Adrenocortical

agents
ADRENOCORTICAL AGENTS
◦ Adrenocortical agents are drugs used
as short-term treatment to suppress
immune system in patients with
inflammatory disorders.
◦ They are also used for replacement
therapy to maintain hormone levels
when adrenal glands are not
functioning adequately.
◦ These agents are classified into three:
glucocorticoids, mineralocorticoids,
and androgens.
 Disease Spotlight:
Adrenal Insufficiency and Crisis
◦ Adrenal insufficiency is a condition when
patients experience a shortage of Adrenocorticotropic
adrenocortical hormones and develop signs hormone (ACTH) is a
and symptoms like confusion, hormone the pituitary gland
hyperpigmentation, hypoglycemia, and poor releases that plays a large
response to stress. role in how the body
◦ This can occur when a patient does not responds to stress. The
produce enough ACTH, when the glands are release of ACTH triggers the
not able to respond to ACTH, when an adrenal adrenal glands to produce
gland is damaged and cannot produce cortisol, the “stress
enough hormones (Addison’s disease), or hormone,” and androgens
secondary to surgical removal of glands. (a group of sex hormones)
◦ A prolonged use of corticosteroid hormones is a
more common cause of adrenal insufficiency.
 Disease Spotlight:
Adrenal Insufficiency and Crisis
•Adrenal crisis occurs when patients
who have an adrenal insufficiency
experience a period of extreme stress like
vehicle accidents, massive infections, or a
surgical procedure.
• The body is not able to supplement the
energy-consuming effects of the
sympathetic reaction. This is characterized
by physiological exhaustion, hypotension,
fluid shift, shock, and even death.
• Patients in adrenal crisis are treated with
massive infusion of replacement steroids,
constant monitoring, and life support
procedures
 Glucocorticoids
◦ Glucocorticoids are agents that stimulate an increase
in glucose levels for energy.
◦ They also increase the rate of protein breakdown and
decrease the rate of protein formation from amino
acids to preserve energy.
◦ They are also capable of lipogenesis, or the formation
and storage of fat in the body for energy source.
Glucocorticoids
◦ Therapeutic Action
• bind to cytoplasmic receptors of target cells to
form complex reactions needed to reduce
inflammation and to suppress immune system.
• Other glucocorticoids like hydrocortisone,
cortisone, and prednisone also have
mineralocorticoid activity so they can
affect potassium, sodium, and water levels.
• They can also limit the activity of lymphocytes to
act within the immune system. Furthermore, they
inhibit the spread of phagocytes to the
bloodstream and injured tissues.
 Glucocorticoids
◦ Indications
• short-term treatment of inflammatory disorders by
blocking the actions of arachidonic acid leading to
decrease in formation of prostaglandins and
leukotrienes.
• Local agents are used to treat local inflammation.
• Systemic use is indicated for treatment of some
cancers, hypercalcemia associated with cancer,
hematological disorders, and some neurological
infections.
• When combined with mineralocorticoids, some of
these drugs can be used in replacement therapy for
adrenal insufficiency.
 Glucocorticoids
Contraindications and Cautions
• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Acute infection. Can be exacerbated by the blocking effects of the drug on
inflammation and immune system.
• Diabetes. Glucose-elevating effect of the drug can disrupt glucose control
• Other endocrine disorders. Potential of imbalance.
• Pregnancy. Potential adverse effects on the fetus
Adverse Effects
• increased methylprednisolone toxicity among African Americans
• growth retardation
• local inflammation and infections
• burning and stinging sensation at injection site.
Glucocorticoids
◦ Nursing Diagnoses

• Altered cardiac output related to fluid retention

• Excess fluid volume related to water retention
• Risk for infection related to immunosuppression
 Glucocorticoids
◦ NURSING CONSIDERATIONS

