Endocrine Medications NUR 2303 Class Slides PDF

Endocrine Medications NUR 2303 – Week 7 Housekeeping Midterm follow-up Content remainder of semester Endocrine System Maintenance of physiological stability Communicates using chemicals called hormones Hormones regulated by a negative feedback loop Chapter 31 Pituitary Drugs Glossary Neg...

Endocrine Medications NUR 2303 – Week 7 Housekeeping Midterm follow-up Content remainder of semester Endocrine System Maintenance of physiological stability Communicates using chemicals called hormones Hormones regulated by a negative feedback loop Chapter 31 Pituitary Drugs Glossary Negative Feedback Loop Thyroid Stimulating Hormone (TSH) Tyroxine (T4) Diabetic Ketoacidosis (DKA) Hemoglobin A1C (HbA1C) Polydipsia Polyphagia Polyuria Hypothalamic-pituitary-adrenal (HPA) axis Neuroendocrine System Regulates reactions to stimuli Integrated activities of the endocrine glands and nervous system Hypothalamus Part of the central nervous system Pituitary gland Anterior pituitary (adenohypophysis) Posterior pituitary (neurohypophysis) Together they govern all bodily functions Hormones Negative feedback loop Pituitary Drugs Anterior pituitary drugs Mechanism of Action Differs depending on the cosyntropin somatropin drug menotropin Either augments or bromocriptine mesylate antagonizes the natural thyrotropin alfa effects of the pituitary hormones Posterior pituitary drugs Table 31.1 Page 521 vasopressin desmopressin acetate Anterior Pituitary Octreotide (Somatostatin®) Carcinoid tumours secrete VIP (vasoactive intestinal polypeptide). VIP causes profuse, watery diarrhea. Octreotide reduces this severe diarrhea, flushing, and potentially life- threatening hypotension that may occur with a carcinoid crisis. Somatropin and Somatrem Recombinantly made growth hormone (GH) Stimulate skeletal growth in patients with deficient growth hormone, such as in hypopituitary dwarfism Posterior: Vasopressin Mimics the action of antidiuretic hormone (ADH) Increase water resorption in the distal tubules and collecting ducts of the nephrons, and concentrate urine, reducing water excretion by up to 90% Used in the treatment of diabetes insipidus Potent vasoconstrictor Hypotensive emergencies such as vasodilatory shock (septic shock) Advanced Cardiac Life Support (ACLS): pulseless cardiac arrest. Also used to stop bleeding of esophageal varices Posterior: Desmopressin Synthetic form of vasopressin (has similar ADH functions) 10x the ADH ability, very little vasoconstriction Available in many forms (spray, SL, injection, tablets) Dose-dependent increase in the plasma levels of factor VIII (antihemophilic factor), von Willebrand factor (acts closely with factor VIII), and tissue plasminogen activator Management of nocturnal enuresis  Question A patient will be receiving somatropin. The nurse expects that the patient has which disorder? A. Adrenocortical insufficiency B. Hypopituitary dwarfism C. Esophageal varices D. Septic shock This Photo by Unknown Author is licensed under CC BY-SA Nursing Implications Obtain thorough nursing assessment and medication history. Assess for contraindications specific to each drug. Assess medication history for possible interactions. Adverse effects-Specific to the individual drugs octreotide acetate: see Table 31-2 desmopressin and vasopressin: see Table 31-3 somatropin: see Table 31-4 Nursing Implications Provide specific instructions for nasal spray forms of desmopressin. Rotate injection sites. Do not discontinue drugs abruptly. Do not have patient take over-the-counter products without checking with health care provider. Parents of children who are receiving growth hormones should keep a journal reflecting the child’s growth.  Question Which effect does the nurse expect to see in a patient receiving hydrocortisone (Solu-Cortef®)? A. Increase in inflammatory leukocyte function B. Reduction of scar tissue formation C. Renal excretion of sodium D. Hypotension This Photo by Unknown Author is licensed under CC BY-SA Question A patient is in pulseless cardiac arrest. Which medication does the nurse anticipate administering? A. vasopressin B. desmopressin C. cosyntropin D. somatropin Chapter 32 Thyroid and Antithyroid Drugs Thyroid Gland This Photo by Unknown Author is licensed under CC BY-SA Thyroid Gland Secretes three hormones essential for proper regulation of metabolism (Thyroxine (T4), Tri-iodothyronine (T3), Calcitonin) Controls rates of protein, CHO and lipid metabolism Increase O2 consumption and body temp Increase blood volume, cell growth and differentiation Increase number of β-adrenergic receptors Increase blood flow to kidney and GFR which increases diuresis Hypothyroidism (Slow Metabolic Rate) Congenital hypothyroidism Hyposecretion of thyroid hormone during infancy and childhood Low metabolic rate, short stature, severely delayed sexual development, possible intellectual disabilities Myxedema Hyposecretion of thyroid hormone during adulthood Decreased metabolic rate, loss of mental and physical stamina, weight gain, loss of hair, firm edema, yellow dullness of the skin Goiter Enlargement of the thyroid gland Results from overstimulation by elevated levels of thyroid-stimulating hormone (TSH) TSH is elevated because there is little or no thyroid hormone in circulation. Thyroid Replacement Drugs levothyroxine (Synthroid®, Eltroxin®, Euthyrox®) Synthetic thyroid hormone T4 liothyronine (Cytomel®) Synthetic thyroid hormone T3 Desiccated thyroid (Thyroid®) Natural thyroid hormone T3 and T4 MOA: same as endogenous (natural) thyroid hormones that your body produces  Question A patient has been taking levothyroxine for 6 months. After this month’s laboratory work, the nurse practitioner tells the nurse that the patient is “euthyroid.” What does that term mean? A. The patient is experiencing hyperthyroidism. B. The patient is experiencing hypothyroidism. C. The patient’s thyroid hormone levels are within normal limits. D. The patient’s thyroid hormone levels are still fluctuating. This Photo by Unknown Author is licensed under CC BY-SA Indications & Adverse Effects Replacement hormonal therapy for patients whose thyroid glands have been surgically removed or destroyed (ablation) Hypothyroidism of pregnancy Cardiac dysrhythmia is the most significant adverse effect. May also cause: Tachycardia, palpitations, angina, dysrhythmias, hypertension, insomnia, tremors, headache, anxiety, nausea, diarrhea, cramps, menstrual irregularities, weight loss, sweating, heat intolerance, fever Nursing Implications Assess for drug allergies, contraindications, and drug interactions. Obtain baseline vital signs and weight. Cautious use with cardiac disease, hypertension, pregnancy. During pregnancy, Tx for hypothyroidism should continue. Fetal growth may be retarded if maternal hypothyroidism is untreated during pregnancy. Adjust dosage every 4 weeks to keep thyroid-stimulating hormone at the lower end of the normal range. Nursing Implications Teach patients to take thyroid drugs once daily in the morning to decrease the likelihood of insomnia if taken later in the day. Teach patients to take the medications at the same time every day and not to switch brands without primary care provider approval. Teach patients the importance of alerting health care providers of thyroid medication use. May enhance activity of anticoagulants Patients with diabetes may need increased dosages of hypoglycemic medications. May decrease serum digoxin levels Nursing Implications Teach patients to report any unusual symptoms, chest pain, or heart palpitations. Teach patients not to take over-the-counter medications or herbal remedies without primary care provider approval. Teach patients that therapeutic effects may take several weeks to occur. Question The nurse is told by a patient who is taking a thyroid replacement medication that the patient is starting to experience cold intolerance, depression, and brittle nails and is tired all of the time. The nurse anticipates that these manifestations are caused by A. inadequate doses of the medication. B. possible overdose of the medication. C. worsening of the underlying disease. D. drug interactions with another medication.  