PH 17 Drugs for Osteoporosis and Hormonal Problems PDF

16 Hormones and Drugs for Osteoporosis LEARNING OUTCOMES 1. Explain the role of hormone replacement therapy for general health and endocrine problems. 2. List the names, actions, possible side effects, and adverse effects of drugs for thyroid problems. 3. Explain what to teach patients and families...

16 Hormones and Drugs for Osteoporosis LEARNING OUTCOMES 1. Explain the role of hormone replacement therapy for general health and endocrine problems. 2. List the names, actions, possible side effects, and adverse effects of drugs for thyroid problems. 3. Explain what to teach patients and families about drugs for thyroid problems. 4. List the names, actions, possible side effects, and adverse effects of drugs for adrenal gland problems. 5. Explain what to teach patients and families about drugs for adrenal gland problems. 6. List the names, actions, possible side effects, and adverse effects of drugs for sex hormone replacement and contraception. 7. Explain what to teach patients and families about drugs for sex hormone replacement and contraception. 8. List the names, actions, possible side effects, and adverse effects of drugs for osteoporosis. 9. Explain what to teach patients and families about drugs for osteoporosis. KEY TERMS aldosterone (ăl-dō-STĔR-ōn, p. 297) A hormone secreted by the adrenal cortex that regulates sodium and water balance. anabolic steroids (ă-nă-BŎL-ĭk STĔR-ōĭd, p. 304) Synthetic drugs with the same use and actions as androgens. androgens (ĂN-drĕ-jĕns, p. 304) Synthetic or natural hormones that help to develop and maintain the male sex organs at puberty and develop secondary sex characteristics in men (facial hair, deep voice, body hair, body fat distribution, and muscle development). antithyroid drugs (ĂN-tĭ-THĪ-rōĭd, p. 296) Thyroid-suppressing drugs that work directly in the thyroid gland to stop production of new hormones by preventing an enzyme from connecting iodine (iodide) with tyrosine to make active thyroid hormones. bisphosphonates (bĭs-FŎS-fĕ-nāts, p. 306) Calcium-modifying drugs that both prevent bones from losing calcium and increase bone density by moving blood calcium into the bone, binding to calcium in the bone, and preventing osteoclasts from destroying bone cells and resorbing calcium. 538 corticosteroid (kōr-tĭ-kō-ˈSTĔR-oid, p. 297) Drug similar to natural cortisol, a hormone secreted by the adrenal cortex that is essential for life. estrogen agonist/antagonist (Ĕ-strĕ-jĕn Ă-gă-nĭst/ ăn-TĂ-gĕ-nĭst, p. 307) Drug for osteoporosis that activates (agonizes) estrogen receptors in the bone to promote calcium retention in the bone and blocks (antagonizes) estrogen receptors in breast tissue and uterine tissue. hormonal contraception (hōr-MŌ-năl, p. 302) The use of hormones to suppress ovulation for the intentional prevention of pregnancy. hormone (HŌR-mōn, p. 292) A protein secreted by an endocrine gland that changes the action of another gland or tissue, known as its target tissue. hormone replacement therapy (HRT) (HŌR-mōn rĭ-PLĀS-mĕnt THĔR-ĕ-pē, p. 293) Temporary or permanent therapy with drugs that perform the function of natural endocrine hormones. osteoporosis (Ŏ-stē-ō-pĕ-RŌ-sĭs, p. 305) The gradual loss of bone density and strength, which leads to spinal shortening and increased risk for bone fractures. thyroid hormone agonist (THĪ-rōĭd HŌR-mōn Ă-gă-nĭst, p. 294) Drug that mimics the effect of thyroid hormones, T3 and T4, helping to regulate metabolism. Overview of the Endocrine System The endocrine system involves many glands that secrete hormones (Fig. 16.1). A hormone is a protein secreted by an endocrine gland that changes the action of another gland or tissue, known as its target tissue. Unlike some glandular secretions, such as from the salivary glands in which a secretion moves through a duct directly to its site of action, hormones do not require a duct to reach their target tissues. For this reason endocrine glands are known as “ductless” glands. Instead, hormones are released into the bloodstream, where they circulate throughout the body. When a specific hormone, such as insulin, reaches a tissue or organ that has insulin receptors, insulin recognizes its target tissue and binds to the receptors, causing a change in the target tissue activity. 539 FIG. 16.1 The endocrine system. (Modified from Herlihy B: The human body in health and illness, ed 5, Philadelphia, 2014, Elsevier.) Many hormones are necessary for life. Some, such as estrogen, are useful at different times during a person's life but are not essential for maintaining critical physiologic functions. At times endocrine glands develop problems and are no longer able to produce adequate amounts of specific hormones. For example, pancreatic beta cells can stop producing insulin, which causes the person to have diabetes. At other times, an endocrine gland may be surgically removed for a specific problem and the person then would be deficient for that hormone. Depending on how important the function of the hormone is to a patient's health and well-being, hormone replacement therapy (HRT) with drugs that perform the function of natural hormones may be needed. HRT may be used for a short time, such as for relief of menopause symptoms, or permanently, such as replacement of thyroid hormones after removal of the thyroid gland. Common uses of hormone replacement therapy include drugs for thyroid problems, adrenal gland problems, sex hormone replacement, contraception, and diabetes. The issues for diabetes management are complex and are discussed separately in Chapter 17. Drugs for Thyroid Problems The thyroid gland in the neck (see Fig. 16.1) produces two thyroid hormones that are critical for life: thyroxine (T4) and triiodothyronine (T3). These hormones enter all cells in the body, where they bind to receptors inside the cell and activate the genes for metabolism. T4 and T3 increase the rate of metabolism, which is the energy use and work performed in the body. These hormones are critical for the following body 540 actions: • brain development and function, including the ability to think, remember, and learn • heart and skeletal muscle contraction and strength • endocrine system production of other hormones • breathing and oxygen use in all cells Hypothyroidism Hypothyroidism, also known as underactive thyroid, is a common problem in which the thyroid gland produces little or no thyroid hormones, slowing all aspects of metabolism. Other symptoms such as weakness, fatigue, weight gain, or depression also occur. If left untreated, serious problems of the cardiovascular, pulmonary, and nervous systems and brain result. Children may have such poor brain development that they are cognitively impaired. Adult metabolism can slow to the point that death from cardiac or respiratory failure can occur. These problems can be prevented using HRT with thyroid hormone agonists. Usually this therapy is needed for the rest of the person's life. Box 16.1 lists the symptoms associated with hypothyroidism. Box 16.1 Symptoms Associated With Thyroid Problems Hypothyroidism • Tired, with no energy, sleeps a lot • Gains weight while eating minimal amounts • Heart rate, blood pressure, and respiratory rate low for age and size • Always feels cold when others are comfortable • Body temperature below normal • Constipation • Increased facial and body hair, decreased scalp hair • Is