Drugs Affecting Endocrine PDF

Drugs Affecting Endocrine  Chapter 30: Pituitary  Chapter 31: Thyroid and Antithyroid Drugs  Chapter 32: Antidiabetic Drugs  Chapter 33: Adrenal Drugs Endocrine System Main goal of this system: physiologic stability Every cell and organ in the body is influenced by the endocrine system. Hormones...

Drugs Affecting Endocrine  Chapter 30: Pituitary  Chapter 31: Thyroid and Antithyroid Drugs  Chapter 32: Antidiabetic Drugs  Chapter 33: Adrenal Drugs Endocrine System Main goal of this system: physiologic stability Every cell and organ in the body is influenced by the endocrine system. Hormones: “chemical language” of endocrine system Copyright © 2020 Elsevier Inc. All Rights Reserved. 2 Chapter 30 Pituitary Drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. Neuroendocrine System: Pituitary Hormones  Hypothalamus  Part  of central nervous system Pituitary gland  Anterior pituitary (adenohypophysis)  Posterior  pituitary (neurohypophysis) Together they govern all bodily functions.  Hormones  Negative feedback loop Copyright © 2020 Elsevier Inc. All Rights Reserved. 4 Negative Feedback Loop (p. 475) Copyright © 2020 Elsevier Inc. All Rights Reserved.  Hormone secretion---commonly regulated by a negative feedback loop.  Surveillance and signaling based on body’s ongoing needs Example: 5 Pituitary Drugs  Anterior pituitary drugs  Cosyntropin  Somatropin  Octreotide  Posterior pituitary drugs  Vasopressin  Desmopressin Copyright © 2020 Elsevier Inc. All Rights Reserved. 6 Pituitary Drugs: Mechanism of Action Differs depending on the drug Copyright © 2020 Elsevier Inc. All Rights Reserved. Either augments or antagonizes the natural effects of the pituitary hormones 7 Anterior Pituitary  Cosyntropin (Cortrosyn)  Stimulates release of cortisol from adrenal cortex  Antiinflammatory effect  Used to diagnose adrenocortical insufficiency  Wasting associated with human immunodeficiency virus (HIV) infection  Promotes renal retention of sodium– can result in edema and hypertension Copyright © 2020 Elsevier Inc. All Rights Reserved. 8 Anterior Pituitary (Cont.)   Somatropin  Recombinantly made growth hormone (GH)  Stimulates skeletal growth in patients with deficient GH  HIV-Tx of wasting and cachexia Octreotide (Sandostatin)  Carcinoid tumors secrete VIP (vasoactive intestinal polypeptide)—causes profuse diarrhea.  Octreotide reduces this severe diarrhea, flushing, and life-threatening hypotension  Esophageal varices Copyright © 2020 Elsevier Inc. All Rights Reserved. 9 Posterior Pituitary Gland  Vasopressin and desmopressin  Mimic  Used the action of antidiuretic hormone in the treatment of diabetes insipidus Copyright © 2020 Elsevier Inc. All Rights Reserved. 10 Posterior Pituitary Gland (Cont.)  Vasopressin  Vasoconstrictor  Improves or vasodilator? BP and is given for:  Advanced Cardiac Life Support (ACLS): pulseless cardiac arrest  Vasopressin is also used to stop bleeding of esophageal varices. Copyright © 2020 Elsevier Inc. All Rights Reserved. 11 Posterior Pituitary Gland (Cont.)  Desmopressin  Treatment of hemophilia A and type I von Willebrand disease  Management of nocturnal enuresis (what is that?) Copyright © 2020 Elsevier Inc. All Rights Reserved. 12 Adverse Effects -specific to the individual Pituitary Drugs: Nursing Implications  Assess/document:  medication  height, history weight, VS  contraindications specific to each drug  medication interactions  diagnostic lab values (e.g., glucose levels, liver, and kidney function) Copyright © 2020 Elsevier Inc. All Rights Reserved. 13 Pituitary Drugs: Nursing Implications (Cont.)  Octreotide (Sandostatin)  May impair gallbladder function; instruct patient to report abdominal pain.  Use with caution in patients with renal impairment.  Monitor glucose levels in patients with diabetes and even in those who do not have diabetes.  Can be given intravenously, intramuscularly, or subcutaneously Copyright © 2020 Elsevier Inc. All Rights Reserved. 14 Pituitary Drugs: Nursing Implications (Cont.) Provide specific instructions for nasal spray forms of vasopressin.  Rotate injection sites.  Do not discontinue drugs abruptly.  Check with provider before taking overthe-counter products.  Parents of children receiving GHs should keep a journal of child’s wt/ht.  Copyright © 2020 Elsevier Inc. All Rights Reserved. 15 Pituitary Drugs: Nursing Implications (Cont.)  Monitor for therapeutic responses:  Somatropin:______________________  Octreotide: ______________________  Vasopressin: _____________________  Desmopressin:  ____________________ Monitor for adverse effects: ________________________ Copyright © 2020 Elsevier Inc. All Rights Reserved. 16 Chapter 31 Thyroid and Antithyroid Drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. Thyroid Gland   Secretes three hormones essential for proper regulation of metabolism  Thyroxine (T4)  Triiodothyronine (T3)  Calcitonin Located near the parathyroid gland, which is responsible for maintaining adequate levels of calcium in the extracellular fluid Copyright © 2020 Elsevier Inc. All Rights Reserved. 