Question Which information will the nurse include when teaching a patient about thyroid replacement therapy? A. “Take the medication before bed.” B. “You will experience beneficial effects of the drug after 1 week of treatment.” C. “Stop taking the drug if you experience insomnia.” D. “Take the medication on an empty stomach.” This Photo by Unknown Author is licensed under CC BY Hyperthyroidism (Increased metabolic rate) Caused by several diseases Diarrhea Graves’ disease Flushing Increased appetite Multinodular disease Muscle weakness Plummer’s disease (rare) Sleep disorders Also called toxic nodular disease Altered menstrual flow Thyroid storm (induced by Fatigue stress or infection) Palpitations Severe and potentially life Nervousness threatening Heat intolerance Irritability Treatment of Hyperthyroidism “Ablation” (I131): works by destroying the thyroid gland Surgery to remove all or part of the thyroid gland Lifelong thyroid hormone replacement will be needed. Antithyroid drugs: thioamide derivatives thiamazole (Tapazole®) propylthiouracil Potassium iodine Nursing Implications Better tolerated when given with food Give at the same time each day to maintain consistent blood levels. Never stop these medications abruptly. Avoid the consumption of foods high in iodine (seafood, soy sauce, tofu, iodized salt). Monitor therapeutic response. No further evidence of hyperthyroidism Watch for and monitor adverse effects. Leukopenia (manifested as fever, sore throat, lesions) Question Which would be the best menu choice for a patient who is taking an antithyroid medication? A. A seafood platter B. Sushi C. Tofu burger D. Pasta with marinara sauce Chapter 33 Antidiabetic Drugs The Pancreas Understanding Diabetes Diabetes Mellitus Elevated fasting blood glucose (higher than 7 mmol/L) or a hemoglobin A1c (HbA1c) level greater than or equal to 6.5% Signs and symptoms Polyuria Polydipsia Polyphagia Glycosuria Weight loss Fatigue Blurred vision Type 1 Diabetes Lack of insulin production, or production of defective insulin Affected patients need exogenous insulin. Fewer than 10% of all cases are type 1. Complications Diabetic ketoacidosis Hyperosmolar hyperglycemic state Type 2 Diabetes Most common type (90% of all cases) Caused by insulin deficiency and insulin resistance Many tissues are resistant to insulin. Reduced number of insulin receptors Insulin receptors less responsive Type 2 Diabetes Several comorbid conditions Obesity Coronary heart disease Dyslipidemia Hypertension Microalbuminemia (protein in the urine) Increased risk for thrombotic (blood clotting) events Comorbidities are collectively referred to as metabolic syndrome or cardiometabolic syndrome. Gestational Diabetes  Hyperglycemia that develops during pregnancy  Insulin must be given to prevent birth defects.  Usually subsides after delivery  30% of patients develop type 2 diabetes within 10 to 15 years. Long-Term Complications Macrovascular (atherosclerotic plaque) Coronary arteries Cerebral arteries Peripheral vessels Microvascular (capillary damage) Retinopathy Neuropathy Nephropathy Nonpharmacological Treatment Type 2: Weight loss Improved dietary habits Smoking cessation Reduced alcohol consumption Regular physical acitivty Glycemic Goal of Treatment HbA1c of less than 7% Fasting blood glucose goal for diabetic patients: 4 to 7 mmol/L 2-hour postprandial target of 5 to 10 mmol/L Types of Antidiabetic Drugs Oral Hypoglycemic Insulin Drugs A combination of oral antihyperglycemic and insulin controls glucose levels. Some new injectable hypoglycemic drugs may be used in addition to insulin or antidiabetic drugs. Insulins Substitute for the endogenous hormone Effects are the same as those of endogenous insulin Restores the diabetic patient’s ability to: Metabolize carbohydrates, fats, and proteins Store glucose in the liver Convert glycogen to fat stores Human insulin Derived using recombinant deoxyribonucleic acid (DNA) technologies Recombinant insulin produced by bacteria and yeast Goal: tight glucose control To reduce the incidence of long-term complications Rapid-Acting Insulin Most rapid onset of action (10 to 15 minutes) Peak: 1 to 2 hours Duration: 3 to 5 hours Patient must eat a meal after injection Insulin lispro (Humalog®) Action similar to that of endogenous insulin Insulin aspart (NovoRapid®) Insulin glulisine (Apidra®) May be given subcutaneously or via continuous subcutaneous infusion pump (but not intravenously)  Question The nurse has just administered the morning dose of a patient’s insulin lispro. Just after the injection, the dietary department calls to inform the patient care unit that breakfast trays will be 45 minutes late. What will the nurse do next? A. Inform the patient of the delay. B. Check the patient’s blood glucose levels. C. Call the dietary department to send a tray immediately. D. Give the patient food, such as cereal, and skim milk and juice. This Photo by Unknown Author is licensed under CC BY-SA-NC Short-Acting Insulins Regular insulin (Humulin R®, Novolin ge Toronto®) Routes