less interested in surroundings and appears to think more slowly • Tongue seems thicker, making speech more difficult • Skin dry and flakey • Decreased sex drive • Decreased or absent menstruation • Erectile dysfunction Hyperthyroidism 541 • Lots of energy, difficulty sleeping • Weight loss even when appetite and eating are increased • Heart rate and blood pressure elevated • Always feels too warm when others are comfortable • Body temperature above normal • Multiple bowel movements daily, diarrhea • Thinning scalp hair • Skin moist, sweaty • Difficulty concentrating, may be irritable • Hand tremors • Menstrual cycle irregular Thyroid Hormone Agonists Action and Uses Thyroid hormone agonists are drugs that mimic the effect of the thyroid hormones T3 and T4, helping to regulate metabolism. These drugs work just like natural thyroid hormones by moving through the blood and entering all cells. The drugs then enter the nucleus and bind to receptors on the DNA, which then activates the genes for metabolism. As a result of turning on these genes, thyroid hormone agonists increase the cells' rate of metabolism, which speeds up both the energy use and the work of each cell. Table 16.1 lists the names, dosages, and nursing implications for the most commonly prescribed thyroid hormone agonists. Consult a drug reference or pharmacist for information about other thyroid hormone agonists. Table 16.1 Examples of Common Drugs for Thyroid Problems Thyroid hormone agonists: These synthetic drugs have the same structure as thyroid hormones and work in the same way to activate the gene for metabolism, speeding up the energy use and work output of each cell. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS levothyroxine sodium [synthetic] (Estre, Eltroxin , • Check the patient's heart rate and blood pressure before giving this drug because increased heart rate and blood pressure can result. Levo-T, Levothroid, Levoxyl, Synthroid, • Check the patient's entire prescription and over-the-counter drug list for potential interactions Unithroid) with thyroid hormone agonist drugs. Oral: 25–250 mcg once daily • Report the use of anticoagulants or NSAIDs because these drugs can interact with levothyroxine IV: 12.5–150 mcg once daily and cause excessive bruising and bleeding. liothyronine sodium [synthetic] (Cytomel, Triostat) • Pregnant women may need a higher dose, and women who are taking thyroid hormone agonists 25–100 mcg orally once daily. are advised not to breast-feed, because the drug can be found in the mother's breast milk. • Check the dose and the specific drug name carefully. Thyroid hormone agonists are not interchangeable because the strength of each drug varies. • Levothyroxine may affect the blood sugar of diabetic patients. Check blood sugar levels closely. Antithyroid drugs: These drugs reduce thyroid hormone levels by entering the thyroid gland and combining with the enzyme responsible for connecting iodine (iodide) with tyrosine. Without this iodide–tyrosine connection, thyroid hormone production is suppressed. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS methimazole (Northyx, Tapazole) • Check the patient's complete blood cell count for signs of bone marrow suppression such as a low Usual maintenance dosage: 5–30 mg orally every white blood cell count, anemia, or thrombocytopenia. 8 hours • Assess the patient for signs of infection. propylthiouracil (Propacil, Propyl-Thyracil , PTU) • Assess the patient's skin for signs of bruising or bleeding such as ecchymosis or petechiae. • Check the patient's drug list for drugs that have antiplatelet actions, such as warfarin. Usual maintenance • Check the patient's liver function tests before giving these drugs. Both thyroid-suppressing drugs dosage: 100–150 mg orally every 8 hours are hepatotoxic. Check the patient daily for yellowing of the skin or sclera that indicates jaundice. • Check the dose and the specific drug name and prescribed dosage carefully. These drugs are not interchangeable because the strength of each drug varies. • Notify the healthcare provider if adverse effects, such as bone marrow suppression or altered liver function, occur. Indicates Canadian drug. 542 Expected Side Effects Thyroid hormone agonist drugs have few side effects because they mimic normal hormones. As cell metabolism increases, the patient may experience symptoms of hyperthyroidism. The symptoms most easily noticed are diarrhea, rapid pulse, high blood pressure (hypertension), difficulty sleeping (insomnia), excessive sweating, and heat intolerance. Adverse Effects The most serious adverse effects of thyroid hormone agonists occur in the cardiac and nervous systems. The activity of both systems increase, sometimes to dangerous levels. Increased cardiac activity can lead to angina (chest pain), myocardial infarction (heart attack), or heart failure. Increased nervous system activity can lead to seizures, although this is more likely to occur in patients who already have a seizure disorder. Drug Interactions When thyroid hormone agonists are taken with drugs that reduce blood clotting (anticoagulants), especially warfarin (Coumadin), their actions are increased. This response can cause excessive bleeding and bruising. Nursing Implications and Patient Teaching Assessment. Before giving the first dose of a thyroid hormone agonist drug, check the patient's heart rate and blood pressure because these drugs can increase metabolic rate and cardiac activity. Check the patient's entire drug list, including prescription drugs, vitamins, minerals, and supplements for potential interactions with thyroid hormone agonist drugs. Report the use of anticoagulants or NSAIDs to the healthcare provider because these drugs can interact with thyroid hormone agonists and cause excessive bruising and bleeding. Assess women of childbearing age for possible pregnancy before beginning thyroid hormone agonists. Pregnant women may need a higher dose, and women who are taking thyroid hormone agonists are advised not to breast-feed because the drug can be found in the mother's breast milk. Carefully check the drug name and dose because thyroid hormone agonists drugs are not interchangeable. Although the actions are similar, the strength of each drug varies. Top Tip for Safety Do not give one brand of thyroid hormone in place of another. The strength of different brands and types vary, and so can patient responses. Liothyronine is four times as potent as levothyroxine. 