Drugs for Thyroid and Adrenal Disorders

Drugs for Diabetes Mellitus

Endocrine System
• Major controller of homeostasis
• Consists of various glands that secrete hormones
• Hormones are chemical messengers released in
response to a change in the body’s internal
environment
Endocrine System:
Negative Feedback

• It is common for one hormone to control

the secretion of another
• Often, the last hormone in a pathway turns
off the secretion from first hormone
• Promotes homeostasis of the endocrine
system
Hypothalamus and
Pituitary Glands
• Hypothalamus and pituitary glands
control many other glands
• They secrete hormones that release
other hormones and profoundly effect
the body
Pharm Facts
• 1 in 20 Canadians has some type of thyroid disorder
• Thyroid disorders are more common in women
• Can affect a woman’s ability to become pregnant and can
cause miscarriages
Thyroid function
• Secretes hormones that affect nearly every cell in the body
• Regulate basal metabolic rate (baseline speed at which cells
perform function)
• By increasing cellular metabolism, thyroid hormone ↑ body
temperature
• Helps maintain BP, growth & development
Thyroid gland
• Secretes calcitonin and thyroid hormone
• Thyroid hormone is combination of:
• thyroxine (T4) and triiodothyronine (T3)
• Iodine is essential for synthesis of these hormones
• Iodine is added to table salt
Thyroxine (T4)
• Major hormone secreted by thyroid gland
• Converted to T3 at target tissues
• Falling T4 levels in the blood signal the hypothalamus to
secrete thyroid-releasing hormone (TRH)
• TRH stimulates pituitary gland to secrete thyroid-stimulating
hormone (TSH)
• This in turn stimulates thyroid to release thyroid hormone
Bloodwork for Thyroid Function
• Thyroid Stimulating Hormone (TSH) and
• Thyroid hormone (T4 and T3) can be
ordered to diagnose and monitor
thyroid function
• These levels will generally be in
opposite directions
• Hypo- and hyperthyroidism refers to the
low or high levels of thyroid hormone
(T3 and T4)
Thyroid Disorder Comparison
Hypothyroidism Hyperthyroidism
↑ TSH ↓ T4 & T3 ↓ TSH ↑ T4 & T3
• Low metabolism: • High metabolism:
• Weight gain • Weight loss
• Fatigue • Nervousness
• Cold intolerance • Heat intolerance
• Constipation • Diarrhea
• Bradycardia • Tachycardia; dysrhythmias
• Dry skin • Oily skin
• Heavy menses • Infrequent menses
Therapeutic Action:
Thyroid Drugs
• Thyroid disorders common; drug therapy
often indicated
• Dose highly individualized; requires careful,
periodic adjustment
Hypothyroidism
• May result from
• poorly functioning thyroid gland
• autoimmune disease of the thyroid
• surgical removal of thyroid gland
• aggressive treatment with antithyroid drugs
• Usually responds well to pharmacotherapy with natural or
synthetic thyroid hormone
 Hypothyroidism:
Thyroid Hormone Replacement
• Levothyroxine (Synthroid) commonly used
• Thoroughly assess cardiovascular function
• can cause dysrhythmias in client’s with undiagnosed cardiac
disease resulting from increased metabolic rate
• Use with caution in patients with impaired renal function
because ↑ metabolic rate ↑ workload of the kidney
Prototype drug:
Thyroid agents
• Prototype drug: levothyroxine (Synthroid)
• Mechanisms of action: same as those of
thyroid hormone
• Primary use: drug of choice for
hypothyroidism
• Adverse effects: hyperthyroidism,
dysrhythmias, osteoporosis in women,
drug-interactions
Thyroid hormone
• Best taken on an empty stomach
• Take at the same time everyday
• preferably in the morning to decrease incidence of drug-
related insomnia
• Clients should be taught S&S of hyperthyroidism and need
to notify health care provider IMMEDIATELY at first sign of
any of these symptoms
• Clients will need to take thyroid hormone replacement for
life
Hyperthyroidism
• Hypersecretion of thyroid hormone
• Most common type is Grave’s
Disease
• Other causes:
• adenoma of thyroid, pituitary tumours,
and pregnancy
• If cannot be controlled by medication
then removal of thyroid is indicated
 Antithyroid Therapy:
Medication vs. Radiation
• Thioamides:
• Drugs that inhibit thyroid hormones
• Sodium iodide:
• Radiation therapy to destroy overactive thyroid glands
• Goal is to destroy enough to restore euthyroid state
Prototype drug:
Antithyroid agents
• Prototype drug: propylthiouracil (PTU)
• Mechanism of action: to interfere with