18 Primary: abnormality in the thyroid gland itself Hypothyroidism: Deficiency in Thyroid Hormones Secondary: results when the pituitary gland is dysfunctional and does not secrete thyroid-stimulating hormone (TSH) Tertiary: results when hypothalamus gland does not secrete thyrotropinreleasing hormone, which stimulates the release of TSH Copyright © 2020 Elsevier Inc. All Rights Reserved. 19 Hypothyroidism Classified also by when it occurs in the lifespan:   Congenital hypothyroidism (Cretinism)  Hyposecretion of thyroid hormone during YOUTH  Low metabolic rate, retarded growth/sexual development, possible mental retardation 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 Copyright © 2020 Elsevier Inc. All Rights Reserved. 20 Hypothyroidism (Cont.)   Goiter  Enlargement of thyroid gland  Results from overstimulation by elevated levels of TSH  TSH is elevated because there is little or no thyroid hormone in circulation. ❖ Remember though: there can be conditions of hyperthyroidism that can lead to goiter also. Common symptoms:______________________ Copyright © 2020 Elsevier Inc. All Rights Reserved. 21 Hyperthyroidism: Excessive Thyroid Hormones  Caused by several diseases  Graves’ disease  Multinodular disease  Plummer’s disease (rare); also called toxic nodular disease  Thyroid storm (induced by stress or infection)  Severe and potentially life threatening Copyright © 2020 Elsevier Inc. All Rights Reserved. 22 Hyperthyroidism  Affects multiple body systems, resulting in an overall increase in metabolism  Diarrhea  Flushing  Increased appetite  Muscle weakness  Sleep disorders  Altered menstrual flow Copyright © 2020 Elsevier Inc. All Rights Reserved. Fatigue Palpitations Nervousness Heat intolerance Irritability 23 Treatment of Hyperthyroidism  Radioactive iodine (I131):________________  Surgery to remove all or part of the thyroid gland;____________  Antithyroid drugs: thioamide derivatives  Methimazole (Tapazole)-rarely used  Propylthiouracil (assure proper administration)  Radioactive iodine (iodine 131)—educate patient  Potassium iodine-Temporarily blocks the production of thyroid hormone ***What labs need to be monitored?_______________ Copyright © 2020 Elsevier Inc. All Rights Reserved. 24 Thyroid Replacement Drugs (needed after treatment of hyperthyroidism)  Levothyroxine (Synthroid, Levoxyl)   Liothyronine (Cytomel)   Synthetic thyroid hormone T4 Synthetic thyroid hormone T3 Liotrix (Thyrolar)  Synthetic thyroid hormone T3 and T4 combined Copyright © 2020 Elsevier Inc. All Rights Reserved. 25 Thyroid Replacement Drugs: Mechanism of Action  Thyroid preparations are given to replace what the thyroid gland cannot produce to achieve normal thyroid levels (euthyroid).  Thyroid drugs work the same way as endogenous thyroid hormones. Copyright © 2020 Elsevier Inc. All Rights Reserved. 26 Thyroid Replacement Drugs: Indications  Replace what the thyroid gland itself cannot produce to achieve euthyroid condition (Levothyroxine)  Diagnosis of suspected hyperthyroidism (as in a TSHsuppression test)  Prevention or treatment of various types of goiters  Replacement hormonal therapy when thyroid glands have been surgically removed/destroyed  Hypothyroidism of pregnancy Copyright © 2020 Elsevier Inc. All Rights Reserved. 27 Thyroid Replacement Drugs: Adverse Effects  Cardiac dysrhythmia is the most significant adverse effect.  May also cause:  Tachycardia, palpitations, angina, hypertension, insomnia, tremors, headache, anxiety, nausea, diarrhea, menstrual irregularities, weight loss, sweating, heat intolerance, fever, others Copyright © 2020 Elsevier Inc. All Rights Reserved. 28 Levothyroxine (Synthroid)  Most commonly prescribed synthetic thyroid hormone  Chemically pure …100% T4 (thyroxine)  Daily dose  Best  at 0600 on an empty stomach Dosed in micrograms (mcg) Copyright © 2020 Elsevier Inc. All Rights Reserved. 29 Antithyroid Drugs  Used to treat hyperthyroidism  Prevents the surge in thyroid hormones that occurs after surgical treatment or during radioactive iodine treatment for hyperthyroidism Mechanism of Action  Methimazole and propylthiouracil  Inhibits the production of precursors of T3 and T4  Impedes formation of thyroid hormone  Propylthiouracil also inhibits the conversion of T4 to T3 in the peripheral circulation. Copyright © 2020 Elsevier Inc. All Rights Reserved. 30 Antithyroid Drugs: Indications  Treat hyperthyroidism  Prevent surge in thyroid hormones after surgical treatment or during radioactive iodine therapy Adverse Effects:  Liver and bone marrow toxicity is the most damaging or serious adverse effect. Copyright © 2020 Elsevier Inc. All Rights Reserved. 31 Propylthiouracil (PTU)  Thioamide antithyroid  2 weeks of therapy may be necessary before symptoms improve. Copyright © 2020 Elsevier Inc. All Rights Reserved. 32 Antithyroid Drugs: Nursing Implications Assess for drug allergies, contraindications, and potential drug interactions. Obtain baseline vital signs and weight. Cautious use is advised for those with cardiac disease or hypertension and for pregnant women. Copyright © 2020 Elsevier Inc. All Rights Reserved. 