543 Planning and implementation. When hypothyroidism is first diagnosed, the thyroid hormone drug dose is kept low for the first several weeks. The drug dose is then increased slowly every 2 to 3 weeks until the patient has normal blood levels of thyroid hormone and signs of normal metabolism. The absorption of thyroid hormone agonists in the GI tract is greatly reduced by food and fiber. Give the drug 2 hours before a meal or fiber supplement or at least 3 hours after a meal or a fiber supplement has been taken. Evaluation. The effects of the drug may not be apparent for several weeks. Check the patient's heart rate and blood pressure to determine whether the drug is working and to check for any side effects because hypothyroid symptoms may be most notable in the cardiac system. The following changes indicate that the drug is effective and the dose is appropriate: • The patient's vital signs (i.e., body temperature, heart rate, blood pressure, and respiratory rate) are within normal limits. • The patient's activity level and mental status are normal for him or her. • The patient's body weight is consistent with the amount of calories he or she eats and his or her activity level. • The patient's bowel habits are what they were before the thyroid problem occurred. Assess the patient for indications of adverse effects on the cardiac system. The first indications may be chest pain or discomfort and hypertension. For patients who are also taking drugs that affect blood clotting, especially warfarin (Coumadin), assess the patient at least once per shift for any sign of increased bleeding. Indications are bleeding from the gums; the presence of unusual or excessive bruising anywhere on the skin; bleeding around intravenous (IV) sites; bleeding for more than 5 minutes after an IM injection or discontinuing an IV; and visible blood in urine, stool, or vomit. Patient and family teaching. Teach the patient and family the following: • Take only the dose that is prescribed for you, because increasing the drug too quickly can lead to adverse effects such as a heart attack or seizures. 544 • Do not skip doses, and you must take the drug daily to maintain normal body function. • Take a missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one. • Do not stop the drug suddenly or change the dose (up or down) without contacting your healthcare provider, to prevent underdosing or overdosing. • Take the drug 2 to 3 hours before a meal or before taking a fiber supplement or at least 3 hours after a meal or after taking a supplement because food and fiber greatly decrease absorption of the drug. • Check your pulse each morning before taking the drug and again each evening before going to bed. If the pulse rate becomes 20 beats higher than the normal rate for 1 week or if it becomes consistently irregular, notify your healthcare provider. • Go to the emergency department immediately if you start to have chest pain. • If you are ill and cannot take the drug orally, contact your healthcare provider to get an injection dose of the drug. • If you also take warfarin (Coumadin), keep all followup appointments and appointments for blood-clotting tests because these drugs increase the effectiveness of warfarin. • Avoid situations that can lead to bleeding and other drugs (such as aspirin) that can make bleeding worse. Lifespan Considerations Pediatric Hypothyroidism can occur in children and some are born with it. Any child with 545 the disorder must take thyroid hormone replacement drugs for his or her entire life. Infants and children going through periods of rapid growth need higher dosages of thyroid agonist drugs. Lifespan Considerations Pediatric Thyroid hormone agonist drugs are safe to take during pregnancy and, in fact, are needed to maintain the pregnancy and prevent problems with the fetus. These drugs do enter breast milk and can cause problems for the nursing infant. Therefore a mother being treated with thyroid hormone agonists should not breast-feed. Lifespan Considerations Older Adults Adults older than 65 years are usually prescribed a lower initial dose of thyroid hormone agonists because they are more likely to have serious adverse cardiac and nervous system effects. For this reason doses are increased more slowly in older adults than in younger adults until an appropriate maintenance dose is reached. Hyperthyroidism Hyperthyroidism, also called an overactive thyroid or thyrotoxicosis, is a condition in which the thyroid gland secretes excessive amounts of thyroid hormones (T3 and T4). This hormone excess causes general body metabolism to be greatly increased. Although there are different causes of hypothyroidism, the most common type is Grave's disease. Box 16.1 lists the symptoms associated with hypothyroidism. Some types of hyperthyroidism cause the patient to have a goiter, which is a swelling in the neck caused by an enlarged thyroid gland. The effects of continued excessive amounts of thyroid hormones can cause toxic side effects to some organs, especially the heart and nervous system. When hyperthyroidism is caused by Grave's disease, bulging or protruding eyes (exophthalmos) (Fig. 16.2) and blurred vision may occur. 546 FIG. 16.2 Facial appearance of a woman with Graves disease. (From Ignatavicius DD, Workman ML: Medical-surgical nursing: Patient-centered collaborative care, ed 8, St. Louis, 2016, Saunders.) Severe hyperthyroidism that causes life-threatening hypertension, heart failure, and seizures is called thyroid crisis or thyroid storm. Often a fever is the first indication of a problem. This condition is an emergency and can lead to death if the thyroid hormone levels are not decreased immediately. Antithyroid Drugs Actions and Uses Without treatment, hyperthyroidism has serious consequences. For some people, treatment consists of surgical removal of all or part of the thyroid gland. Radiation therapy with radioactive iodine can also reduce thyroid gland function and production of thyroid hormones. Therapy with antithyroid drugs can be used shortterm before surgery or long-term to prevent thyroid hormone production and control of the disease. Antithyroid drugs are methimazole and propylthiouracil, which belong to the thionamide class of drugs. Table 16.1 lists the names, dosages, and nursing implications for common antithyroid drugs. These drugs are not interchangeable because methimazole is 10 times stronger than propylthiouracil. Top Tip for Safety Do not substitute methimazole for propylthiouracil because methimazole is 10 times stronger than propylthiouracil. Antithyroid drugs work directly in the thyroid gland to stop production of the hormones. They serve as a decoy for the enzyme that normally connects iodine (iodide) with tyrosine to make active thyroid hormones. So the enzyme works on the drug instead of connecting these two substances. As a result, new hormones are not made, but the ones already made and stored in the thyroid gland are not affected by the drug. The drugs do not affect stored hormones, so it may take several weeks 547 before the effects of all of the stored thyroid hormones are gone. Top Tip for Safety Teach patients that thyroid-suppressing drugs must be taken for 3 to 4 weeks to start being effective because they have no effect on thyroid hormones already stored in the thyroid gland. Expected Side Effects Most common side effects of antithyroid drugs are minor. Some of these include taste changes, headache, itchiness, rash, muscle and joint aches, drowsiness, nausea, vomiting, enlarged lymph nodes, and swelling of the lower extremities. Adverse Effects Bone marrow suppression can occur and make the patient anemic and more at risk for infection. These drugs often induce hypothyroidism in patients who take them. Propylthiouracil can be hepatotoxic (liver damage). Methimazole is preferred over propylthiouracil. In some patients these drugs can also damage the kidneys. Drug Interactions Both methimazole and propylthiouracil drugs increase the effectiveness of anticlotting drugs, especially warfarin (Coumadin). As a result, patients who are taking these drugs with any anticlotting drug are at greater risk for excessive bleeding and bruising. Nursing Implications and Patient Teaching Assessment. Assess the patient's vital signs, especially for elevated temperature that may be associated with infection. Check the patient's blood counts