N5375 Lesson 7 Endocrine_Part II.pptx

Week 7 : Drugs for Endocrine Disorders II N5375: Pharmacology Columbia University School of Nursing Dr. Ana Maria Kelly Summer 2024 1  Drugs for Endocrine Disorders – Textbook Chapters Chapter 61...

Week 7 : Drugs for Endocrine Disorders II N5375: Pharmacology Columbia University School of Nursing Dr. Ana Maria Kelly Summer 2024 1  Drugs for Endocrine Disorders – Textbook Chapters Chapter 61: Drugs for Thyroid Disorders Chapter 62: Drugs related to Hypothalamic and 2 Pituitary Function Chapter 63: Drugs for Disorders of the Adrenal Cortex  Endocrine Study Questions For each hormonal condition, think about what happens when you have too much (hyper-) or too little (hypo-). 1. Part 1: Thyroid hormones and thyroid gland, how do we treat hyperthyroidism – Graves Disease (too much thyroid hormone) vs Hashimoto’s Disease – hypothyroidism (too little thyroid hormone)? A. S/sx of hyper- and hypothyroidism B. Two meds to know: levothyroxine and methimazole C. Think of examples of symptomatic support with all cases 2. Part 2: Antidiuretic hormone (ADH) from the posterior pituitary gland, how do we treat syndrome of inappropriate antidiuretic hormone (SIADH, too much ADH) vs diabetes insipidus (DI, too little ADH)? A. Think about urine output, water retention and sodium levels with these 2 conditions B. Two “meds” to know: desmopressin (DDAVP) and hypertonic 3% saline 3. Part 3: Aldosterone and Cortisol from adrenal gland, how do we treat Cushing’s Disease (high aldosterone and high cortisol) vs Addison’s Disease (low aldosterone and low cortisol)? 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 Chapter 61 Thyroid Hormones Wrapped around trachea, can’t feel it if you touch neck Produce & store thyroid hormones (T3 triiodothyronine and T4 thyroxine) #1 job: metabolism (stimulation of energy use) and #2 cardiac function (stimulation of the heart) and #3 growth and development Iodine is required to produce thyroid hormones, but we are an iodine-sufficient country, so rarely the issue. Instead, the issue comes from 2 autoimmune conditions.  Hyperthyroidism Graves Disease is the most common cause of hyperthyroidism Autoimmune condition Immunoglobins stimulate receptors for thyroid stimulating hormone on thyroid gland, so can ultimately synthesize more hormone Need to know s/sx of hyperthyroidism, for hyperthyroid, think of metabolic processes speeding up 🐇 (for hypothyroidism, think of them slowing down 🐢 ) Try to fill out table on next slide yourself; answers found at end of this presentation. Choices presented in couplets Place these s/sx in correct column: 1a. Weight loss Hypothyroidism Hyperthyroidism 1b. Weight gain 1. 1. 2a. Constipation 2b. Diarrhea 2. 2. 3a. Cold intolerance 3. 3. (with hypothermia) 3b. Heat intolerance 4. 4. (present flushed) 5. 5. 4a. Nervousness/Anxiety 6. 6. 4b. Depression 7. 7. 5a. Dry skin 5b. Sweating 8. 8. 6a. Extreme fatigue 9. Myalgia & weakness 6b. Hyperexcitable 7a. Tachycardia & 10. Impaired memory palpitations 7b. Bradycardia 8a. Exophthalmos 8b. Puffy face Treatment for Hyperthyroidism In most cases, thyroidectomy or radioactive iodine For medical treatment: Methimazole [Tapazole] Meth-IM-a-zole MOA: Inhibits synthesis of thyroid hormone in the thyroid gland How do you know if it’s working? Signs you listed in last slide start to slow down SE: could be extreme hypothyroid signs AND/OR fever, rash, sore throat, jaundice, leukopenia due to agranulocytosis (dangerous!) Agranulocytosis = low neutrophil count ( risk of infection), plus because of impact on bone marrow, could also decrease RBC ( anemia/fatigue), and platelets ( risk of bleeding) Need to check CBC Also check hepatic function, can be hepatotoxic, see next slide FYI: other –mazole drug = carbimazole Also other other drug: propylthiouracil (neither on exam) Pause: Jaundice Sign of hepatic failure or injury Bilirubin normal breakdown product of heme in RBC, processed by liver and excreted through urine & stool Jaundice is bilirubin build up Aways look at sclera!  Hypothyroidism Hashimoto’s Thyroiditis is the most common cause of hypothyroidism Also 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 Note: for all my clever scholars, you will learn about TRH and TSH and the negative feedback loop between hypothalamus, pituitary gland, and the thyroid gland in patho & medsurg; this applies for CRH and ACTH in the adrenal, as well Treatment for Hypothyroidism Levothyroxine [Synthroid] MOA: Synthetic T4 (thyroxine) hormone Admin: PO or IV How do you know it’s working? Speed things up SE: will feel like bad hyperthyroidism, everything sped up: cardiac = tachycardia & palpitations (dysrhythmias & angina more severe); nervousness, can also feel shaky & have trouble sleeping, picture some anxious Need to report s/sx that feel like MI: those more serious cardiac symptoms, sometimes they can even feel SOB  For all the conditions we will discuss today, you can also provide symptomatic treatment. Hyperthyroidism causes tachycardia, so….. How about a beta blocker? Symptomatic Support Hypothyroidism causes depression, so ….. How about an SSRI? Let’s play this game again when we get to the adrenal cortex How might I ask a thyroid question? 