of administration: intravenous (IV) bolus, IV infusion, intramuscular, subcutaneous Clear in appearance Onset (subcutaneous route): 30 minutes Peak (subcutaneous route): 2 to 3 hours Duration (subcutaneous route): 6.5 hours Intermediate-Acting Insulins Insulin isophane suspension (also called NPH) Cloudy appearance Often combined with regular insulin Onset: 1 to 3 hours Peak: 5 to 8 hours Duration: up to 18 hours Long-Acting Insulins Insulin glargine (Lantus®) or detemir (Levemir) Clear, colourless solution Constant level of insulin in the body Usually dosed once daily Can be dosed every 12 hours Referred to as basal insulin Onset: 90 minutes Peak: none Duration: 24 hours Question 2 A patient with type 1 diabetes is admitted to the medical unit with an acute exacerbation of chronic obstructive pulmonary disease. The patient is placed on IV piggyback antibiotics, nebulizer treatments with albuterol, and an IV corticosteroid, and is also taking a proton pump inhibitor for gastroesophageal reflux disease. The patient takes a dose of glargine insulin every evening. This evening the nurse notes that the patient’s blood glucose level is 9.4 mmol/L. The next morning, the fasting glucose level is 11.2 mmol/L. What is the most likely cause of the elevated glucose levels? A. albuterol B. Antibiotics C. Proton pump inhibitor D. Corticosteroid Fixed-Combination Insulins Humulin 30/70 Novolin 30/70, 40/60, 50/50 NovoMix® 30 Humalog Mix25® Humalog Mix50® Each contains two different insulins, fixed combinations One intermediate-acting type and.. Either one rapid-acting type (Humalog, NovoLog) or one short-acting type (Humulin) Sliding-Scale Insulin Dosing Subcutaneous rapid-acting (lispro or aspart) or short-acting (regular) insulins are adjusted according to blood glucose test results. Typically used in hospitalized diabetic patients or those on total parenteral nutrition or enteral tube feedings SC insulin is given in an amount that increases as the bld glucose increases. Disadvantage: Delays insulin administration until hyperglycemia occurs, resulting in large swings in glucose control. Recent research does not support sliding-scale use; nonetheless, sliding scale is still commonly used. Basal-Bolus Insulin Dosing Preferred method of treatment for hospitalized patients with diabetes Mimics a healthy pancreas -delivers insulin constantly as a basal and then as needed as a bolus Basal insulin is a long-acting insulin (insulin glargine). Bolus insulin (insulin lispro or insulin aspart) Nursing Implications: Insulin Check blood glucose level before giving insulin. To mix suspensions, roll vials between hands instead of shaking Ensure correct storage of insulin vials. Only use insulin syringes, calibrated in units Ensure correct timing of insulin dose with meals. Insulin order and prepared dosages are second-checked with another registered nurse (or per agency policy). When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting (clear) insulin first. Type 2 Diabetes Treatment Protocol Lifestyle interventions Oral biguanide - metformin If lifestyle modifications + max tolerated metformin dose do not achieve the recommended A1c goals after 3 to 6 months - add dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagonlike peptide 1 (GLP-1) receptor agonists (exenatide, semaglutide) or insulin. Biguanide: Metformin (Glucophage) First-line drug, most common oral med for type 2 DM MOA: ↓ hepatic glucose production, ↑ insulin sensitivity Indications Contraindications: kidney disfunction, renal disease Adverse effects Abdominal bloating, nausea, cramping, a feeling of fullness, and diarrhea Metallic taste, hypoglycemia, and a reduction in vitamin B 12 levels after long-term use Lactic acidosis is an extremely rare complication. Sulfonylureas Second generation: glimepiride (Amaryl), gliclazide (Diamicron), glyburide (DiaBeta) MOA: stimulates β-cells to release insulin, ↓ secretion of glucagon Indications: adjunct to metformin Contraindications: recurrent hypoglycemia Adverse effects: hypoglycemia, weight gain, skin rash, nausea, epigastric fullness, and heartburn Injectable Antidiabetic Drugs: MOA Amylin agonist - pramlintide (Symlin®) Mimics the natural hormone amylin Slows gastric emptying Suppresses glucagon secretion, reducing hepatic glucose output Used when other drugs have not achieved adequate glucose control Subcutaneous injection Nausea, vomiting, anorexia, headache