for signs of bone marrow suppression, such as a low white blood cell count, anemia, or thrombocytopenia. Check the patient's drug list for drugs that have antiplatelet actions, such as warfarin. Assess the patient's skin for signs of bruising or bleeding, such as ecchymosis or petechiae. Notify the healthcare provider if these appear. Before giving these drugs, check the patient's liver function tests because both are toxic to the liver (hepatotoxic), especially propylthiouracil. For patients who already have liver problems, the effects of antithyroid drugs on the liver are more severe and occur at lower doses. Planning and implementation. Carefully check the dose and the specific drug name and prescribed dosage. These drugs are not interchangeable because methimazole is 10 times stronger than propylthiouracil. Notify the healthcare provider if adverse effects such as bone marrow suppression 548 or altered liver function occur. Evaluation. Check the patient's complete blood cell count (CBC) whenever it is drawn because these drugs cause some degree of bone marrow suppression. When white blood cells are reduced, the patient's risk for infection increases. Report changes in blood cell counts to the healthcare provider. Bone marrow suppression can increase the risk for bleeding. Also, these drugs increase the action of anticlotting drugs. For patients who also take anticlotting drugs, look for bleeding from the gums; unusual or excessive bruising anywhere on the skin; bleeding around IV sites or for more than 5 minutes after discontinuing an IV; and the presence of blood in urine, stool, or vomit. Both drugs are hepatotoxic, especially propylthiouracil, so check the patient daily for yellowing of the skin or sclera (jaundice), coffee-colored urine, and clay-colored stools. These are all symptoms of liver problems. Patient and family teaching. Tell the patient and family the following: • Even if you do not notice a reduction of your symptoms in the first 1 to 2 weeks, do not increase the dosage on your own. These drugs take several weeks to be effective. • Keep all follow-up appointments and appointments for blood-clotting tests because these drugs increase the effectiveness of warfarin. • Avoid situations that can lead to bleeding and other drugs that can make bleeding worse. • Avoid crowds and people who are ill because these drugs can reduce your immunity and resistance to infection. • Check the color of the roof of the mouth and the whites of your eyes daily for a yellow tinge that may indicate a liver problem. If this appears, notify your healthcare provider as soon as possible. Lifespan Considerations Pregnancy and Breast-Feeding 549 Antithyroid drugs increase the risk for birth defects, fetal damage, and miscarriages. They should not be taken during pregnancy unless the benefits of treatment outweigh the risks. Women who are taking antithyroid drugs should not breast-feed because these drugs enter breast milk and would suppress the infant's thyroid function. Lifespan Considerations Older Adults Older adults who are taking antithyroid drugs are more likely to have more severe adverse effects. The older patient's immune system is already lower than that of a younger person, which increases the older person's risk for infection. Bone marrow suppression from these drugs increases the risk for severe infection. For older adults who also take warfarin (Coumadin), the risks for bleeding are even greater while taking an antithyroid. Drugs for Adrenal Gland Problems Adrenal Gland Hypofunction The adrenal glands are a pair of small endocrine glands located on top of the kidneys, although they are not part of kidney function (Fig. 16.3). They have an outer layer known as the cortex and an inner layer known as the medulla. The cortex secretes aldosterone and cortisol. Both are steroid hormones, also called corticosteroids, which means their main structure is composed of the steroid cholesterol. Aldosterone controls sodium and water balance. It is also known as a mineralocorticoid because it regulates sodium. Cortisol, of which there are many types, has many more functions that are essential for life. Cortisol helps maintain critical blood glucose levels, the stress response, excitability of cardiac muscle, immunity, and blood sodium levels. Because cortisol was first discovered to affect blood glucose levels, it is also known as a glucocorticoid. FIG. 16.3 Location of adrenal gland on top of the kidney. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) 550 Adrenal gland hypofunction is a disorder in which the adrenal gland produces little or no cortisol and aldosterone. Conditions that cause it include autoimmune disease attacking and destroying the adrenal glands, adrenalectomy, abdominal radiation therapy, and reduced function of the anterior pituitary gland. Major problems from adrenal gland hypofunction are hypoglycemia (low blood glucose levels), salt wasting, hypotension, weakness, and high blood potassium levels. Without replacement of cortisol and aldosterone, this endocrine problem eventually leads to death. Corticosteroid replacement therapy involves the glucocorticoids, especially prednisone. If further help is needed to replace aldosterone action, fludrocortisone (Florinef) may be used. Action and Uses Although glucocorticoids (corticosteroids) are used for HRT, their most common use is as powerful anti-inflammatory drugs. See Chapter 12 for a detailed discussion of corticosteroid drug therapy, including specific drugs, side effects, adverse effects, and nursing implications. Glucocorticoid drugs act just like natural cortisol. Because glucocorticoids have some mineralocorticoid action, many people with adrenal gland hypofunction only need HRT with glucocorticoids. When this replacement is not enough to manage blood sodium levels, fludrocortisone may be added to correct the deficiency. Fludrocortisone (Florinef) is a synthetic drug that acts like natural aldosterone. With the use of this drug more sodium is retained to prevent excessive sodium wasting and more potassium is excreted to prevent dangerously high blood potassium levels. So fludrocortisone helps prevent hyponatremia, hyperkalemia, and hypotension. The usual adult dosage is 0.1 to 0.2 mg orally once daily. Expected Side Effects Side effects of fludrocortisone therapy include hypertension, edema formation, low blood potassium levels, and high blood sodium levels. The cause of these problems is the drug's action on fluid and electrolyte balance. Adverse Effects Congestive heart failure is a serious adverse effect of fludrocortisone. It requires that the drug dose be either reduced or stopped. Nursing Implications and Patient Teaching Patient and family teaching. Tell patients and families the following: • Take fludrocortisone at the same time daily with food to prevent GI problems. • Weigh yourself daily and keep a record because the drug can cause fluid retention with weight gain, edema, and heart failure. 