synthesis of T3 and T4 in thyroid gland
• Also prevents conversion of T4 to T3 in
target tissues
• Primary use: treats hyperthyroidism
• Adverse effects: hypothyroidism,
abnormal bleeding, infection, liver
dysfunction
Nursing considerations:
Radioactive isotopes
• In clients receiving radioactive isotopes:
• Avoid pregnant women and children for 1 week and 2-3
days for all other populations
• Birth control; notify healthcare provider IMMEDIATELY if
client suspects she is pregnant
• No breastfeeding
Hyperthyroidism and Diet
• Avoid foods with high iodine content such as:
• soy
• tofu
• turnips
• iodized salts
• some breads
Adrenal Gland Disorders
• Adrenals secrete hormones that affect every body tissue
• Secrete three essential classes of steroid hormones:
• glucocorticoids,
• mineralocorticoids, and
• gonadocorticoids
Glucocorticoids
• More than 30 glucocorticoids are secreted from the adrenal
cortex – including: cortisol, corticosterone, and cortisone
• Cortisol, also called hydrocortisone, is secreted in the highest
amount and is most important pharmacologically
28
Glucocorticoids: Indications
• Used as:
• replacement therapy for clients with adrenocortical
insufficiency, and
• to ↓ inflammatory and immune responses
Glucocorticoids: Indications
• Adrenal insufficiency (eg. Addison’s disease)
• Allergies
• Asthma
• Chronic inflammatory bowel disease
• Neoplastic disease (Hodgkin’s, leukemias,
lymphomas)
• Post transplant rejection
• Rheumatic disorders
• Shock
• Skin disorders
Effects of Glucocorticoids
• ↑ level of blood glucose
• ↑ breakdown of proteins and lipids
• ↓ immune and inflammatory response
• ↑ sensitivity of vascular smooth muscle to
norepinephrine and angiotensin II
thus ↑ BP
• Influence the CNS by affecting mood and
maintaining normal brain excitability
Adrenocortical Insufficiency
• Adrenocortical insufficiency is lack of
adequate corticosteroid production
• May be caused by hyposecretion of the
adrenal cortex or by
• inadequate secretion of the
adrenocorticotropic hormone (ACTH) from
the pituitary
 Signs and Symptoms of
Addison’s Disease
Addison’s Disease (need to ADD glucocorticoid)
• Primary adrenocortical insufficiency
• Symptoms
• Hypoglycemia, fatigue, hypotension
• Increased skin pigmentation
• GI disturbances: anorexia, vomiting, diarrhea
• ↑ ACTH and ↓ cortisol levels
Acute
Adrenocorticol Insufficiency
• May result when a glucocorticoid has been abruptly
withdrawn from a client that has been on long-term
glucocorticoid therapy
• When glucocorticoids are taken as medications for
prolonged periods, they provide negative feedback to the
pituitary to stop secreting ACTH; adrenal cortex shrinks;
stops secreting endogenous glucocorticoids and
symptoms acute adrenocortical insufficiency appear –
N&V, lethargy, confusion and coma
Treatment: Acute Adrenocorticol
Insufficiency
• IMMEDIATE administration of IV
hydrocortisone is essential as shock may
quickly result if symptoms remain
untreated!!!!
Chronic
Adrenocorticol Insufficiency
• For chronic corticosteroid insufficiency –
replacement with glucocorticoid therapy is
indicated
• May need to take glucocorticoids their entire
lifetime
• Do not abruptly discontinue, titrate slowly
• Closely monitor blood sugar; will ↑ BG levels
• Monitor for peptic ulcer disease when taking
concurrently with ASA or NSAIDS; ↑ risk of ulcer
Strategies to Decrease
Adverse Effects
• Keep doses to lowest possible amount that
achieve therapeutic effect
• Administer every other day to limit adrenal
atrophy
• For acute conditions, give client large amounts for
few days then gradually decrease dose until
discontinued
• Give drugs locally by inhalation, intra-articular
injection, or topical application to skin, eyes, or
ears, when feasible, to diminish possibility of
systemic effects
Cushing’s Disease
• Occurs when high levels of glucocorticoids
are present in the body over a prolonged
period
• Most common cause is long-term
administration of glucocorticoids
• Also hypersecretion of glucocorticoids from
pituitary or adrenal tumours
Signs and Symptoms of Cushing’s Syndrome
• Adrenal atrophy
• Osteoporosis
• Increased risk of infection; delayed wound healing
• Peptic ulcers
• Moon face, buffalo hump
• Mood and personality disorders
• Client can become psychologically dependent on the drug
Cushing’s
Syndrome
 Drug Classes to know for Testing