Injectable Antidiabetic Drugs: MOA Incretin mimetic - exenatide (Byetta®), semaglutide (Ozempic) AKA: glucagon-like peptide 1 (GLP-1) receptor agonists Mimics the incretin hormones Enhances glucose-driven insulin secretion from β cells of the pancreas Used only for type 2 diabetes Injection pen device Nausea, vomiting, and diarrhea Rare cases of hemorrhagic or necrotizing pancreatitis Weight loss  Glinides and Thiazolidinediones Glinides Thiazolidinediones “Glitazones” repaglinide (GlucoNorm®) pioglitazone (Actos®) nateglinide (Starlix®) rosiglitazone (Avandia®) Same MOA as sulfonylureas Insulin-sensitizing drugs Shorter DOA, must be given at each Inhibit glucose production meal Preserve β cell function Cause weight gain  α-Glucosidase & DPP – 4 Inhibitors α-Glucosidase inhibitors DPP – 4 Inhibitors “Gliptins” Delays glucose absorption in (Dipeptidyl Peptidase 4) the intestine Delay the breakdown of incretin GI upset Reduces fasting and postprandial acarbose (Glucobay) glucose sitagliptin (Januvia®) saxagliptin (Onglyza®) linagliptin (Tradjenta®) alogliptin (Nesina®) Sodium Glucose Cotransporter 2 Inhibitors Causes an increase in renal glucose excretion. This inhibitor is a newer class of oral drugs for the treatment of type 2DM canaglifozin (Invokana®), dapaglifozin (Forxiga®), empagliflozin (Jardiance) MOA: work independently of insulin to prevent glucose reabsorption from the glomerular filtrate, resulting in a reduced renal threshold for glucose and glycosuria Weight loss and reduced SBP Question The patient was taking metformin before this hospitalization. To facilitate better glucose control, the patient has been switched to insulin therapy while hospitalized. The patient asks the nurse why it is so important to time meals with the insulin injection and also asks for an example of a long-acting insulin. Which drug will the nurse tell the patient is a long- acting insulin? A. Insulin glulisine (Apidra®) B. Insulin isophane suspension (NPH) C. Insulin detemir (Levemir®) D. Regular insulin (Humulin R) DM: Nursing Implications Thorough patient education is essential regarding: Disease process Diet and exercise recommendations Self-administration of insulin or oral drugs Potential complications Glucose changes: When under stress When pregnant or lactating With infection, illness or trauma Nursing Implications Before giving drugs that alter glucose levels, obtain and document: A thorough history and vital signs Blood glucose levels, HbA1c level Potential complications and drug interactions Assess the patient’s ability to consume food, nausea or vomiting If a patient is to take nothing by mouth (NPO) for a test or procedure, consult the primary provider to clarify orders Nursing Implications Oral antidiabetic drugs Always check blood glucose levels before administering. Usually given 30 minutes before meals α-Glucosidase inhibitors are given with the first bite of each main meal. Metformin is taken with meals to reduce gastrointestinal effects. Monitor therapeutic response. Decrease in blood glucose levels to the level prescribed by physician Measure HbA1c to monitor long-term compliance with diet and drug therapy. Watch for and monitor hypoglycemia and hyperglycemia. Nursing Implications Assess for signs of hypoglycemia. If hypoglycemia occurs: Administer oral form of glucose if the patient is conscious. Give the patient glucose tablets, liquid, or gel; corn syrup; honey; fruit juice or nondiet soft drink; or have the patient eat a small snack, such as crackers or a half sandwich. Deliver D50W or IV glucagon if the patient is unconscious. Monitor blood glucose levels. Question After the 0700-hours report, the day shift nurse notices that a patient has a dose of insulin due at 0730 hours and goes to the automated dispensing machine to retrieve the insulin. The nurse sees that the night shift nurse removed the 0730-hours dose of insulin, but the medication administration record has not been signed by the nurse. The patient is confused and “thinks” the night nurse administered the insulin. The patient’s blood glucose level is 7.9 mmol/L. What will the day shift nurse do? A. Give the insulin because it was not signed off. B. Hold the insulin because the patient thinks it was administered, and it is recorded in the machine. C. Ask the charge nurse to call the night nurse at home to clarify whether the insulin was given. D. Report this to the nursing supervisor.  