551 • Report a weight gain of 2 lb in a day or 3 lb in a week to the healthcare provider immediately. Adrenal Gland Hyperfunction Most of the time when adrenal gland hyperfunction occurs, only one hormone is oversecreted. Excessive secretion of cortisol is known as hypercortisolism or Cushing's disease. Excessive secretion of aldosterone is hyperaldosteronism. The most common cause of adrenal gland hyperfunction is an adrenal gland tumor. Sometimes a problem in the pituitary gland produces excessive amounts of hormones that stimulate the adrenal gland to produce adrenal hormones in excess. Action and Uses Surgery is the most common treatment for adrenal gland hyperfunction that is caused by a problem in the adrenal gland. Drug therapy can help manage the problems caused by adrenal gland hyperfunction before surgery or for those patients unable to have surgery. Table 16.2 lists the names, dosages, and nursing implications of the most common drugs used to manage adrenal gland hyperfunction. Some drugs reduce cortisol production, whereas others help control the problems caused by hyperaldosteronism. Table 16.2 Examples of Common Drugs to Treat Adrenal Gland Hyperfunction Corticosteroid receptor blocker: reduces symptoms and problems of hypercortisolism by interfering with the binding of cortisol with its receptor, acting as an antagonist DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS mifepristone (Korlym) 300 mg orally once daily; can • This drug is to be given only for use in people who have type 2 diabetes and hyperglycemia along be increased to 1200 mg orally daily with hypercortisolism. • Instruct sexually active woman of childbearing age to use two reliable forms of birth control while taking mifepristone because this drug can cause a pregnancy loss. Steroid production inhibitors: reduce symptoms and problems of hypercortisolism by preventing the adrenal cortex from producing cortisol and other adrenal cortex hormones DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS mitotane (Lysodren) 1–2 g orally every 6–8 hours • Teach patients the signs and symptoms of adrenal insufficiency: hypoglycemia, salt craving, muscle weakness, hypotension, and fatigue. • Teach patients the importance of laboratory blood work because these drugs affect levels of sodium and potassium. • Teach patients to take these drugs with food because they can cause nausea, vomiting, and other GI upsets. Mitotane (Lysodren) is a steroid production inhibitor that works by directly preventing adrenal gland production of cortisol and other adrenal cortex hormones. A specialized drug for hypercortisolism is Mifepristone (Korlym). This drug works by blocking corticosteroid receptors. Although this does not reduce cortisol levels, it does inhibit cortisol responses in different tissues. It is approved for use only in people who have type 2 diabetes and hypercortisolism. Drug therapy for hyperaldosteronism focuses on reducing potassium levels and relies on spironolactone (Aldactone, Spironol, Novo-Spiroton), a potassium-sparing diuretic. See Chapter 8 for more information on spironolactone therapy. Expected Side Effects Common side effects for drugs that suppress adrenal hormone production are likely to cause nausea, vomiting, skin rashes, and dizziness. Mitotane can also cause 552 bloody urine (hematuria). Mifepristone causes many side effects, including menstrual irregularities. Adverse Effects Any drug that suppresses adrenal production of cortisol can lead to problems of adrenal insufficiency. Allergic reaction to mifepristone can occur. Emergency help is needed for hives, difficult breathing, and swelling of the face, lips, tongue, or throat. Mifepristone is also used to induce abortion and can cause pregnancy loss. Patient Teaching Teach patients who are taking any drug that suppresses adrenal hormone production the signs and symptoms of adrenal insufficiency. Common indicators are salt craving, muscle weakness, hypotension, hypoglycemia (with headache, difficulty concentrating, shakiness), and fatigue. Tell the patient and family the following: • Keep all appointments for laboratory blood work because these drugs alter blood levels of sodium and potassium. • Report symptoms of adrenal insufficiency to your healthcare provider immediately. These include salt craving, muscle weakness, hypotension, low blood glucose levels, headache, difficulty concentrating, shakiness, and fatigue. • Take these drugs with food because they all can cause nausea, vomiting, and other GI upsets. • If you are a sexually active woman in your childbearing years, use two reliable forms of birth control while taking mifepristone because this drug can cause a pregnancy loss. Lifespan Considerations Pregnancy and Pediatric The drugs used for suppressing adrenal hormone production are not approved for use in children or in women who are pregnant or breast-feeding. Female Sex Hormones 553 Overview Hormones secreted throughout a woman's menstruating years promote conception and pregnancy. The beginning of menstruation is menarche, usually occurring during adolescence. Menstruation occurs as a result of the secretion of gonadotropinreleasing hormone (GnRH) in the brain. Secretion of this hormone begins with the start of puberty in both females and males to initiate sex hormone secretion and start the physical changes leading to interest in sexual activity (libido) and the ability to perform sexual intercourse. During menstruation, shedding of the uterine lining occurs resulting from changes in hormone levels in females during their menstrual cycles. Estrogen is the main female sex hormone secreted by the ovaries and adrenal glands. In females the secretion of GnRH from the hypothalamus stimulates the release of two hormones from the pituitary gland: follicle-stimulating hormone (FSH) and luteinizing hormone (LH) (Fig. 16.4). FSH triggers the ovary to make and secrete estrogen, along with maturing one ovum (egg) each month. Rising estrogen levels allow the uterine lining to grow and thicken (see Fig. 16.4). After about 14 days (midcycle), the uterine lining is thick enough to allow a fertilized egg to implant. At this time, GnRH triggers the release of LH, which, in turn, causes secretion of progesterone by the ovary and allows the release of the mature ovum or egg (ovulation). FIG. 16.4 Hormone interactions for ovulation and menstruation. GnRH, Gonadotropinreleasing hormone. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) When the ovulated egg is fertilized by a sperm, the egg's outer covering grows and secretes both estrogen and progesterone. It is these two hormones that keep the uterine lining intact and able to support a pregnancy until the placenta forms and 554 maintains the pregnancy. Therefore functional pregnancy resulting in birth requires conception, continued secretion of estrogen and progesterone, successful implantation 5 to 8 days after conception, and placental development. If, after ovulation, conception and pregnancy do not occur, the outer covering from the released ovum degenerates, and circulating levels of estrogen and progesterone decline in about 12 days. Low levels of these hormones cause the uterine lining to shed as menstruation. Fig. 16.5 shows the feedback loops controlling the secretion of estrogen and progesterone. FIG. 16.5 Positive and negative feedback control over estrogen and progesterone secretion. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) Menopause Menopause is the life period of women when menstruation and ovulation no longer occur. This occurs because of age-related changes that make the ovary stop functioning. Estrogen secretion and ovulation stop. Perimenopause is when a woman transitions from having regular menstrual periods from hormone cycles to when menstrual periods have stopped for a full year as a result of reduced hormone levels. The reduction of hormone levels causes a variety of uncomfortable symptoms. As a result of negative feedback, decreased blood levels of estrogen trigger the brain to secrete GnRH, which then forces the pituitary gland to oversecrete FSH (see Fig. 16.5). The FSH has no effect on the ovary because these cells are no longer functional and blood levels of estrogen remain low. Continuing low blood estrogen levels constantly stimulate the brain to secrete GnRH in large amounts for a time, resulting in the secretion of even more FSH (Fig. 16.6). This extra FSH does not have any effect on the ovary but does cause responses in other body tissues. Box 16.2 lists the symptoms associated with decreased estrogen levels and increased FSH levels. 555 FIG. 16.6 Mechanism for hot flushes and night sweats associated with menopause. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) Box 16.2 Symptoms Associated With the Low Estrogen Levels and High FSH Levels of Menopause Symptoms Caused by Reduced Estrogen Levels • Irregular and absent menses • Dry skin and vaginal mucous membranes • Painful intercourse • Increased rate of osteoporosis Symptoms Caused by Increased FSH Levels • Hot flushes/flashes • Night sweats • Sleep difficulty • Difficulty concentrating on cognitive tasks Memory Jogger 556 • Symptoms of menopause are caused by low levels of estrogen and high levels of FSH. • Hot flashes (hot flushes) with facial redness and feelings of overheating are caused by high levels of FSH acting on blood vessels to make them dilate suddenly. • At night, hot flashes or hot flushes may be followed by excessive sweating that leaves nightclothes and bedding wet. Drugs for Menopause Relief Action and Uses Menopausal HRT during the perimenopausal period is the replacement of naturally secreted estrogen and progesterone with hormones given in the form of a drug. Giving a woman low doses of estrogen increases blood estrogen levels. The mildly increased estrogen levels help reduce perimenopausal symptoms by relieving the problems from low estrogen levels (see Box 16.2) and by inhibiting the feedback system to lower the FSH levels. This action reduces hot flashes, night sweats, and difficulty sleeping. Table 16.3 lists the names, dosages, and nursing implications for common drugs used for relief of menopausal symptoms. Be sure to consult a drug handbook or drug reference source for information about additional drugs for relief of menopausal symptoms. Table 16.3 Examples of Common Drugs for Relief of Menopausal Symptoms Conjugated female sex hormones: reduce menopausal symptoms by providing enough estrogen or estrogen and progesterone to disrupt the feedback loop and lower follicle-stimulating hormone levels DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS conjugated estrogens (Cenestin, C.E.S. , Enjuvia, Premarin) 0.3, 0.45, or 0.625 mg orally • Teach the patient to take drugs for perimenopausal hormone replacement therapy exactly as prescribed to once daily, given cyclically or continuously, alone in women without a uterus, in reduce the risk for excessive uterine bleeding. combination with a progestin in women with a uterus • Advise the patient to quit or reduce smoking to reduce the conjugated estrogens: risk for blood clots, heart attacks, and strokes. medroxyprogesterone (Premphase) 0.625 mg conjugated estrogens orally once daily on • Teach the patient to assess the color of the roof of the days 1–14, then 1 light-blue tablet (0.625 mg conjugated estrogens, 5 mg acetate) mouth and the sclera of the eyes weekly for the presence of orally once daily on days 15–28 jaundice. medroxyprogesterone (Prempro) 0.3 or 0.45 mg along with medroxyprogesterone • Instruct the patient to call 911 immediately for chest pain, acetate 1.5 mg/day, or 0.625 mg along with medroxyprogesterone 2.5 mg, and the difficulty breathing, swelling in one leg, or symptoms of 0.625 mg along with 5 mg medroxyprogesterone stroke. • Teach the patient that taking hormone replacement therapy for long periods increases the risk for cancers of the cervix, breast, ovary, and uterus. Indicates Canadian drug. Expected Side Effects The most common side effects of perimenopausal HRT are breast tenderness, breakthrough bleeding, fluid retention, weight gain, and acne. These occur with estrogen alone and when estrogen is combined with progesterone. Adverse Effects Women who are taking estrogen-based HRT have been found to have a slightly higher incidence of myocardial infarction (heart attack). For this reason perimenopausal HRT is not recommended for long-term therapy. Estrogen and progesterone drugs increase the risk for blood clotting and 557 inappropriate development of thrombi and emboli. These risks increase with age and are greatly increased with cigarette smoking. Potential health problems associated with increased clot formation include heart attack, stroke, pulmonary embolism, and deep vein thrombosis. The uterine lining in women who have a uterus and who take perimenopausal HRT can become very thick and bleed excessively. In addition, perimenopausal HRT promotes the growth of hormone-sensitive cancers of the cervix, uterus, ovary, and breast. These hormones should not be used by women who have a history of or are at high risk for these types of cancer. Perimenopausal HRT also is associated with liver impairment, gallbladder disease, and pancreatitis. Nursing Implications and Patient Teaching Patient and family teaching. Tell the patient and family the following: • Take drugs for perimenopausal HRT exactly as prescribed with regard to dosage and timing. Taking perimenopausal HRT drugs more often than prescribed or not following instructions for timing increases the risk for excessive uterine bleeding. • Quit or reduce smoking during the time you take these drugs to reduce your risk for blood clots, heart attacks, and strokes. • Check the color of the roof of your mouth and the whites of your eyes weekly for the presence of a yellow tinge because these drugs can impair the liver. If you see this yellowing, report it to your healthcare provider as soon as possible. • Go to the emergency department or call 911 immediately if you have chest pain or difficulty breathing, swelling in one leg, or symptoms of stroke. • Taking HRT for long periods of time increases the risk for cancers of the cervix, breast, ovary, and uterus. Discuss the optimum length of time for taking these drugs with your healthcare provider. Drugs for Hormonal Contraception Hormonal contraception is the use of hormones to suppress ovulation for the 558 intentional prevention of pregnancy. When used correctly, hormonal contraception is highly effective. These hormones can be taken orally; used as topical applications in the form of transdermal patches, uterine rings, or released by a device directly in the uterus; implanted under the skin; and injected parenterally as a slow-absorbing drug form (Table 16.4). Oral contraceptives (OCs; often called birth control pills or BCPs) are the most commonly used form of hormonal contraceptive. The mechanism of action and side effects of hormonal contraception are the same for all forms. Table 16.4 Common Hormonal Contraceptives GENERIC NAMES TRADE NAMES Combination Oral Contraceptives drospirenone; ethinyl estradiol Yasmin ethinyl estradiol; desogestrel Apri, Azurette, CAZIANT, Cyclessa, Desogen, Kariva, Mircette, Ortho-Cept, Pimtrea, Reclipsen, Solia, Velivet ethinyl