• Administer drug daily at 8 to 9 AM to mimic normal peak diurnal

concentration levels and thereby minimize suppression of the
hypothalamic-pituitary axis (HPA).
• Space multiple doses evenly throughout the day to try to
achieve homeostasis.
• Taper doses when discontinuing to give the adrenal glands a chance to
recovr and produce adrenocorticoids.
• Protect patient from unnecessary exposure to infection and invasive
procedure because the steroids suppress the immune system and the
patient is at increased risk for infection.
• Provide comfort measures to help patient cope with drug effects.
• Provide patient education about drug effects and warning signs to report
to enhance patient knowledge and to promote compliance.
Mineralocorticoids

•Mineralocorticoids affect
electrolyte levels directly
and help maintain
homeostasis.
•The classic
mineralocorticoid
is aldosterone.
Mineralocorticoids
◦ Therapeutic Action
• aldosterone increases sodium
reabsorption in the renal tubules and increases potassium and
hydrogen excretion, leading to water and sodium retention.

◦ Indications
• partial replacement therapy in cortical insufficiency conditions
• treatment of salt-losing adrenogenital syndrome;
• off-label use: treatment of hypotension.
 Mineralocorticoids
Contraindications and Cautions
• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Severe hypertension, heart failure, or cardiac disease. Resultant increased blood
pressure
• Lactation. Potential adverse effects to the baby.
• Infection. Can alter adrenal response
• High sodium intake. Severe hypernatremia can occur.
◦ Adverse Effects
• CNS: headache, weakness
• CV: edema, hypertension, heart failure,
• Others: possible hypokalemia, allergic reactions from skin rash to anaphylaxis.
Mineralocorticoids
◦Nursing Diagnoses and Care Planning

•Imbalanced nutrition: more than body

requirements related to metabolic changes
•Excess fluid volume related to sodium retention
•Impaired urinary elimination related to sodium
retention
Glucocorticoids
◦ NURSING CONSIDERATIONS

• Use only in conjunction with appropriate glucocorticoids to

maintain control of electrolyte balance.
• Increase dose in times of stress to prevent adrenal insufficiency
and to meet increased demands for corticosteroids under stress.
• Monitor for hypokalemia (weakness, serum electrolytes) to
detect the loss early and treat appropriately.
• Discontinue if signs of overdose (excessive weight gain, edema,
hypertension) occur to prevent the development of more
severe toxicity.
• Provide comfort measures to help patient cope with drug
effects.
 Androgens
◦ Drugs affecting the male reproductive
system include androgens (male steroid
hormones), anabolic steroids, and drugs that
improve penile dysfunction.
◦ Androgens are male sex hormones, which
include testosterone (produced in the testes)
and androgens (produced in the adrenal
glands).
◦ Testosterone (Duratest, Testoderm) is the primary
natural androgen and is the classic androgen
used today.
◦ It is used for treatment of certain breast cancers
and hypogonadism, a condition where there is
undeveloped testis. All testosterones are class III
controlled substances.
 Androgens
◦ Therapeutic Action
• Growth and development of male sex
organs and the maintenance of secondary
male sex characteristics.
• Increase the retention of
nitrogen, sodium, potassium, and phosphorus
and decrease the urinary excretion
of calcium.
• Increase protein anabolism and decrease
protein catabolism.
• Increase the production of red blood cells.
 Androgens
◦ Indications