33 Antithyroid Drugs: Nursing Implications During pregnancy, treatment for hypothyroidism should continue. Fetal growth may be retarded if maternal hypothyroidism is untreated during pregnancy. Adjust dosage _____________to keep TSH at the lower end of the normal range. Copyright © 2020 Elsevier Inc. All Rights Reserved. 34 Antithyroid Drugs: Nursing Implications (Cont.) 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. Copyright © 2020 Elsevier Inc. All Rights Reserved. 35 Thyroid Crisis (Thyroid Storm)  Exacerbation of hyperthyroidism and is potentially life threatening  Assess for precipitating causes   Stress  Infection Assess for drug interactions Copyright © 2020 Elsevier Inc. All Rights Reserved. 36 Thyroid/Antithyroid Drugs: Nursing Implications Teach patients to report any unusual symptoms, chest pain, or heart palpitations. Teach patients not to take over-thecounter medications without primary care provider approval. Teach patients that therapeutic effects may take several weeks to occur. Copyright © 2020 Elsevier Inc. All Rights Reserved. 37 Thyroid/Antithyroid Drugs: Nursing Implications (Cont.) Teach patients to alert health care providers of thyroid medication use May enhance activity of anticoagulants May need increased dosages of hypoglycemic medications May decrease serum digoxin levels Copyright © 2020 Elsevier Inc. All Rights Reserved. Antithyroid medications Better tolerated with food Give at the same time each day to maintain consistent blood levels Never stop these medications abruptly Avoid eating foods high in iodine (seafood, soy sauce, tofu, and iodized salt) 38 Thyroid/Antithyroid Drugs: Nursing Implications Monitor for therapeutic response:_________________ Monitor for adverse effects. Copyright © 2020 Elsevier Inc. All Rights Reserved. 39 Small Group Activity Break Chapter 32 Antidiabetic Drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. Pancreas  Located behind stomach  Both exocrine and endocrine gland  Produce two hormones that play an important role in regulation of glucose homeostasis   Insulin  Glucagon Glycogen   Excess glucose stored in liver and skeletal muscle tissue Glycogenolysis  Conversion of glycogen into glucose when needed Copyright © 2020 Elsevier Inc. All Rights Reserved. 43 Insulin  Direct effect on fat metabolism  Stimulates lipogenesis and inhibits lipolysis  Stimulates protein synthesis  Promotes intracellular shift of potassium and magnesium into the cells  Cortisol, epinephrine, and growth hormone work synergistically with glucagon to counter the effects of insulin. Copyright © 2020 Elsevier Inc. All Rights Reserved. 44 Diabetes Mellitus  Diabetes mellitus (DM) actually is not a single disease but a group of progressive diseases. It is often regarded as a syndrome rather than a disease.  Two types  Type 1  Type 2 Copyright © 2020 Elsevier Inc. All Rights Reserved. 45 Diabetes Mellitus (Cont.)  Signs and symptoms  Elevated fasting blood glucose (higher than 126 mg/dL) or a hemoglobin A1C (HbA1C) level greater than or equal to 6.5%  Polyuria  Polydipsia  Polyphagia  Glycosuria  Unexplained weight loss  Fatigue  Blurred vision 46 Type 1 Diabetes Mellitus  Lack of insulin production or production of defective insulin  Affected patients need exogenous insulin.  Fewer than 10% of all DM cases are type 1.  Complications  Diabetic ketoacidosis (DKA)  Hyperosmolar hyperglycemic syndrome (HHS) Copyright © 2020 Elsevier Inc. All Rights Reserved. 47 Acute Diabetic Complications  DKA  Hyperglycemia  Ketones in the serum  Acidosis  Dehydration  Electrolyte imbalances  Approximately 25% to 30% of patients with newly diagnosed type 1 DM present with DKA. Copyright © 2020 Elsevier Inc. All Rights Reserved. 48 Acute Complications  HHS (Hyperosmolar Hyperglycemic Syndrome)  Usually Type II Diabetics  Very high blood sugar > 600  Person creates insulin and so symptoms occur gradually  Very dehydrated  Usually present with neurological symptoms  Electrolyte imbalances  Treatment: Administer: ________ and _________ Type 2 Diabetes Mellitus  Most common type: 90% of all cases  Caused by insulin deficiency and insulin resistance  Many tissues are resistant to insulin:  Reduced  Insulin number of insulin receptors receptors less responsive Copyright © 2020 Elsevier Inc. All Rights Reserved. 50 Type 2 Diabetes Mellitus (Cont.)   Several comorbid conditions  Obesity  Coronary heart disease  Dyslipidemia  Hypertension  Microalbuminemia (protein in the urine)  Increased risk for thrombotic (blood clotting) events These comorbidities referred to as:  metabolic syndrome, or  insulin-resistance syndrome, or  syndrome X Copyright © 2020 Elsevier Inc. All Rights Reserved. 51 Major Long-Term Complications of Both Types of Diabetes  Macrovascular (atherosclerotic plaque)  Coronary arteries  Cerebral arteries  Peripheral  vessels Microvascular (capillary damage)  Retinopathy  Neuropathy  Nephropathy Copyright © 2020 Elsevier Inc. All Rights Reserved. 52 Gestational Diabetes     Hyperglycemia that develops during pregnancy Insulin must be given to prevent birth defects. Usually subsides after delivery 30% of patients may develop type 2 DM within 10 to 15 years. Copyright © 2020 Elsevier Inc. All Rights Reserved. 