estradiol; ethynodiol Demulen, Kelnor, Zovia diacetate ethinyl estradiol; levonorgestrel Aviane, Enpresse, Jolessa, Lessina, Levlen, Levlite, Levora, Lutera, Portia, Quasense, Seasonale, Seasonique, Sronyx, Tri-Levlen, Triphasil, Trivora ethinyl estradiol; norethindrone Aranelle, Balziva, Brevicon, Femcon, Genora, Jenest, Leena, Modicon, Necon, Norinyl, Nortrel, Ortho-Novum, Ovcon, Tri-Norinyl, Zenchent ethinyl estradiol; norethindrone Estrostep, Femhrt, Junel, Loestrin, Microgestin, Pirmella, Tilia, Tri-Legest acetate ethinyl estradiol; norgestimate MonoNessa, Ortho Tri-Cyclen, Previfem, Sprintec-28, Tri-Previfem, Tri-Sprintec, TriNessa ethinyl estradiol; norgestrel Cryselle, Low-Ogestrel, Ogestrel, Ovral mestranol; norethindrone Genora, Necon, Necon, Norinyl, Ortho-Novum Combination Topical Contraceptives Vaginal Rings ethinyl estradiol; etonogestrel NuvaRing Patches ethinyl estradiol; Ortho Evra norelgestromin Progestin-Only Oral Contraceptives norethindrone Aygestin, Camila, Errin, Jolivette, Nor-QD, Nora-BE, Ortho Micronor norgestrel Ovrette Intrauterine Contraceptives (Progestin Only) levonorgestrel Mirena Subcutaneous Implants (Progestin Only) etonogestrel Implanon levonorgestrel Norplant Action and Uses As described earlier, the control of natural estrogen and progesterone secretion is through a “feedback” system involving the hypothalamus, the pituitary gland, and the ovary (see Fig. 16.5). In a manner similar to perimenopausal hormone replacement therapy, OCs provide enough estrogen and/or progesterone to interfere with feedback and decrease the body's natural production of estrogen and progesterone. As a result, ovulation stops and the cervical mucous thickens, making fertilization difficult (see Fig. 16.5). The most effective OCs contain two synthetic hormones, a synthetic estrogen and progestin, a synthetic progesterone. When taken consistently, this hormone combination keeps the blood levels of estrogen and progesterone high, signaling the hypothalamus that further secretion of these hormones is not needed. With this influence, GnRH, FSH, and LH secretion are stopped and the ovary has no stimulation to produce estrogen or progesterone. Ovulation does not occur and the lining of the uterus is too thin to support pregnancy. So OCs make the endocrine system act as though the woman is pregnant and further hormone production by the ovary is not needed. The specific drugs in combination and their dosages vary, as does the dosing schedule. Be sure to consult a drug handbook for specific dosages and scheduling. 559 Mini-pills are OCs that contain only progestin rather than a combination of estrogen and progestin. They increase blood levels of progesterone, turning off the hormone pathway with positive feedback, which prevents ovulation. Mini-pills are not as effective as combination OCs and most must be taken daily continuously. Expected Side Effects The most common side effects of OCs include breast enlargement and tenderness, nausea, fluid retention, and weight gain. Depending on dosage and whether the OCs contain estrogen and progestin or only progestin, breakthrough vaginal bleeding can occur. Acne can become worse for some women or clear up for others while taking OCs. Adverse Effects Just as for other types of sex hormones, OCs increase the risk for blood clot formation. This problem can lead to deep vein thrombosis, pulmonary embolism, myocardial infection, and stroke. The risk increases among women who smoke and in those older than 35 years. Most hormonal contraceptives cause fluid and sodium retention, which can lead to hypertension. Hormonal contraception is not recommended for women with moderate-to-severe hypertension. The estrogen and progestin in OCs can cause liver toxicity. Indications of liver toxicity include elevated liver enzymes, yellowing of the skin and whites of the eyes, tiredness, coffee-colored urine, clay-colored stools, and nausea. Hormonal contraceptives are not recommended for women who have known liver problems. The estrogen and/or progestin of OCs promote the growth of hormone-sensitive cancers of the cervix, uterus, ovary, and breast. Hormonal contraceptive should not be used by women who have a history of or are at high risk for these types of cancer. OCs that use drospirenone as the progestin (Ocella, Yasmin, YAZ28) can increase the serum potassium level, which can lead to heart block and other irregular heart rhythms. Women who have kidney, liver, or adrenal disease and those who are taking other drugs that increase potassium levels (e.g., angiotensin-converting enzyme inhibitors for hypertension and potassium-sparing diuretics) are not recommended to use contraceptives that contain drospirenone. Drug Interactions Many drugs and herbal supplements interact with OCs. Be sure to ask women prescribed to take OCs about all other drugs and supplements. Check with the pharmacist to avoid a possible drug interaction. Nursing Implications and Patient Teaching Patient and family teaching. Tell the patient and family the following: • Use an additional method of contraception during the first cycle because OCs require a full cycle before they are 560 effective. • Take the drug as prescribed or an unplanned pregnancy may result because scheduling is important for best effectiveness. • Remember that OCs are only effective at preventing pregnancy when taken exactly as prescribed. • Take the OC with food once daily at the same time each day for best effect and remember to take it. • Do not smoke or use nicotine in any form to reduce your risk for blood clots, heart attacks, and strokes. • If you miss one dose within the cycle, the drug should still be effective in preventing pregnancy. However, if you miss more than one dose within a cycle, especially two doses in a row, continue to use it for the rest of the cycle but also use another method of contraception for the rest of the cycle. • Be sure to tell any other healthcare provider that you are taking this drug, because of the potential for drug interactions. • Do not take any over-the-counter drug without checking with your healthcare provider who prescribed the contraceptive, to prevent possible interactions. • Notify your healthcare provider if you develop yellowing of the skin or eyes, darkening of the urine, or lightening of the stools. These problems are signs of liver toxicity, a serious adverse effect of hormonal contraceptives. Lifespan Considerations Pregnancy and Lactation • Hormonal contraceptives should not be used during pregnancy because they can interrupt the pregnancy and can cause birth defects. Women should know for certain that they are not pregnant before starting hormonal contraceptives. Instruct women to immediately notify their healthcare provider if a pregnancy 561 is suspected. • Hormonal contraceptives interfere with lactation. They are also present in breast milk and may harm the infant. These drugs should not be used by lactating women. Male Sex Hormones Overview Male sex hormones are produced under the influence of the anterior pituitary gland. The male hormone testosterone and its related hormones are called androgens. Androgens help to develop and maintain the male sex organs at puberty and develop secondary sex characteristics in men (e.g., facial hair, deep voice, body hair, body fat distribution, and muscle development). They promote the anabolic or tissue-building processes in the body. Anabolic steroids are