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: (answer & rationale at end of presentation) A. Administration of levothyroxine [Synthroid] B. Consultation for thyroidectomy C. Consultation for radioactive iodine D. Administration of methimazole [Tapazole]  Drugs related to Hypothalamic and Pituitary Function Chapter 62  Antidiuretic Hormone (ADH) = Vasopressin Antidiuretic hormone, pay attention to the name anti-diuretic. That means its job is to stimulate water retention through the kidneys (which will raise BP). Why also called vasopressin? Because it also vasoconstricts. (Another BP raiser) Low ADH means you will have more urine (more diuresis) & more dehydration  Diabetes Insipidus High ADH means you will retain more fluid, low urine output & become fluid overloaded  Syndrome of Inappropriate Antidiuretic Diabetes Insipidus (DI) Low ADH How is this related to Diabetes Mellitus? Polyuria and polydipsia Common cause? Damage to pituitary, like brain tumor or accident If pituitary not producing enough ADH, urine levels? Increased, dilute. Which will then cause? Dehydration Could we just administer synthetic ADH until problem solved? Yes! 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) How would we know it’s working? Decreased polyuria and polydipsia, increased specific gravity of urine SE: most dangerous one, water intoxication and hyponatremia  altered mental status & seizures; desmopressin has weak vasopressin effect, so cardio SE not really a problem Patient teaching? See practice Q on next slide A patient with A) "Take the medication with central diabetes meals.” insipidus is prescribed B) "Report any signs of nasal desmopressin congestion or rhinitis.” (DDAVP). Which of the following instructions C) "Expect to urinate more should the frequently.” nurse include in the patient D) "Limit your fluid intake to teaching? avoid water intoxication."  Correct Answer: D) "Limit your fluid intake to avoid water intoxication." Answer Explanation: Desmopressin reduces urine output by increasing water reabsorption in the kidneys. Patients should be instructed to limit fluid intake to avoid water intoxication and hyponatremia. Flip side of DI is SIADH Too much ADH Why? Similar to DI in that something impacts the hypothalamus or pituitary, but in this case, causes over-secretion, could also be a tumor What are the s/sx SIADH? Same as the dangerous SE of DDAVP on slide 17  Water intoxication and hyponatremia Should they be on fluid restriction? Treatment? Not going to focus on drug, instead they need hypertonic, 3% NaCl fluid Fluids Drugs for Disorders of the Adrenal Cortex Chapter 63 Hormones of the Adrenal Cortex Mineralcorticoid = Aldosterone Glucocorticoid = Cortisol Where have we heard of Name because they aldosterone before? RAAS increase the availability of What does aldosterone glucose do? Promotes sodium Often called stress reabsorption in exchange hormone, need fast sugar for potassium secretion source during times of emotional or physical stress (ie, injury, infection)  Spironolactone Revisited Spironolactone [Aldactone] 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 Too much action of adrenal cortex! Addison’s Disease cortex! Cushing’s Syndrome Low aldosterone and cortisol High aldosterone and cortisol Main cause: autoimmune Could be from hypersecretion Treatment? To replace the of the adrenal gland, then cortisol, often require long term called Cushing’s disease steroid use  hydrocortisone, Or due to long-term steroid use one of the steroids that helps increase both aldosterone and Treatment? If from steroid use, cortisol AND/OR fludricortisone hopefully we can decrease or (not listed on steroid name stop steroids. If from from slide) is special because it’s Cushing’s Disease, almost like synthetic aldosterone always try surgical, so we will focus on symptom support. Symptom Support What kind of support will someone with Addison’s need? Tx for hypoglycemia, consider D5NS instead of NS, maybe D50 in highly acute situation Tx for hypotension, fluid will help with this, as well What kind of support will someone with Cushing’s need? Tx for hyperglycemia, like insulin or metformin Tx for fluid retention, like diuretic Tx for high BP, diuretic could also help with this or BB, CCB  Re-visit 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 Name the steroids –(S)ONE Methylprednisolo Prednisone Prednisolone Beclomethasone ne Dexamethasone Hydrocortisone Cortisone Fluticasone  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) Let’s finish with a question: A patient has been A. Weight gain prescribed prednisone for chronic B. Increased inflammation. Which of the appetite following side effects should C. Signs of the nurse inform infection the patient to report D. Mood swings immediately?  Correct Answer: C) Signs of infection Answer Explanation: Prednisone, a corticosteroid, suppresses the immune system, increasing the risk of infections. Patients should be instructed to report any signs of infection (e.g., fever, sore throat) immediately.  Hypothyroidism Hyperthyroidism 1. Weight gain 1. Weight loss 2. Constipation 2. Diarrhea 3. Cold intolerance 3. Heat intolerance (with hypothermia) (present flushed) 4. Depression 4. ANSWERS 5. Dry skin Nervousness/Anxiety 6. Extreme fatigue 5. Sweating Just for interest: Amenorrhea (both) 7. Bradycardia 6. Hyperexcitable Thinning or brittle 7. Tachycardia & hair (both) 8. Puffy face Palpitations 9. Myalgia & weakness 8. Exophthalmos 10. Impaired memory 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]