• Danazol is used for treatment of

endometriosis, fibrocystic breast disease, and
hereditary angioedema.
• It does this by inhibiting the hypothalamic-
pituitary-adrenal (HPA) and gonadotropin-
releasing hormones (GnRH), leading to a
drop in follicle-stimulating hormone (FSH) and
luteinizing hormone (LH).
 Androgens
◦ Contraindications and Cautions
• Allergy to androgens or other ingredients in the
drug. Prevent hypersensitivity reactions.
• Pregnancy, lactation. Potential adverse effects on the
neonate. It is not clear whether androgens enter breast
milk.
• Presence of prostate or breast cancer in
men. Aggravated by the testosterone effects of the
drug.
• Liver dysfunction, CV disease. Can be exacerbated by
the effects of the hormones.
• Topical forms of testosterone have a Black Box Warning
alerting user to the risk of virilization in children who
come in contact with the drug from touching the
clothes and skin of the man using the drug.
• Danazol has Black Box warning regarding the risk of
thromboembolic events, fetal abnormalities, hepatitis,
and intracranial hypertension.
 Androgens
Adverse Effects
• Androgenic effects: acne, edema, hirsutism
(increased hair distribution), deepening of the
voice, oily skin and hair, weight gain, decrease in
breast size, and testicular atrophy.
• Antiestrogen effects: flushing, sweating, vaginitis,
nervousness, and emotional lability.
• Common effects: headache (possibly related to
fluid and electrolyte changes), dizziness, sleep
disorders and fatigue, rash, and altered
serum electrolytes.
• A potentially life-threatening effect that has been
documented is hepatocellular cancer.
 Androgens
◦Nursing Diagnoses

•Disturbed body image related

to androgenic effects
•Sexual dysfunction related to
androgenic effects
 Androgens
Nursing Considerations
• Monitor responses carefully when beginning therapy so that the dose can be
adjusted accordingly.
• Remove an old dermal system before applying a new system to clean, dry, and
intact skin to ensure accurate administration and decrease risk of toxicity.
• Monitor liver function periodically with long-term therapy and arrange to
discontinue the drug at any sign of hepatic dysfunction.
• Provide thorough patient teaching (e.g. measures to avoid adverse effects,
warning signs, need for regular evaluation, especially blood pressure, etc.) to
enhance patient knowledge about drug therapy and to promote compliance
with the drug regimen.
• Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to prevent
injuries.
 Androgens
Nursing Considerations
• Monitor patient response to therapy (e.g. onset of puberty, maintenance
of male sexual characteristics, palliation of breast cancer, etc.).
• Monitor for adverse effects (e.g. androgenic effects, hypoestrogen
effects, serum electrolyte imbalance, headache, etc).
• Evaluate patient understanding on drug therapy by asking patient to
name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.
Anabolic Steroids
◦ Anabolic steroids are testosterone
analogues that have been developed to
produce the tissue-building effects of
testosterone with less androgenic effect.

◦ Therapeutic Action
• Promote body tissue-building processes.
• Reverse catabolic or tissue-destroying
processes
• Increase hemoglobin and red blood cell
mass.
 Anabolic Steroids
◦ Indications
• Anemias, certain cancers, and
angioedema
• Promote weight gain and tissue repair in
debilitated patients and protein
anabolism in patients who are receiving
long-term corticosteroid therapy.
• Also known to be used illegally for the
enhancement of athletic performance
by promoting increased muscle mass,
hematocrit, strength, and endurance.
◦Muscle protein anabolism - refers to a state in
skeletal muscle tissue where synthesis exceeds
degradation, and thus lean tissue is being built.
◦Muscle protein catabolism - refers to a state in
skeletal muscle tissue where degradation
exceeds synthesis, and thus lean tissue is being
broken down.
 Anabolic Steroids
◦ Contraindications and Cautions
• Allergy to androgens or other ingredients in the drug. Prevent
hypersensitivity reactions.
• Pregnancy, lactation. Potential masculinization in neonates.
• Liver dysfunction. Drug is metabolized in the liver and are known to
cause hepatic toxicity.
• Coronary disease. Potentional increase in cholesterol level through
the effect of the drug on the liver.
• Prostate/breast cancer in males. Exacerbated by the effects of
these drugs.
 Anabolic Steroids
◦ Adverse Effects