synthetic drugs with the same use and actions as androgens. These drugs may be given as replacement therapy for testosterone deficiency. Androgens Action and Uses Androgens are steroid hormones synthesized from cholesterol, and they work to stimulate or control the development and maintenance of male characteristics. This includes the activity of the male sex organs and the development of male secondary sex characteristics. Androgens are primarily used in the treatment of hypogonadism, hypopituitarism, eunuchism (absence of testes or undeveloped gonads in a male), cryptorchidism (undescended testes), oligospermia (lack of sperm in the semen), and general androgen deficiency in males. The most commonly used androgen is testosterone. Androgens also help in the development of skeletal muscle cells exerting action on several cell types in skeletal muscle tissue. Expected Side Effects Common side effects of androgens include edema caused by sodium retention (usually with larger doses), acne, hirsutism (excessive body hair), male pattern baldness, mouth irritation, diarrhea, nausea, and vomiting. Adverse Reactions Tumors of the liver, liver cancer, or hepatitis have occurred with long-term, highdose therapy with androgens. Adverse reactions to androgens also include jaundice, a decreased sperm count, gynecomastia (enlargement of the breasts), impotence, and urinary retention. In children, use of androgens may result in early puberty and short stature because of premature closing of the bone growth plates. Drug Interactions Anabolic steroids may increase the effects of anticoagulants, antidiabetic agents, and other drugs. Corticosteroids given at the same time as androgens increase the possibility of edema. Barbiturates decrease the therapeutic effects of androgens 562 because of increased breakdown in the liver. Nursing Implications and Patient Teaching Patient and family teaching. Tell the patient and family the following: • Take this drug as instructed by your healthcare provider. • Do not increase the dose without consulting your healthcare provider if you do not see the expected effects within the first 1 to 2 months because response to the drug may take several months. • Report any new or troublesome symptoms that may develop, including fluid retention, especially in the feet and hands, breast enlargement, shortness of breath, excessive physical or sexual stimulation, prolonged or painful penile erection of the penis, impotence, urinary retention, and jaundice. • If you are taking the drug under the tongue (sublingually) or putting the drug in your cheek (buccally), do not eat, drink, smoke, or chew tobacco until the drug is dissolved for best absorption. • If you are using a topical gel form of the drug, do not let women or children come into contact with the areas where you have applied it, to prevent them from absorbing the drug. Drugs for Osteoporosis Good health and mobility require that bones remain strong enough to support mobility. Normal bone formation and maintenance continue throughout the lifespan, not just during childhood growth. Even after bones have achieved their final length, old bone cells are continually removed by a process known as osteoclastic activity, and new bone cells are continually added by a process known as osteoblastic activity. For bones to remain strong and dense, these two processes must be balanced. Osteoporosis is the gradual loss of bone density and strength, which leads to spinal shortening and increased risk for bone fractures (Fig. 16.7). This results when osteoclastic activity occurs at a faster rate than osteoblastic activity. When excessive 563 osteoclastic activity occurs, minerals (especially calcium) are lost from the bones, making them thinner and weaker. Osteoporosis is commonly more severe in women after menopause, but it does occur in people of both genders at any age. The rate and degree of bone density loss varies from person to person but does occur to some degree in everyone during the aging process. For some people, severe osteoporosis is present as early as age 40 years. For other people, bone density loss may not be obvious until 75 years or older. Factors that influence at what age a person develops this bone-thinning problem and how severe it is include a genetic predisposition, nutritional status, amount of weight-bearing activity, cigarette smoking, presence of sex hormones, and drug use. Osteoporosis occurs earlier and at faster rates in people who have a strong family history for the problem; smoke; have a diet poor in calcium, other minerals, vitamin D, and protein; have lower than normal levels of estrogen (women) or testosterone (men); and who take corticosteroids daily. FIG. 16.7 A normal spine at age 40 years and osteoporotic changes at age 60 and 70 years. (From Ignatavicius DD, Workman ML: Medical-surgical nursing: Patient-centered collaborative care, ed 8, St. Louis, 2016, Saunders.) Although osteoporosis cannot be cured or completely prevented, its progress can be delayed with drug therapy. Drugs and supplements that are used to manage the disorder include calcium, activated vitamin D, bisphosphonates, estrogen agonists/antagonists, and osteoclast monoclonal antibodies. The names, dosages, and nursing implications for common examples of these drugs are summarized in Table 16.5. Table 16.5 Examples of Common Drugs for Osteoporosis 564 Bisphosphonates: reduce the rate of osteoporosis by moving blood calcium into the bone, binding to calcium in the bone, and preventing osteoclasts from destroying bone cells and resorbing calcium DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS alendronate (Fosamax) 10 mg orally daily • Teach patients to take drug first thing in the morning before breakfast and before ibandronate (Boniva) 2.5 mg orally daily or 150 mg orally once per taking other drugs for best absorption and to prevent drug interactions. month, or 3 mg IV bolus once every 3 months • Tell patients to remain upright (sitting or standing) for 30 minutes after taking risedronate (Actonel, Atelvia) 5 mg orally daily, or 35 mg orally once the drug to help prevent esophageal irritation or reflux. weekly, or 75 mg orally twice per month, or 150 mg orally once per • Remind patients to have a dental examination every 6 months and to tell the month dental professional about taking a bisphosphonate because it can cause jaw bone zoledronic acid (Reclast) 5 mg IV infusion over 15–30 minutes once osteonecrosis. yearly • Infuse the IV form of the drug slowly over 15–30 minutes to reduce the risk for cardiac complications. Estrogen agonists/antagonists: slow the rate of osteoporosis by activating estrogen receptors in the bone, which leads to reduced calcium resorption and increased bone density DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS estrogen/bazedoxifene (Duavee) 1 tablet orally daily (contains 0.45 • Urge patients not to smoke while taking these drugs to reduce the risk for blood mg conjugated estrogen and 20 mg bazedoxifene) clots, heart attacks, and strokes. raloxifene (Evista) 60 mg orally once daily Osteoclast monoclonal antibodies: work by binding to a receptor on immature osteoclasts and on certain white blood cells, preventing them from becoming mature and attacking bone tissue; the result is decreased bone loss and increased bone density and strength DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS denosumab (Prolia) 60 mg subcu