6024 M12 Study Guide - Endocrine Drugs PDF

6024 M12 Study Guide Endocrine Drugs Page 1 of 4 Thyroid Exemplar Drugs Name Indication(s) Side Effects Patient Education Take 1st thing in morning on empty stomach (30-60 mins before food, drink, or other meds). levothyroxine (Synthroid) Hypothyroidism Hyperthyroidism liothyronine (Triost...

6024 M12 Study Guide Endocrine Drugs Page 1 of 4 Thyroid Exemplar Drugs Name Indication(s) Side Effects Patient Education Take 1st thing in morning on empty stomach (30-60 mins before food, drink, or other meds). levothyroxine (Synthroid) Hypothyroidism Hyperthyroidism liothyronine (Triostat) Hypothyroidism Hyperthyroidism - Methimazole (Northyx) Hyperthyroidism Hypothyroidism - propylthiouracil (PTU) Hyperthyroidism Hypothyroidism - Radioactive iodine (Iodine-131) Hyperthyroidism Certain thyroid cancers Hypothyroidism Generally well tolerated. Resolution may take a few weeks to several months. Notes TSH every 6 weeks BBW: not for weight loss Synthetic T3 More common than PTU. Avoid in 1st trimester of pregnancy Use in 1st trimester of pregnancy See last question below Thyroid Study Questions • • • • • • • • • • Which type of thyroid therapy is recommended in most guidelines for adults with primary hypothyroidism? o Levothyroxine What are some considerations of prescribing brand vs generic levothyroxine? o Bioequivalence: generic or name brand is acceptable, but do NOT change HRT unless required What are some considerations for selecting an initial dose of levothyroxine, such as for a young, healthy patient vs an older patient or patient with cardiovascular disease? o Young, healthy patient may use standard starting dose considerations (e.g., 50 mcg) o Older patient (60+) may start with ½ of normally anticipated dose (e.g., 25 mcg) o CVD patient may start with ½ of normally anticipated dose (e.g., 25 mcg) o Weight-based model: 1.6 mcg/kg ideal body weight ▪ Ideal body weight = weight per height aligned with 24-25 BMI ▪ T4 requirements better correlated to lean body mass than total body weight o Serum TSH model: starting dose is based on serum TSH lab results ▪ TSH = 4 – 8 → 25 mcg ▪ TSH = 8 – 12 → 50 mcg ▪ TSH = 13+ → 75 mcg How is dosing of levothyroxine influenced by its categorization as a narrow therapeutic index drug? o Therapeutic index: narrow, so start low and use small dose increases (e.g., 12.5 mcg) to titrate What are some reasons you would anticipate a dose increase? o Pregnancy, weight gain (>10% of body weight), estrogen therapy (and maybe oral contraceptives) What are some substances that can affect absorption of levothyroxine? o Bile acid sequestrants, calcium carbonate, ferrous sulfate, GI meds, ion exchange resins, orlistat For hyperthyroidism, what are the drugs that treat symptoms, vs treatment of the underlying cause of the condition? o Treat symptoms: beta blockers (atenolol) o Treat condition: thionamide (methimazole, propylthiouracil), radioactive iodine, surgery When are thionamides used? o Hyperthyroidism What are two rare, but serious potential adverse effects of thionamide drugs, such as PTU and methimazole? o Agranulocytosis, hepatotoxicity, vasculitis What is radioactive iodine and why might it be used? o RAI treats hyperthyroidism by damaging or destroying thyroid cells through radiation. Usually, a single oral capsule is taken that targets thyroid cells with little exposure to other body cells. o RIA may be used when: ▪ medication management failed ▪ planned pregnancy (1-2 years prior to pregnancy to avoid thionamide during pregnancy) 6024 M12 Study Guide Endocrine Drugs Page 2 of 4 Osteoporosis Name Considerations Side Effects Monitoring Antiresorptive Therapies [depress osteoclasts and diminish resorption of bone] PO wkly or mnthly Esophagitis is the alendronate principal concern (p. st (bisphosphonate) 1 line (alendronate) Renal function 546), hypocalcemia, Calcium GI upset, atypical Tx may be Vitamin D risendronate femur fraction continuous or with (bisphosphonate) (related to long use) holidays The most common IV once yearly reaction is transient Calcium zoledronic acid fever with flu-like Phosphorus May be given if PO (bisphosphonate) symptoms (p. 548). Magnesium options above are not ONJ mostly seem (p. 548) well tolerated with IV administration SubQ every 6 mnths Hypocalcemia, ONJ, Calcium denosumab pain, infection, Creatinine (RANK ligand Alternative Tx vertebral fractures Magnesium inhibitor) Lifelong use after stopping (p. 553) raloxifene PO daily (selective estrogen DXA every 1-2 years BBW: DVT and PE receptor modulators Mammogram yearly Alternative for women (SERM)) Anabolic Therapies [stimulate bone formation and activate bone remodeling] SubQ daily teriparatide (parathyroid hormone analog) abaloparatide (parathyroid hormone analog) Tx: 18-24 months Severe OP and failed other treatments SubQ daily Hypercalcemia, calciuria (transient) BBW: osteosarcoma Uric acid levels, hypercalcemia, and erythema (p. 552) BBW: osteosarcoma If back pain reported, monitor