Question A male patient who has a history of type 2 diabetes is admitted to the medical unit with a diagnosis of pneumonia. The patient has many questions regarding care and asks the nurse why everyone keeps talking about hemoglobin A1c (HbA1c). The nurse will inform the patient that HbA1c provides information about A. which type of diabetes the patient has. B. whether the patient has an infection. C. their adherence to the treatment regimen for several months previously. D. the patient’s current fasting blood glucose level. This Photo by Unknown Author is licensed under CC BY Hypoglycemia Abnormally low blood glucose level (below 4 mmol/L) Adrenergic Anxiety, tremors, sensation of hunger, palpitations, sweating Central nervous system Difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, dizziness and headache Later signs Hypothermia, seizures Coma and death will occur if not treated Glucose-Elevating Drugs Oral forms of concentrated glucose Gel, liquid, or tablet form 50% dextrose in water (D50W) Glucagon  Question The nurse enters the patient’s room to complete the discharge process and finds the patient lying in bed unresponsive and breathing. The patient has a blood glucose reading of 2.7 mmol/L. What is the most appropriate response by the nurse? A. Place a packet of table sugar in the patient’s mouth. B. Start cardiopulmonary resuscitation (CPR). C. Roll the patient onto his or her side and administer the ordered glucagon. D. Have the patient drink orange juice. This Photo by Unknown Author is licensed under CC BY-SA-NC Chapter 34 Adrenal Drugs Adrenal System This Photo by Unknown Author is licensed under CC BY Adrenal Gland Adrenal medulla secretes catecholamines Epinephrine Norepinephrine Adrenal cortex secretes corticosteroids. Glucocorticoids Mineralocorticoids (primarily aldosterone) Oversecretion leads to Cushing’s syndrome Undersecretion leads to Addison’s disease Glucocorticoids In the body natural betamethasone glucocorticoids: cortisone Secrete adrenocorticotropic hormone (ACTH) dexamethasone Anti-inflammatory actions hydrocortisone CHO, protein, lipid metabolism methylprednisolone Maintenance of normal BP Stress effects prednisolone triamcinolone Mechanism of Action Most corticosteroids work by modifying enzyme activity. Glucocorticoids differ in their potency, duration of action, and the extent to which they cause salt and fluid retention. Glucocorticoids inhibit or help control inflammatory and immune responses. Indications Adrenocortical deficiency Adrenogenital syndrome Allergic disorders Autoimmune blistering diseases Bacterial meningitis Cancer Cerebral edema Collagen diseases (e.g., systemic lupus erythematosus) Indications Dermatological diseases (e.g., exfoliative dermatitis, pemphigus) Endocrine disorders (thyroiditis) Gastrointestinal diseases (e.g., ulcerative colitis, regional enteritis) Exacerbations of chronic respiratory illnesses such as asthma and chronic obstructive pulmonary disease Hematological disorders (reduction of bleeding tendencies) Indications Nonrheumatic inflammation Ophthalmic disorders Organ transplantation (prevent organ rejection) Leukemias and lymphomas (palliative management) Nephrotic syndrome (remission of proteinuria) Spinal cord injury Rheumatic disorders: rheumatoid arthritis, psoriatic arthritis, acute gouty arthritis, ankylosing spondylitis (adjunctive therapy) Adverse Effects: CV and CNS Heart failure, cardiac edema, hypertension—all caused by electrolyte imbalances (hypokalemia, hypernatremia), impaired glucose tolerance, dysrhythmias, bradycardia, pulmonary edema, syncope, vasculitis Convulsions, headache, vertigo, mood swings, nervousness, aggressive behaviours, psychotic symptoms, neuritis, peripheral neuropathy, paresthesia, arachnoiditis, meningitis, insomnia Adverse Effects: Endocrine & GI Growth suppression, Cushing’s syndrome, menstrual irregularities, CHO intolerance, hyperglycemia, hypothalamic– pituitary–adrenal axis suppression, hirsutism, hypertrichosis, glycosuria Peptic ulcers, pancreatitis, ulcerative esophagitis, abdominal distension Adverse Effects: Skin, MSK, Eyes Fragile skin, petechiae, ecchymosis, facial erythema, poor wound healing, urticarial, hypersensitivity reactions, acne, dry skin, skin hyperpigmentation, skin striae Myopathy, muscle weakness, loss of muscle mass, osteoporosis, osteonecrosis of femoral and humeral heads, pathological