• Thyroid agents
• Antithyroid agents
• Radiation therapy for hyperthyroidism
• Glucocorticoids
 Chapter 28
Drugs for Diabetes Mellitus
Diabetes Mellitus (DM)
• The pancreas is the main organ involved in diabetes
• Insulin is released when blood glucose increases
• Glucagon is released when blood glucose decreases
• Insulin assists in glucose transport
• Without insulin, glucose cannot get INTO the cell
• It is just like a “key” to a door into the cell
• REMEMBER other drugs and hormones can affect
blood glucose levels
47
Diabetes Mellitus (DM)

Type 1 DM Type 2 DM
• No insulin secretion
• ↓ Insulin secretion and/or
• Treatment: • ↓ sensitivity to insulin
• Lifestyle modifications • Treatment:
• Insulin • Lifestyle modifications
and possibly:
• Oral antihyperglycemic agents
• Insulin
Blood Glucose
• There are many target blood glucose levels,
see Table 40.1
• For testing purposes, we will use
4 - 6 mmol/L
• as the normal range of blood glucose
S & S of Blood Glucose Abnormalities
Hypoglycemia Hyperglycemia

• BG less than 4 mmol/L • B more than 6 mmol/L

• Pale, moist skin/sweating • Polyuria
• Tachycardia • Polydipsia
• Confusion • Polyphagia
• Drowsiness • Glucosuria
• Weight loss/gain
• Seizures
• Fatigue
• Coma
Normal Insulin Secretion

Fig. 52-1. Normal endogenous insulin secretion. In the first hour or two after meals, insulin concentrations rise
rapidly in blood and peak at about 1 hour. After meals, insulin concentrations promptly decline toward
preprandial values as carbohydrate absorption from the gastrointestinal tract declines. After carbohydrate
absorption from the gastrointestinal tract is complete and during the night, insulin concentrations are low
and fairly constant, with a slight increase at dawn.

Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Insulin
• Know the following table well (Table 40.2)
• You will be responsible for knowing the
type (i.e. rapid acting) and corresponding
time of onset, peak action, and duration
• You do not need to memorize the insulin
names that belong to the different types
(i.e. Humalog is a rapid acting insulin- this
will be given to you on the test)
Insulin
• Only Regular insulin may be given IV
• Other types of insulin are to be given ONLY as
subcutaneous injections
• Insulin cannot be taken orally as gastric acid will
inactivate the insulin
 Prototype Drug: Insulins
• Prototype drug: regular insulin (Humulin-R,
Novolin ge Toronto)
• Mechanism of action: to promote entry of
glucose into cells
• Primary use: short-acting insulin, to quickly
decrease blood glucose
• Adverse effects: hypoglycemia
• Antidote: Glucagon
 Nursing considerations: Insulin
• When administering insulin, ensure that the units on the
syringe match the units on the insulin vial (ie. U100 on vial
must be on syringe, too)
• When mixing insulins – clear insulin (regular) must be drawn
up first before cloudy (NPH) to prevent contamination of
clear by insulin containing suspension
• Rotate sites to prevent lipodystrophy
• Encourage client to wear medic alert bracelet
Oral Antihyperglycemics
• Sometimes called oral hypoglycemics
• Therapy usually initiated with a single agent
• If therapeutic levels not achieved than two agents are
administered concurrently
• Failure to reach therapeutic levels indicates need for insulin
Drug Classes to Treat
Type 2 Diabetes Mellitus
Classes of oral antihyperglycemics:
• Sulfonylureas
• Meglitinides
• Biguanides
• Thiazolidinediones
• Alpha-glucosidase inhibitors

40-59
Sulfonylureas
• Stimulate release of insulin and increase sensitivity of
receptors
• Most common adverse effect is hypoglycemia
• Also include weight gain, GI distress, hepatotoxicity
• Do not take with alcohol- causes Antabuse-like reaction
• Prototype Drug: glyburide
Meglitinides
• Stimulate release of insulin
• Hypoglycemia is a common adverse
effect
• Work very similarly to sulfonylureas
Biguanides
• Decreases hepatic production of glucose
• Does not stimulate insulin release by pancreas
• Titrate slowly to avoid GI adverse effects
• Does not cause hypoglycemia or cause weight gain
• First-line therapy
• Prototype Drug: Metformin
Thiazolidediones
• Decrease insulin resistance/ inhibit gluconeogenesis
• May take 3-4 months for onset to occur
• Adverse effects of fluid retention, headache, weight gain
• Contraindicated in heart failure or pulmonary edema
Alpha-Glucosidase Inhibitors
• Act by delaying glucose digestion
• Some minor GI adverse effects
• Do not cause hypoglycemia when used alone
• Monitor for hypoglycemia when used with glyburide
or insulin
Oral Antihyperglycemics
Oral Antihyperglycemics (cont.)
 Newer agents of
Oral Anti-hyperglycemics
• Incretins
• Incretins are hormones that signal insulin secretion to
increase and glucose production in the liver to stop
• Prototype Drug: saxagliptin (Onglyza)
• DPP4 inhibitors
• The DPP4 enzyme breaks down incretins, so inhibiting
their breakdown allows for improved insulin secretion
and reduces glucose production
• Prototype Drug: sitagliptin (Januvia)
Health teaching: Diabetes
Teach client to:
• Check blood glucose and eat simple sugar at first sign of
hypoglycemia; if symptoms do not improve call 911
• Exercise may increase insulin needs
• ALWAYS carry source of simple sugar in case of hypoglycemia
Health Teaching: Diabetes
• If blood glucose less than 4 mmol/L, take a fast-acting
carbohydrate; 15g of glucose tablets, 3 tsp sugar, ½ cup
orange juice
• Repeat blood sugar in 15 minutes if blood glucose still less
than 4 mmol/L and if there is more than one hour until the
next meal, eat a snack of a starch and protein (cheese and 6
crackers, or half a peanut butter sandwich)
 Drug Classes to know for Testing

• Insulin:
• Rapid acting
• Regular/fast acting
• Intermediate acting
• Long-acting
• Extended long-acting
 Drug Classes to know for Testing

• Oral Anti-hyperglycemics:
• Sulfonylureas
• Meglitinides
• Biguanides
• Thiazolidinediones
• Alpha-glucosidase inhibitors