• In prepubertal males: virilization (e.g. phallic

enlargement, hirsutism, increased skin
pigmentation).
• In postpubertal males: inhibition of testicular
function, gynecomastia, testicular atrophy,
priapism (painful and continual erection of
the penis), baldness, and change in libido.
• In women: hirsutism, hoarseness, deepening
of the voice, clitoral enlargement,
baldness, menstrual irregularitie.
 Androgens
◦Nursing Diagnoses

•Disturbed body image related

to systemic effects
•Acute pain related to GI or
CNS effects
Anabolic Steroids
Nursing Considerations
• Administer with food if GI effects are severe to relieve GI distress.
• Monitor endocrine and hepatic functions, serum electrolytes before and
periodically during therapy so that dose can be adjusted appropriately
and severe adverse effects can be avoided.
• Provide thorough patient teaching (e.g. measures to avoid adverse
effects, warning signs, need for regular evaluation, especially blood
pressure, etc.) to enhance patient knowledge about drug therapy and to
promote compliance with the drug regimen.
Anabolic Steroids
Nursing Considerations
• Monitor patient response to therapy (e.g. increase in haematocrit, protein
anabolism, etc.).
• Monitor for adverse effects (e.g. androgenic effects, serum electrolyte
disturbances, epiphyseal closure, hepatic dysfunction, etc).
• Evaluate patient understanding on drug therapy by asking patient to
name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.
Drugs For Treating Penile Erectile Dysfunction
◦ Penile erectile dysfunction is a
condition in which the corpus
cavernosum does not fill with blood
to allow for penile erection.

◦ Approved drugs for treatment of

penile erectile dysfunction
include prostaglandinalprostadil
and phosphodiesterase type 5
(PDE5) receptor inhibitor sildenafil.
Drugs For Treating Penile Erectile Dysfunction
◦ Therapeutic Action
• Alprostadil acts locally to relax the
vascular smooth muscle and allow filling
of the corpus cavernosum, causing
penile erection.
• PDE5 receptor inhibitors act to
increase nitrous oxide levels in the
corpus cavernosum.
• Nitrous oxide activates the enzyme
cyclic guanosine monophosphate
(cGMP) to cause smooth muscle
relaxation and increased flow of blood.
Drugs For Treating Penile Erectile Dysfunction

◦Indications
•Treatment of
penile erectile
dysfunction.
Drugs For Treating Penile Erectile Dysfunction
◦ Contraindications and Cautions
• Presence of any anatomical obstruction or condition that might predispose to
priapism. The risk could be exacerbated by these drugs.
• Penile implants.
• Bleeding disorders, CV diseases, optic neuropathy, severe hepatic and renal
disorders.
◦ Adverse Effects
• Local effects associated with alprostadil: pain at injection site, infection, priapism,
fibrosis, rash.
• Effects associated with PDE5 inhibitors: headache, flushing, dyspepsia, urinary tract
infection, diarrhea, dizziness, possible eight cranial nerve toxicity and loss of hearing.
• A potentially life-threatening effect that has been documented is hepatocellular
cancer.
 Androgens
◦Nursing Diagnoses

•Disturbed body image related

to drug effects
•Sexual dysfunction related to
drug effects
Anabolic Steroids
Nursing Considerations
• Assess the cause of dysfunction before beginning therapy to ensure
appropriate use of these drugs.
• Monitor patients with vascular disease for any sign of exacerbation so that
the drug can be discontinued before severe adverse effects occur.
• Monitor responses carefully when beginning therapy so that the dose can
be adjusted accordingly.
• Provide thorough patient teaching (e.g. measures to avoid adverse
effects, warning signs, need for regular evaluation, especially blood
pressure, etc.) to enhance patient knowledge about drug therapy and to
promote compliance with the drug regimen.
Anabolic Steroids
Nursing Considerations

• Monitor patient response to therapy (improvement of penile erection).

• Monitor for adverse effects (e.g. dizziness, flushing, local inflammation or
infection, fibrosis, diarrhea, etc.).
• Evaluate patient understanding on drug therapy by asking patient to
name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.