53 Screening for Diabetes  Prediabetes  Categories  HbA1C  Fasting of increased risk for DM of 5.7% to 6.4% plasma glucose levels: 100 mg/dL to 125 mg/dL  Impaired glucose tolerance test (oral glucose challenge): 140-199 mg/dL  Screening recommended every 3 years for all patients 45 years and older Copyright © 2020 Elsevier Inc. All Rights Reserved. 54 Nonpharmacologic Treatment Interventions  Type 1: always requires insulin therapy  Type 2  Weight loss  Improved dietary habits  Smoking cessation  Reduced alcohol consumption  Regular  Oral physical exercise meds and/or insulin Copyright © 2020 Elsevier Inc. All Rights Reserved. 55 Glycemic Goal of Treatment  HbA1C of less than 7% (but should be individualized)  HbA1C diagnostic criteria;  6.5 = Type 2 diabetes  Fasting blood glucose goal for diabetic patients: 70 to 130 mg/dL  Estimated average glucose Copyright © 2020 Elsevier Inc. All Rights Reserved. 56 Treatment for Diabetes  Type 1  Insulin  therapy Type 2  Lifestyle  Oral changes drug therapy  Insulin when the above no longer provide glycemic control Copyright © 2020 Elsevier Inc. All Rights Reserved. 57 Types of Antidiabetic Drugs  Insulins  Oral hypoglycemic drugs  Both aim to produce normal blood glucose states  Some new injectable hypoglycemic drugs may be used in addition to insulin or antidiabetic drugs. Copyright © 2020 Elsevier Inc. All Rights Reserved. 58 Insulins  Function as a substitute for the endogenous hormone  Effects are the same as normal endogenous insulin.  Restores the diabetic patient’s ability to:  Metabolize  Store carbohydrates, fats, and proteins glucose in the liver  Convert glycogen to fat stores Copyright © 2020 Elsevier Inc. All Rights Reserved. 59 Insulins (Cont.)  Human insulin  Derived using recombinant DNA technologies  Recombinant  insulin produced by bacteria and yeast Goal: tight glucose control  To reduce the incidence of long-term complications Copyright © 2020 Elsevier Inc. All Rights Reserved. 60 Insulins (Cont.)  Rapid-acting insulin  Most rapid onset (5 to 15 minutes)  Peak: 1 to 2 hours  Duration: 3 to 5 hours  Patient must eat a meal after injection  Insulin lispro (Humalog)  Similar action to endogenous insulin  Insulin aspart (NovoLog)  Insulin glulisine (Apidra)  May be given subcutaneously (SQ) or via continuous SQ infusion pump (but not intravenously [IV])  Prevents a post-prandial increase in blood sugar Copyright © 2020 Elsevier Inc. All Rights Reserved. 61 Rapid-Acting Insulins  Afrezza  Rapid-acting insulin that is inhaled  Peak: 12 to 15 minutes  Short duration (2 to 3 hours)  Administered within 20 minutes before each meal  Must be given in conjunction with long-acting insulins or oral diabetic agents (for type 2 DM)  Side effects: hypoglycemia, cough, and throat pain  Contraindicated: smokers and those with chronic lung diseases  Black box warning regarding the risk of acute bronchospasms Copyright © 2020 Elsevier Inc. All Rights Reserved. 62 Short-Acting Insulins  Short acting  Regular  Routes insulin (Humulin R) of administration: IV bolus, IV infusion, IM, SQ  Onset  Peak (SQ route): 30 to 60 minutes (SQ route): 2.5 hours  Duration  Prevent (SQ route): 6 to 10 hours a post-prandial increase in blood sugar Copyright © 2020 Elsevier Inc. All Rights Reserved. 63 Insulin Dosing and Syringes  U100   U200   Insulin pen U300   Standard for most (100 units/mL) Insulin pen U500 Newer concentration for those patients needing very high doses of insulin  500 units/mL  Copyright © 2020 Elsevier Inc. All Rights Reserved. 64 Intermediate-Acting Insulins  Intermediate acting  Insulin isophane suspension (also called NPH)  Cloudy  Often appearance combined with regular insulin  Onset—1  Peak—4 to 2 hours to 8 hours  Duration—10 to 18 hours Copyright © 2020 Elsevier Inc. All Rights Reserved. 65 Long-Acting Insulins  Long acting (also called basal)  Insulin glargine (Lantus)  Clear, colorless solution  Constant  Usually dosed once daily/can be dosed every 12 hours  Referred  Onset:  Peak: level of insulin in the body to as basal insulin 1 to 2 hours none  Duration:  Toujeo: 24 hours more concentrated U-300 Copyright © 2020 Elsevier Inc. All Rights Reserved. 66 Long-Acting Insulins (Cont.)  Long acting (Cont.)  Insulin detemir (Levemir) Duration of action is dose dependent.  Lower doses require twice-daily dosing.  Higher doses may be given once daily.   Insulin glargine (Basaglar) Biosimilar insulin  U100   Insulin degludec (Tresiba) Ultra long acting  Once daily  U100 or U200  Copyright © 2020 Elsevier Inc. All Rights Reserved. 67 Fixed-Combination Insulins  Fixed combinations  Humulin 70/30  Humulin 50/50  Novolin 70/30  Humalog Mix 75/25  Humalog 50/50  NovoLog 70/30 Copyright © 2020 Elsevier Inc. All Rights Reserved. 68 Fixed-Combination Insulins (Cont.)  Each contains two different insulins, fixed combinations  One intermediate-acting type  Either one rapid-acting type (Humalog, NovoLog) or one short-acting type (Humulin) Copyright © 2020 Elsevier Inc. All Rights Reserved. 69 Sliding-Scale Insulin Dosing     SQ rapid-acting (lispro or aspart) or shortacting (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 SQ insulin is ordered in an amount that increases as the blood glucose increases. Disadvantage: delays insulin administration until hyperglycemia occurs; results in large swings in glucose control Copyright © 2020 Elsevier Inc. All Rights Reserved. 