | | 代謝太快 | gain（身體產生的內量不更，代謝 | | | | 變慢，所以變胖） | | | 2. Diarrhea 腸胃蠕動 | | | | | 2. Constipation | | | 3. Heat intolerance | （代謝變慢，所以變胖） | | | (present flushed) | | | | | | | | 因代謝身體會散熱，臉&全會潮紅 | 3. Cold intolerance | | | | (with | | | | hypothermia失溫症) | | | 4. Nervousness/Anxie | | | | ty | | | | 心跳很快所以焦慮 | 4. Depression | | | | 能量不足，所以憂鬱 | | | 5. Sweating | | | | 容易出汗來排熱 | | | | | 5. Dry skin | | | 6. Hyperexcitable | 沒出汗，沒adp，沒油脂 | | | 過度興奮 | | | | | | | | 7. Tachycardia & | 6. Extreme fatigue | | | Palpitations 心悸 | 想動，但能量不足，身體每個細胞沒有 | | | | adp能量去促進酵素代謝。 | | | 8. Exophthalmos | | | | 凸眼症 | | | | | 7. Bradycardia | | | | | | | | 8. Puffy face | | | | | | | | 9. Myalgia 肌肉痛 & | | | | weakness | | | | 能量不夠，訊息傳遞不夠，肌肉萎縮， | | | | 肌肉使用不足，會痠痛。 | | | | | | | | | | | | 10\. Impaired memory | | | | 能量不足，記憶力不足 | +-----------------------+-----------------------+-----------------------+ | 用藥& | 1. **Methimazole | **Levothyroxine | | | (Tapazole)**: | \[Synthroid\]**: | | treat | Reduces hormone | Synthetic T4 | | | production. | (thyroxine) hormone. | | | | | | | 2. Thyroidectomy: | 因為這個藥物只合成t4 | | | Surgical removal | | | | of thyroid. | | | | 割調，不夠再注射 | | | | | | | | 3. Radioactive | | | | Iodine: Shrinks | | | | thyroid tissue. | | | | 放射性碘，把甲狀腺變少。 | | +-----------------------+-----------------------+-----------------------+ | SE | - Potential severe | - Can mimic severe | | | hypothyroidism. | hyperthyroidism, | | | | causing: | | | - Fever, | | | | rash(皮疹，是藥物過敏反應), | - Cardiac issues: | | | | tachycardia, | | | sore | palpitations, | | | throat(因為抑制合成，所以喉 | dysrhythmias, | | | 嚨痛). | angina. | | | | | | | - Jaundice | - Nervousness, | | | (下游反映) | shakiness, | | | -\>膽汁由肝臟分系，肝細胞受吮， | trouble sleeping, | | | bilirubin | anxiety. | | | 膽紅素(本身有毒)，他是合成膽汁的 | | | | 主要色素，被丟出來，他是黃橙色的，細胞會破 | - Need to Report: | | | 掉，顏色跑出來，全身都會。"紅血球老化降解 | Signs of a | | | 時會流到肝臟，肝臟會幫助降解紅血球，所以會 | possible MI, such | | | 導致紅血球" | as severe cardiac | | | | symptoms and | | | - Leukopenia due to | shortness of | | | agranulocytosis | breath. | | | (increased | | | | infection risk). | | | | | | | | - Agranulocytosis: | | | | Low neutrophil | | | | count (→ risk of | | | | infection), | | | | impact on bone | | | | marrow can also | | | | decrease RBC (→ | | | | anemia/fatigue) | | | | and platelets (→ | | | | risk of | | | | bleeding). | | | | | | | | - Need to check CBC | | | | (WBC) | | | | | | | | - Also check | | | | hepatic function, | | | | can be | | | | hepatotoxic | | | | 因為代謝是由肝代謝，不然會導致肝中 | | | | 毒。 | | +-----------------------+-----------------------+-----------------------+ **Part 2**: Antidiuretic hormone (**ADH**) from the posterior pituitary gland +-----------------------+-----------------------+-----------------------+ | | Antidiuretic hormone | | | | (**ADH**)， | | | | | | | | 像是scar | | | | 因抗利尿，所以血壓會增加，所以又可以叫加壓 | | | | 素。也會導致全身的血管收縮(因為抑制了副交 | | | | 感)。 | | | | | | | | from the posterior | | | | pituitary gland | | +-----------------------+-----------------------+-----------------------+ | | too much ADH | too little ADH | | | | | | | -tumor | -tumor | +-----------------------+-----------------------+-----------------------+ | 極端會造成的病 | syndrome of | diabetes insipidus | | | inappropriate | (DI) | | | antidiuretic hormone | | | | (SIADH) | | | | | | | | - **Causes**: | | | | over-secretion of | | | | ADH. This can be | | | | due to issues | | | | with the | | | | hypothalamus or | | | | pituitary gland, | | | | or it could be | | | | caused by a | | | | tumor. | | | | | | | | - **Signs/Symptoms* | | | | *: | | | | Water | | | | intoxication and | | | | hyponatremia低血鈉 | | | | | | | | (similar to | | | | dangerous side | | | | effects of | | | | desmopressin). | | +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | S/sx | **High ADH**: Leads | **Low ADH**: Results | | | to fluid retention, | in increased urine | | | low urine output, and | output (more | | | fluid overload, | diuresis) and | | | causing **Syndrome of | dehydration, leading | | | Inappropriate | to **Diabetes | | | Antidiuretic Hormone | Insipidus**. | | | (SIADH)**. | | | | | | | |  **Fluid | | | | Restriction**: Yes, | | | | patients should be on | | | | fluid restriction to | | | | manage fluid | | | | overload. | | +-----------------------+-----------------------+-----------------------+ | urine output | Decreased (low). | Increased (more | | | | diuresis). | +-----------------------+-----------------------+-----------------------+ | water retention | Increased. | decreased | +-----------------------+-----------------------+-----------------------+ | sodium levels | Decreased (due to | Elevated (due to | | | dilution). | dehydration). | | | | | | | | 高血鈉 Hypernatremia | +-----------------------+-----------------------+-----------------------+ | Treat | 3% Sodium Chloride, | desmopressin (DDAVP) | | | **to** address sodium | | | | imbalance. | 一種化學物質，可以用來合成adh， | | | | | | | | | | | | 會影響腎臟的受體結合，使得水再攜手跑回身體 | | | | ，在遠區小館，和急尿管。 | +-----------------------+-----------------------+-----------------------+ | SE | n/a | - - Cardiovascula | | | | r | | | 這個比較少用,why? ) | Side Effects: | | | | Less of a concern | | | | because | | | | desmopressin has | | | | a weak | | | | vasopressin | | | | effect. | +-----------------------+-----------------------+-----------------------+ **Part 3**: Aldosterone and Cortisol from adrenal gland +-----------------------+-----------------------+-----------------------+ | | **Aldosterone** and | | | | **Cortisol** from | | | | adrenal gland | | | | | | | | 腎上腺皮質會同時分泌醛固酮，和皮質素。 | | | | | | | | | | | | 基本上依樣多，依樣低 | | +-----------------------+-----------------------+-----------------------+ | | Cushing's Disease | Addison's Disease | | | (high aldosterone and | (low aldosterone and | | | high cortisol) | low cortisol) | | | | | | | 醛固酮使男性維持男性激素，並使女性維持女性 | | | | 特偵 | | +-----------------------+-----------------------+-----------------------+ | S/SX | 1.本身分泌過高 | 自身免疫導致 | | | | | | | 2.或是使用太多類固醇(因為你長期使用類固 | 血糖過低 | | | 醇) | | | | | 低血壓， | | | | | | | | 體重流失，因為葡糖不夠，使用脂肪或肌肉 | | | | | | | | | | | | 沒有葡萄糖 沒有能量 | | | | | | | | 改變頭髮的分布。導致女生有鬍子，因為醛固酮 | | | | 不足。 | +-----------------------+-----------------------+-----------------------+ | Treat | 停止使用類固醇藥物 | 增加醛固酮和皮質醇 | | | | | | | 切除腎上腺皮質 | 要用類固醇類 | +-----------------------+-----------------------+-----------------------+ | SE | | | +-----------------------+-----------------------+-----------------------+ A. Review the anti-androgen effects of spironolactone B. Know treatment for Addison's and Cushing's, including symptomatic management A. Fludricortisone and hydrocortisone, D5NS C. Focus on steroids and their side effects **Drugs for Thyroid Disorders** 1. Thyroid Gland Location: Wrapped around the trachea and not palpable by touch. 2. Hormone Production: Produces and stores T3 (triiodothyronine) and T4 (thyroxine). 3. Primary Functions: 1. Metabolism: Stimulates energy use. 2. Cardiac Function: Enhances heart performance. 3. Growth and Development: Supports overall bodily growth and functional development. 