for vertebral fractures. Monitor for signs and symptoms of kidney stones d/t hypercalcemia (p. 552). romosozumab SubQ monthly Dental exam and BBW: MI, stroke, (monoclonal anticalcium at baseline CVA death sclerostin antibody) Tx: 12 months (epocrates) Supplementation [supplementation is standard part of treatment regimen] Calcium PO daily PO daily Vitamin D VD3 - cholecalciferol (recommended) VD2 - ergocalciferol Name Considerations nephrolithiasis, dyspepsia, constipation, CVA Hypervitaminosis (syndrome characterized by hypercalcemia, hypercalciuria, decalcification of bone, and deposition of calcium in soft tissues (p. 543). Side Effects Vitamin D 25(OH) and serum calcium must be normal before starting therapy and monitored throughout therapy. Monitoring Patient Education Take on empty stomach, sit upright for 30 minutes, and no food or drink during 30-minute wait Bisphosphonates impair perfusion by inhibiting growth of blood vessels → osteonecrosis of the jaw (p. 548) Associated with fractures if stopped, if started then Tx is lifelong with this Rx Can cause weight gain Requires special storage Ensure adequate vit D and calcium intake Ensure adequate vit D and calcium intake No specific data found Take calcium carbonate with meals and calcium citrate fasted. Swallow oral preparations intact, without crushing or chewing (p. 543). Patient Education 6024 M12 Study Guide Endocrine Drugs Page 3 of 4 Hormones Study Questions Section 1: Contraception Therapy • What are some potential adverse effects and contraindications for oral and transdermal estrogens and progestins? o Contraindications: Women with hypertension (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg as per the CDC), breast cancer, known ischemic heart disease, migraines with auras, endometrial cancer, cirrhosis, hepatocellular adenoma, or malignant hepatoma are contraindicated to use combined hormone contraceptive pill (NIH: https://www.ncbi.nlm.nih.gov/books/NBK430882) o Adverse effects: ACHES Table of AEs • When might an oral progestin only option be selected over an oral combined hormonal contraceptive? o Patients with medical conditions in which estrogen is not recommended • What are important considerations with oral progestin only contraceptives? o Risk of ectopic pregnancy o Decreased efficacy when compared to combined products o Possible amenorrhea o Strict 3-hour window daily dosing • What are general considerations for administration of DMPA, Depo Provera? Potential adverse effects? o Depot medroxyprogesterone acetate (DMPA) ▪ Depo-Provera (150 mg IM Q12 weeks) OR Depo-SubQ (104 mg subQ Q12 weeks) ▪ Considerations: prevents ovulation; added benefits in sickle cell, seizures, endometriosis pain; continue use >2 years only if other methods are inappropriate; recommend calcium and vitamin D supplementation and weight-bearing exercise ▪ AEs: menstrual irregularities, weight gain, short-term bone loss, delayed return to fertility; increased risk of osteoporosis • What are examples of LARCs? What is the duration of use of the different options? o Long-acting Reversible Contraceptive (LARC): IUDs and implants ▪ Hormonal IUDs ▪ Non-hormonal IUDs: ParaGard – effective for 10 years 6024 M12 Study Guide Endocrine Drugs Page 4 of 4 Section 2: Hormone Replacement Therapy (HRT) • For menopause hormone therapy (MHT), when must progesterone be administered with an estrogen? Why? o When: women with uterus o Why: progestin is present for one reason only: to counterbalance estrogen-mediated stimulation of the endometrium, which can lead to endometrial hyperplasia and cancer (p. 431). • What are contraindications for oral and transdermal hormone therapy in menopause? o Personal or family history of breast cancer and/or cardiovascular disease (p. 432). • What hormone therapy is scheduled/controlled? o All formulations of testosterone are Schedule III Controlled Substances • What are potential adverse effects of testosterone? o Fluid and sodium retention o Worsening of BPH symptoms, increased PSA levels o Decrease HDL o Decrease blood glucose o Induction or worsening of sleep apnea o Gynecomastia o Acne, male pattern baldness o Infertility – impairs spermatogenesis by suppressing pituitary gonadotropin secretion o Progression of hormone-dependent prostate and breast cancer o May increase CV risk o Increased hematocrit → risk of blood clots • What baseline data, monitoring, and contraindications are noted for androgens in the textbook (Rosenthal & Burchum, Ch. 52, p. 452)? o Baseline Data: Serum testosterone concentration, complete blood count (CBC), lipid panel, liver function, prostate specific antigen (PSA). o Monitoring: Serum testosterone concentration, lipids, liver function, and PSA after 1 year (refer to urologist for evaluation if PSA is greater than 4.0 ng/mL or greater than 1.4 ng/mL above baseline) o Identifying High-Risk Patients: Androgens are contraindicated for pregnant women, for men who have prostate cancer or breast cancer, and for enhancing athletic performance.