70 Basal-Bolus Insulin Dosing Preferred method of treatment for hospitalized patients with DM  Mimics a healthy pancreas by delivering basal 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) given at meals.  Copyright © 2020 Elsevier Inc. All Rights Reserved. 71 Oral Antidiabetic Drugs  Used for type 2 DM  Effective treatment involves several elements.  Careful monitoring of blood glucose levels  Therapy with one or more drugs  Treatment of associated comorbid conditions such as high cholesterol and high blood pressure Copyright © 2020 Elsevier Inc. All Rights Reserved. 72 Oral Antidiabetic Drugs (Cont.)  2013 American Diabetes Association guidelines  New-onset type 2 DM treatment  Lifestyle  Oral interventions biguanide drug metformin  If lifestyle modifications and the maximum tolerated metformin dose do not achieve the recommended HbA1C goals after 3 to 6 months:_________ Copyright © 2020 Elsevier Inc. All Rights Reserved. 73 Oral Antidiabetic Drugs: Biguanide  Metformin (Glucophage)  First-line drug and is the most commonly used oral drug for the treatment of type 2 DM  Not used for type 1 DM Copyright © 2020 Elsevier Inc. All Rights Reserved. 74 Oral Antidiabetic Drugs: Mechanism of Action  Biguanides (metformin)     Decrease production of glucose by the liver Increase uptake of glucose by tissues Decrease intestinal absorption of glucose Do not increase insulin secretion from the pancreas (does not cause hypoglycemia) Copyright © 2020 Elsevier Inc. All Rights Reserved. 75 Oral Antidiabetic Drugs: Adverse Effects  Biguanides (metformin)  Primarily affects gastrointestinal (GI) tract. S.E.: abdominal bloating, nausea, cramping, diarrhea, feeling of fullness  May also cause metallic taste, reduced vitamin B12 levels  Lactic acidosis is rare but lethal if it occurs.  Contrast  Does dyes not cause hypoglycemia Copyright © 2020 Elsevier Inc. All Rights Reserved. 76 Oral Antidiabetic Drugs: Sulfonylureas  Second generation: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta)  Stimulate insulin secretion from the beta cells of the pancreas  Beta cell function must be present  Improve sensitivity to insulin in tissues  Result in lower blood glucose level  Adverse effects: hypoglycemia, hematologic effects, nausea, epigastric fullness, heartburn, many others Copyright © 2020 Elsevier Inc. All Rights Reserved. 77 Oral Antidiabetic Drugs: Glinides  Glinides  Repaglinide  Indication:  Action type 2 DM similar to sulfonylureas  Increase  Need (Prandin), nateglinide (Starlix) insulin secretion from the pancreas to take with every meal Copyright © 2020 Elsevier Inc. All Rights Reserved. 78 Oral Antidiabetic Drugs: Adverse Effects  Glinides  Adverse effects: headache, hypoglycemic effects, dizziness, weight gain, joint pain, upper respiratory infection, or flulike symptoms Copyright © 2020 Elsevier Inc. All Rights Reserved. 79 Oral Antidiabetic Drugs: Thiazolidinediones (Glitazones)  Thiazolidinediones (TZDs)  Pioglitazone (Actos)  Rosiglitazone (Avandia)  Controversial  Insulin-sensitizing drugs  Indication: type 2 DM  MOA:  Decrease insulin resistance  Increase glucose uptake and use in skeletal muscle  Inhibit glucose and triglyceride production in the liver Copyright © 2020 Elsevier Inc. All Rights Reserved. 80 Oral Antidiabetic Drugs: Adverse Effects  Alpha-glucosidase inhibitors (acarbose, miglitol)  Flatulence, diarrhea, abdominal pain  Do not cause hypoglycemia, hyperinsulinemia, or weight gain  These drugs are not used very often but for some people are an option  Contraindications: IBS, malabsorption syndrome, intestinal obstruction Copyright © 2020 Elsevier Inc. All Rights Reserved. 81 Oral Antidiabetic Drugs: Mechanism of Action  Alpha-glucosidase inhibitors  Reversibly inhibit the enzyme alpha glucosidase in the small intestine  Result in delayed absorption of glucose  Must be taken with meals to prevent excessive postprandial blood glucose elevations (with the “first bite” of a meal) Copyright © 2020 Elsevier Inc. All Rights Reserved. 82 Oral Antidiabetic Drugs: Dipeptidyl Peptidase-IV (DPP-IV) Inhibitors  Dipeptidyl peptidase-IV (DPP-IV) inhibitors (gliptins)  Sitagliptin (Januvia)  Saxagliptin (Onglyza)  Linagliptin (Tradjenta)  Alogliptin (Nesina) Copyright © 2020 Elsevier Inc. All Rights Reserved. 83 Oral Antidiabetic Drugs: Mechanism of Action  DPP-IV inhibitors  Delay breakdown of incretin hormones by inhibiting the enzyme DPP-IV.  Incretin hormones increase insulin synthesis and lower glucagon secretion.  Reduce fasting and postprandial glucose concentrations. Copyright © 2020 Elsevier Inc. All Rights Reserved. 84 Oral Antidiabetic Drugs: Adverse Effects  DPP-IV inhibitors  Upper respiratory tract infection, headache, and diarrhea  Hypoglycemia can occur and is more common if used in conjunction with a sulfonylurea. Copyright © 2020 Elsevier Inc. All Rights Reserved. 