4. Iodine and Thyroid Hormones: - Iodine is necessary for thyroid hormone production. - The USA has sufficient iodine levels, so deficiency is rare. - Issues often stem from autoimmune conditions. **Hyperthyroidism** Hyperthyroidism: The most common cause is Graves\' Disease. - Autoimmune Condition: Immunoglobulins stimulate receptors for thyroid-stimulating hormone on the thyroid gland, leading to increased hormone synthesis. 甲狀腺導致更多的甲狀腺激素產生 **Treatment for Hyperthyroidism** 1. **Thyroidectomy**: Surgical removal of thyroid. 2. **Radioactive Iodine**: Shrinks thyroid tissue. 3. medication:**Methimazole (Tapazole)**: Reduces hormone production. - **Methimazole \[Tapazole\]** - Methimazole (Tapazole): Inhibits thyroid hormone synthesis in the thyroid gland. - Effectiveness Indicators: Signs you listed in last slide start to slow down - Side Effects (SE): - Potential severe hypothyroidism. - Fever, rash, sore throat. - Jaundice - Leukopenia due to agranulocytosis (increased infection risk). - Agranulocytosis: Low neutrophil count (→ risk of infection), impact on bone marrow can also decrease RBC (→ anemia/fatigue) and platelets (→ risk of bleeding). - Need to check CBC - Also check hepatic function, can be hepatotoxic Jaundice: Sign of hepatic failure or injury. - Bilirubin: Normal breakdown product of heme in RBC, processed by liver and excreted through urine and stool. - Cause: Jaundice is caused by bilirubin buildup. - Examination: Always look at sclera! **Hypothyroidism**: reason: **1**. Hashimoto\'s Thyroiditis. (The most common cause) 2\. autoimmune Whereas the autoimmune effect of Graves led to synthesis of more thyroid hormone, autoimmune effect of Hashimoto's leads to formation of fibrotic tissue (scar tissue, which is not functional), after antibodies attack the thyroid gland 🡪 less thyroid hormone production **Treatment for Hypothyroidism** **Levothyroxine \[Synthroid\]** - MOA: Synthetic T4 (thyroxine) hormone. - Administration: PO or IV. - Effectiveness: Symptoms will speed up. - Side Effects: - Can mimic severe hyperthyroidism, causing: - Cardiac issues: tachycardia, palpitations, dysrhythmias, angina. - Nervousness, shakiness, trouble sleeping, anxiety. - Need to Report: Signs of a possible MI, such as severe cardiac symptoms and shortness of breath. **Symptomatic Treatment:** Focus: Relieve symptoms without addressing the root cause. Hyperthyroidism: A beta blocker can help manage tachycardia by reducing heart rate. Hypothyroidism: An SSRI (Selective Serotonin Reuptake Inhibitor) can help manage depression, but it typically takes several weeks to take effect. Therefore, SSRIs are more suitable for long-term support rather than immediate relief. **Underlying Treatment:** Focus: Target and treat the root cause of the disease. Hyperthyroidism: Antithyroid medications like Methimazole, radioactive iodine therapy, or thyroidectomy to reduce thyroid hormone production. Hypothyroidism: Levothyroxine (Synthroid) to supplement low thyroid hormone levels and restore normal thyroid function. **Drugs related to Hypothalamic and Pituitary Function** Antidiuretic Hormone (ADH) = Vasopressin Function: - Water Retention: Stimulates water retention through the kidneys, raising blood pressure (BP). - Vasoconstriction: Causes blood vessels to constrict, further increasing BP, which is why it is also called vasopressin.  **Low ADH**: Results in increased urine output (more diuresis) and dehydration, leading to **Diabetes Insipidus**.  **High ADH**: Leads to fluid retention, low urine output, and fluid overload, causing **Syndrome of Inappropriate Antidiuretic Hormone (SIADH)**. - - Diabetes Insipidus (DI) - (這裡少了第16頁的文字內容) **Desmopressin acetate (DDAVP)** - Desmopressin is synthetic ADH - MOA: Also binds to receptors in kidney (just like real ADH) to enhance water reabsorption at the end of the nephron (distal tubule, collecting duct), leaving urine more concentrated, less dilute, to hold more fluid in the body - Admin: Nasal Spray, SQ, IV (new SL (sublingual)) - - How to Know It's Working: - Decreased polyuria (reduced excessive urine output). - Decreased polydipsia (reduced excessive thirst). - Increased specific gravity of urine (more concentrated urine). Side Effects: - Most Dangerous: Water intoxication and hyponatremia, which can lead to altered mental status and seizures. - Cardiovascular Side Effects: Less of a concern because desmopressin has a weak vasopressin effect. - Patient teaching? - Monitor for Symptoms: Watch for headaches, nausea, confusion, or seizures. - Control Fluid Intake: Avoid drinking excessive fluids. - Regular Check-ups: Have regular tests for electrolytes and kidney function. - Follow Instructions: Use the medication as directed (nasal, SQ, IV, or SL). - Report Issues: Inform your doctor of any unusual symptoms. **Specific Gravity** 是測量尿液濃縮度的一個指標，它表示尿液中溶解物質的濃度。具體來說，它是尿液的密度與水的密度之比。以下是具體說明： **Specific Gravity**: 衡量尿液濃度的指標。數值高表示尿液濃縮，數值低則表示尿液稀釋。 **正常範圍**: 通常在 1.005 到 1.030 之間。 **用途**: 可用來評估腎臟的濃縮能力以及體內水分狀態 **SIADH**: - **Description**: Opposite of DI; characterized by too much ADH. - **Causes**: over-secretion of ADH. This can be due to issues with the hypothalamus or pituitary gland, or it could be caused by a tumor. - **Signs/Symptoms**: Water intoxication and hyponatremia (similar to dangerous side effects of desmopressin).  **Fluid Restriction**: Yes, patients should be on fluid restriction to manage fluid overload.  **Treatment**: Administer hypertonic saline, specifically 3% NaCl, to address sodium imbalance. **Drugs for Disorders of the Adrenal Cortex** Hormones of the Adrenal Cortex: **Mineralcorticoid: Aldosterone** - **RAAS**: Aldosterone is part of the Renin-Angiotensin-Aldosterone System (RAAS). - **Function**: Promotes sodium reabsorption in the kidneys, leading to increased sodium levels and potassium excretion. **Glucocorticoid: Cortisol** - **Function**: Increases glucose availability, especially during stress (emotional or physical). - **Role**: Often called the \"stress hormone\" as it helps provide a quick source of energy. **Spironolactone** Spironolactone \[Aldactone\]  **Mechanism**: Blocks aldosterone receptors in the distal convoluted tubules of the nephron. This results in: - Increased sodium loss in urine (and water follows). - Decreased potassium loss in urine (potassium is retained, hence \"potassium-sparing\").  **Anti-Androgen Effect**: - **Doses**: 50-100 mg for hypertension; 200-400 mg for anti-androgen effects. - **Action**: Blocks dihydrotestosterone (DHT), a derivative of testosterone. - **Effects**: - **AMAB (Assigned Male at Birth)**: Can cause feminization, such as gynecomastia. - **AFAB (Assigned Female at Birth)**: Used to treat acne or hirsutism (excessive hair growth).  **Main Side Effect**: Hyperkalemia (high potassium levels). - works by blocking aldosterone receptors in the distal convoluted tubules in the nephron. That means it will increase the loss of sodium into the urine (and water will follow) and it will decrease the secretion of potassium into the urine, instead keeping it in the body (hence, potassium-sparing) What's the anti-androgen effect? - We use doses like 50mg or 100mg for HTN; more commonly 200-400 mg for anti-androgen effect - Thought to block dihydrotestosterone 🡪 testosterone - Feminization for AMAB (i.e. gynecomastia) - Whereas can treat acne or hirsutism for AFAB - Main SE overall: hyperkalemia as featured heavily on Exam 2 Let's Compare: Too little action of the adrenal cortex!  Addison's Disease - Low aldosterone and cortisol - Main cause: autoimmune - Treatment? To replace the cortisol, often require long term steroid use 🡪 hydrocortisone, one of the steroids that helps increase both aldosterone and cortisol AND/OR fludricortisone (not listed on steroid name slide) is special because it's like synthetic aldosterone Too much action of adrenal cortex! Cushing's Syndrome - High aldosterone and cortisol - Could be from hypersecretion of the adrenal gland, then called Cushing's disease - Or due to long-term steroid use - Treatment? If from steroid use, hopefully we can decrease or stop steroids. If from from Cushing's Disease, almost always try surgical, so we will focus on symptom support. - Symptom Support Steroids - Anti-inflammatory effect for many conditions, already discussed respiratory, can also include allergic reactions, many autoimmune conditions, arthritis, cancer.....so many - MOA: Steroids suppress the inflammatory genes that are turned on during times of chronic inflammation *(for those who want more patho, see notes)* - Patient Education: - Steroids **must** be tapered (increased/decreased gradually) to give body time to adjust, especially for longer term treatment - It's almost impossible to remember which meds are best taken with food and which ones best on empty stomach. But do remember this: if the med causes GI issues, then it's better to take on a full belly. If the med has absorption issues (absorption too variable when taken with food or not well absorbed with food), then it's better to take on an empty stomach. 🡪 For steroids, they cause GI upset, so recommended to take with food - Name the steroids **--(S)ONE (有八個，找出來)** **Side effects of steroids** - Has CNS SE like altered mental status (can be as severe as psychosis \[first sign nightmares\] or causing seizures) - More CNS: mood swings, behavioral changes, sleep disturbances, & psychomotor alterations - Increased risk of infection, can be serious - Poor wound healing - Hyperglycemia - Fluid retention - Muscle wasting - Increased appetite - Weight gain (fluid fluid or appetite) Question (from p.18 )A patient with central diabetes insipidus is prescribed desmopressin (DDAVP). Which of the following instructions should the nurse include in the patient teaching? - Answer question: A patient has been prescribed prednisone for chronic inflammation. Which of the following side effects should the nurse inform the patient to report immediately? Answer How might I ask a thyroid question? (Answer) A client presents with sweating, diarrhea and notable exophthalmos. HR found to be 115 on cardiac monitor. Blood test returns with elevated T4 levels. The nurse anticipates any of the following **except**: this is classic hyperthyroidism A. **Administration of levothyroxine \[Synthroid\]** because this treats hypothyroidism, all the rest are for hyper B. Consultation for thyroidectomy C. Consultation for radioactive iodine D. Administration of methimazole \[Tapazole\]