fracture, malaise Ocular system: increased intraocular pressure, glaucoma, cataracts Other: weight gain, leukocytosis, opportunistic infections, hypokalemia alkalosis, impaired healing Contraindications Drug allergies Cataracts, glaucoma, peptic ulcer disease, mental health problems Diabetes, cardiac, renal, or liver dysfunction Often avoided with serious infections, including septicemia, systemic fungal infections, and varicella Exception: TB meningitis, glucocorticoids may be used to prevent inflammatory CNS damage. Drug Interactions Non–potassium-sparing diuretics (e.g., thiazides, loop diuretics) can lead to severe hypocalcemia and hypokalemia. Aspirin, (NSAIDs), and other ulcerogenic medications produce additive gastrointestinal effects Anticholinesterase medications produce weakness in patients with myasthenia gravis. Immunizing biologics inhibit the immune response to the biological. May reduce the hypoglycemic effects of antihyperglycemics and result in elevated blood glucose levels. Prednisone Most common oral glucocorticoid for anti-inflammatory or immunosuppressant purposes Also used to treat exacerbations of chronic respiratory illnesses Inadequate for the management of adrenocortical insufficiency (Addison’s disease) Methylprednisolone (Solu-Medrol) Most common injectable glucocorticoid drug Primary use: anti-inflammatory or immunosuppressant drug Usually administered intravenously Not recommended for use during pregnancy Contains a preservative (benzyl alcohol) that cannot be given to children younger than 28 days of age. Look-Alike/Sound-Alike Drugs Solu-Cortef® and Solu-Medrol® Both are glucocorticoids, and both are given intravenously, but they are different. 4 mg of Solu-Medrol is equivalent to 20 mg of Solu-Cortef. These drugs are not interchangeable. Other Adrenal Drugs Mineralocorticoids fludrocortisone 21-acetate Catecholamines epinephrine, norepinephrine Adrenal steroid inhibitor ketoconazole Nursing Implications Baseline weight, height, intake and output status, vital signs, hydration and nutritional status, skin condition, and immune status. Obtain baseline laboratory studies. Assess for edema and electrolyte imbalances. Prepare and administer according to manufacturer’s directions. Oral forms should be given with food or milk to min GI upset Nursing Implications Assess for contraindications to adrenal drugs, especially the presence of peptic ulcer disease. Assess for drug allergies and potential drug interactions (prescription drugs, natural health products and OTC drugs. Be aware that these drugs may alter serum glucose and electrolyte levels (e.g., serum potassium levels). Nursing Implications For topical applications, follow instructions for their use and the type of dressing (if any) to apply. Clear nasal passages before giving a nasal corticosteroid After using an orally inhaled corticosteroid, instruct the patient to rinse the mouth with lukewarm water to prevent possible oral fungal infections. Teach clients to avoid contact with people with infections and to report any fever, increased weakness, lethargy, or sore throat. Nursing Implications Sudden discontinuation of these medications can precipitate an adrenal crisis caused by a sudden drop in serum levels of cortisone. Doses are usually tapered before the medication is discontinued. Monitor therapeutic responses. Watch for and monitor adverse effects. Question A patient is taking an inhaled corticosteroid for asthma. After the patient takes a dose of the inhaler, the nurse’s priority should be to A. listen to the patient’s breath sounds. B. have the patient rinse the mouth with warm water. C. instruct the patient to cough and breathe deeply. D. take the patient’s apical pulse for 1 minute. Question The nurse should teach a patient taking an oral corticosteroid to take the medication at what time? A. 0800 hours B.1200 hours C. 1700 hours D. 2100 hours  Question Which instruction should the nurse include when teaching a patient about glucocorticoid therapy? A. Do not abruptly stop taking the medication. B. Take the medication on an empty stomach. C. Avoid use of anti-ulcer medications when taking glucocorticoids. D. When used long term, alternate-day dosing of glucocorticoids will help minimize thyroid suppression. This Photo by Unknown Author is licensed under CC BY Wrap-up Questions? Next week: Study Week Week 8: Autonomic Nervous System – tricky concepts – do not miss