85 Oral Antidiabetic Drugs: Indications  Used alone or in combination with other drugs and/or diet and lifestyle changes to lower the blood glucose levels in patients with type 2 DM Copyright © 2020 Elsevier Inc. All Rights Reserved. 86 Injectable Antidiabetic Drugs  Amylin agonist   Pramlintide (Symlin) Incretin mimetics       Exenatide (Byetta) Dulaglutide (Trulicity) Liraglutide (Victoza) Albiglutide (Tanzeum) Lixisenatide (Adlyxin) Combo agent: Soliqua (insulin glargine and lixisenatide)  Xultophy (insulin degludec and liraglutide)  Copyright © 2020 Elsevier Inc. All Rights Reserved. 87 Injectable Antidiabetic Drugs: Mechanism of Action  Amylin agonist  Mimics  Slows the natural hormone amylin gastric emptying  Suppresses glucagon secretion, reducing hepatic glucose output  Centrally modulates appetite and satiety  Used when other drugs have not achieved adequate glucose control  SQ injection Copyright © 2020 Elsevier Inc. All Rights Reserved. 88 Injectable Antidiabetic Drugs: Mechanism of Action (Cont.)  Incretin mimetic  Mimics the incretin hormones  Enhances glucose-driven insulin secretion from beta cells of the pancreas  Only used for type 2 DM  Exenatide: injection pen device Copyright © 2020 Elsevier Inc. All Rights Reserved. 89 Injectable Antidiabetic Drugs: Adverse Effects  Amylin agonist  Nausea,  vomiting, anorexia, headache Incretin mimetics  Nausea, vomiting, and diarrhea  Rare cases of hemorrhagic or necrotizing pancreatitis  Weight loss Copyright © 2020 Elsevier Inc. All Rights Reserved. 90 Sodium Glucose Cotransporter (SGLT2) Inhibitors  Inhibition of SGLT2 leads to a decrease in blood glucose caused by an increase in renal glucose excretion.  SGLT2 inhibitors: new class of oral drugs for the treatment of type 2 DM  Canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance)  Action: work independently of insulin to prevent glucose reabsorption from the glomerular filtrate, resulting in a reduced renal threshold for glucose and glycosuria Copyright © 2020 Elsevier Inc. All Rights Reserved. 91 Sodium Glucose Cotransporter (SGLT2) Inhibitors (Cont.)  Other effects: may increase insulin sensitivity and glucose uptake in the muscle cells and decrease gluconeogenesis  Results: improved glycemic control, weight loss, and a low risk of hypoglycemia Copyright © 2020 Elsevier Inc. All Rights Reserved. 92 Antidiabetic Agents: mechanisms of action  Decrease GI absorption of glucose  Decrease glucose production  Decrease glucagon production  Increase uptake of glucose to cells  Increase insulin receptor sensitivity  Decrease appetite  Increase excretion of glucose (renal)  Increase insulin production/secretion Hypoglycemia  Abnormally low blood glucose level (below 50 mg/dL)  Mild cases can be treated with diet—higher intake of protein and lower intake of carbohydrates—to prevent rebound postprandial hypoglycemia. Copyright © 2020 Elsevier Inc. All Rights Reserved. 94 Hypoglycemia Symptoms  Early  Confusion,  irritability, tremor, sweating Late  Hypothermia,  Coma seizures and death will occur if not treated. Copyright © 2020 Elsevier Inc. All Rights Reserved. 95 Glucose-Elevating Drugs  Oral forms of concentrated glucose  Buccal tablets, semisolid gel  50% dextrose in water (D50W)  Glucagon Copyright © 2020 Elsevier Inc. All Rights Reserved. 96 Hypoglycemics: Nursing Implications  Before giving drugs that alter glucose levels, obtain and document: A thorough history  Vital signs  Blood glucose level, HbA1C level  Potential complications and drug interactions Copyright © 2020 Elsevier Inc. All Rights Reserved. 97 Hypoglycemics: Nursing Implications (Cont.)  Before giving drugs that alter glucose levels, assess:  patient’s  nausea  Has ability to consume food or vomiting the patient eaten recently?  If a patient is NPO for a test or procedure, consult the provider to clarify orders Copyright © 2020 Elsevier Inc. All Rights Reserved. 98 Hypoglycemics: Nursing Implications (Cont.)  Keep in mind that overall concerns for any patient with DM increase when the patient:  Is under stress  Has an infection  Has an illness or trauma  Is pregnant or lactating Copyright © 2020 Elsevier Inc. All Rights Reserved. 99 Hypoglycemics: Nursing Implications  Thorough patient education is essential regarding:  Disease  Diet process and exercise recommendations  Self-administration  Potential of insulin or oral drugs complications Copyright © 2020 Elsevier Inc. All Rights Reserved. 100 Hypoglycemics: Nursing Implications (Cont.)  When insulin is ordered, ensure:  Correct route  Correct type of insulin  Timing of the dose  Correct dosage  Insulin order and prepared dosages are second checked with another nurse.  Administer insulin at room temperature. Copyright © 2020 Elsevier Inc. All Rights Reserved. 101 Hypoglycemics: Nursing Implications (Cont.)  Insulin  Check blood glucose level before giving insulin.  Roll vials between hands instead of shaking them to mix suspensions.  Ensure correct storage of insulin vials.  Only use insulin syringes, calibrated in units, to measure and give insulin.  Ensure correct timing of insulin dose with meals. Copyright © 2020 Elsevier Inc. All Rights Reserved. 102 Hypoglycemics: Nursing Implications (Cont.)  Insulin (Cont.)  When drawing up two types of insulin in one syringe, always draw up the regular or rapid-acting insulin first.  Provide thorough patient education regarding self-administration of insulin injections, including timing of doses, monitoring blood glucose levels, and injection site rotations. Copyright © 2020 Elsevier Inc. All Rights Reserved. 103 Hypoglycemics: Nursing Implications  Oral antidiabetic drugs  Always check blood glucose levels before giving  Usually given 30 minutes before meals  Alpha-glucosidase inhibitors are given with the first bite of each main meal. Why?  Metformin is taken with meals. Why?  Metformin will need to be discontinued if the patient is to undergo studies with contrast dye because of possible renal effects; check with the prescriber. Copyright © 2020 Elsevier Inc. All Rights Reserved. 104 -Assess for signs of hypoglycemia:________ -Also assess vital signs and fingerstick blood sugar Hypoglycemics: Nursing Implications (Cont.) If hypoglycemia occurs: Administer oral form of glucose if the patient is conscious. Give the patient glucose tablets 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 glucagon IV if the patient is unconscious. Monitor blood glucose levels. Copyright © 2020 Elsevier Inc. All Rights Reserved. 105 Hypoglycemics: Nursing Implications (Cont.)  Monitor for 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.  Monitor for hypoglycemia and hyperglycemia. Copyright © 2020 Elsevier Inc. All Rights Reserved. 106 Chapter 33 Adrenal Drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. Adrenal Gland  Located on top of the kidney  Adrenal cortex  Adrenal medulla  Each portion has different functions and secretes different hormones.  Feedback process of hormone regulation Copyright © 2020 Elsevier Inc. All Rights Reserved. 108 Adrenal Gland (Cont.)   Adrenal medulla secretes catecholamines.  Epinephrine  Norepinephrine  Oversecretion can result in pheochromocytoma Adrenal cortex secretes corticosteroids.  Glucocorticoids  Mineralocorticoids (primarily aldosterone)  Disruptions of corticosteroids can lead to Cushing’s syndrome or Addison’s Disease Copyright © 2020 Elsevier Inc. All Rights Reserved. 109 Adrenocortical Hormones  Oversecretion leads to Cushing’s syndrome.   “Moon face,” “hump back,” hirsutism, ecchymosis, hypertension, hypokalemia, hypernatremia, abnormal glucose tolerance, muscle atrophy Undersecretion leads to Addison’s disease.  Decreased blood sodium and glucose levels, increased potassium levels, dehydration, weight loss Copyright © 2020 Elsevier Inc. All Rights Reserved. 110 Adrenal Drugs  Can be either synthetic or natural  Many different drugs and forms  Glucocorticoids   Mineralocorticoid   Topical, systemic, inhaled, nasal Systemic Glucocorticoids examples: -Adrenocorticotropic hormone -Betamethasone -Cortisone -Dexamethasone -Hydrocortisone -Methylprednisolone -Prednisolone -Triamcinolone Adrenal steroid inhibitors  Systemic Copyright © 2020 Elsevier Inc. All Rights Reserved. 111 Adrenal Drugs: Mechanism of Action Copyright © 2020 Elsevier Inc. All Rights Reserved.  Action of corticosteroids is related to the involvement in the synthesis of certain proteins.  Most corticosteroids exert their effects 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. 112 Adrenal Drugs: Indications Copyright © 2020 Elsevier Inc. All Rights Reserved.  Adrenocortical deficiency  Adrenogenital syndrome  Bacterial meningitis  Cerebral edema  Collagen diseases (e.g., lupus erythematosus)  Dermatologic diseases (e.g., exfoliative dermatitis)  Endocrine disorders (thyroiditis) 113 Adrenal Drugs: Indications (Cont.) Copyright © 2020 Elsevier Inc. All Rights Reserved.  Gastrointestinal (GI) diseases (e.g., ulcerative colitis  Exacerbations of asthma and COPD  Hematologic disorders (reduce bleeding)  Ophthalmic disorders (e.g., nonpyogenic inflammations)  Organ transplantation (decrease immune response to prevent rejection)  Leukemias and lymphomas (palliative management)  Nephrotic syndrome (remission of proteinuria)  Spinal cord injury 114 Administration  Glucocorticoids administration  By inhalation for control of steroidresponsive bronchospastic states  Nasally for rhinitis and to prevent the recurrence of polyps after surgical removal  Topically for inflammations of the eye, ear, and skin Copyright © 2020 Elsevier Inc. All Rights Reserved. 115 Adrenal Drugs: Contraindications  Drug allergies  Serious infections, including septicemia, systemic fungal infections, and varicella  However, in the presence of tuberculous meningitis, glucocorticoids may be used to prevent inflammatory central nervous system (CNS) damage.  Cautious use in patients with:  Gastritis, reflux disease, ulcer disease  Diabetes  Cardiac, renal, or liver dysfunction Copyright © 2020 Elsevier Inc. All Rights Reserved. 116 Adrenal Drugs: Adverse Effects  Potent effects on all body systems—part 1  Cardiovascular: heart failure, cardiac edema, hypertension—all caused by electrolyte imbalances (hypokalemia, hypernatremia)  CNS: convulsions, headache, vertigo, mood swings, nervousness, insomnia  Endocrine: growth suppression, Cushing’s syndrome, menstrual irregularities, carbohydrate intolerance, hyperglycemia, hypothalamic– pituitary–adrenal axis suppression  GI: peptic ulcers, pancreatitis, ulcerative esophagitis, abdominal distension Copyright © 2020 Elsevier Inc. All Rights Reserved. 117 Adrenal Drugs: Adverse Effects  Potent effects on all body systems—part 2  Integumentary: fragile skin, petechiae, ecchymosis, poor wound healing, hirsutism, urticaria  Musculoskeletal: muscle weakness, loss of muscle mass, osteoporosis  Ocular: glaucoma, cataracts  Other: weight gain Copyright © 2020 Elsevier Inc. All Rights Reserved. 118 Adrenal Drugs: Interactions  Multiple drug interactions, including:  Non–potassium-sparing diuretics (e.g., thiazides, loop diuretics)  Aspirin, other nonsteroidal antiinflammatory drugs (NSAIDs), and other ulcerogenic drugs  Anticholinesterase drugs  Corticosteroids can reduce the effectiveness of antidiabetic medications and lead to elevated blood glucose levels  Others  Thyroid hormones  Antifungal drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. 119 Corticosteroids  Systemic corticosteroids consist of 13 chemically different but pharmacologically similar hormones.  Pregnancy category C drugs (risk cannot be ruled out)  Steroids must not be stopped abruptly.  Can lead to adrenal suppression Copyright © 2020 Elsevier Inc. All Rights Reserved. 120 Fludrocortisone (Florinef)  Mineralocorticoid that restores fluid/electrolyte imbalances and improves BP  Indications: Addison’s disease and treatment of saltlosing adrenogenital syndrome  Adverse effects:  Generally relate to water retention  Heart failure, hypertension, and elevated intracerebral pressure  Skin rash, peptic ulcers, hyperglycemia, hypokalemia  Muscle pain, weakness, compression bone fractures Copyright © 2020 Elsevier Inc. All Rights Reserved. 121 Addison’s vs. Cushing’s Addison’s Cushing’s Hypofunction of adrenal gland (lack of cortisol and aldosterone) Excess amounts of cortisol Lethargy/fatigue/muscle weakness Muscle wasting/weakness GI disturbance Moonface and buffalo hump Weight Loss Truncal obesity with thin extremities/weight gain/stretch marks on abdomen Menstrual changes in women; impotence in men Hirsutism (masculine characteristics in women) Hypoglycemia and hyponatremia Hyperglycemia and hypernatremia Hyperkalemia and hypercalcemia Hypokalemia and hypocalcemia Postural hypotension Hypertension Hyperpigmentation of skin Fragile skin, easily bruised Treatment Prednisone  Most commonly used oral glucocorticoid for antiinflammatory or immunosuppressant purposes  Also used to treat exacerbations of chronic respiratory illnesses  Inadequate for the management of adrenocortical insufficiency (Addison’s disease) Copyright © 2020 Elsevier Inc. All Rights Reserved. 124 Methylprednisolone (Solu-Medrol)  Most commonly used injectable glucocorticoid drug  Primary use: antiinflammatory or immunosuppressant drug  Usually administered IV  Available in a long-acting (depot) formulation  Most injectable formulations contain a preservative (benzyl alcohol) that cannot be given to children younger than 28 days of age. Copyright © 2020 Elsevier Inc. All Rights Reserved. 125 Adrenal Drugs: Nursing Implications  Perform a physical assessment  Obtain baseline laboratory studies.  Assess for edema and electrolyte imbalances.  Assess skin condition.  Assess for contraindications to adrenal drugs, especially the presence of peptic ulcer disease. Copyright © 2020 Elsevier Inc. All Rights Reserved. 126 Adrenal Drugs: Nursing Implications (Cont.)  Assess for drug allergies and potential drug interactions (prescription and over-the-counter drugs).  Be aware that these drugs may alter serum glucose and electrolyte levels.  Systemic forms may be given by oral, intramuscular, intravenous, or rectal routes (not subcutaneous).  Prepare and administer according to manufacturer’s directions. Copyright © 2020 Elsevier Inc. All Rights Reserved. 127 Adrenal Drugs: Nursing Implications (Cont.)  Oral forms should be given with food or milk to minimize GI upset.  For topical applications, follow instructions about use and type of dressing, if any, to apply.  Clear nasal passages before giving a nasal corticosteroid.  After using an orally inhaled corticosteroid, instruct patients to rinse their mouths to prevent possible oral fungal infections. Copyright © 2020 Elsevier Inc. All Rights Reserved. 128 Adrenal Drugs: Nursing Implications  Teach patients taking corticosteroids to avoid contact with people with infections and to report any fever, increased weakness, lethargy, or sore throat.  Patients should be taught to take all adrenal medications at the same time every day, usually in the morning, with meals or food.  Patients should not take adrenal medications with alcohol, aspirin, or NSAIDs. Copyright © 2020 Elsevier Inc. All Rights Reserved. 129 Adrenal Drugs: Nursing Implications (Cont.)  Sudden discontinuation of these drugs can precipitate an adrenal crisis caused by a sudden drop in serum levels of cortisone.  Doses are usually tapered before the drug is discontinued.  Monitor for therapeutic responses.  Monitor for adverse effects. Copyright © 2020 Elsevier Inc. All Rights Reserved. 130 Questions?