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Neuroendocrine System:Pituitary Hormones

Hypothalamus Part of the CNS

Pituitary glandAnterior pituitary (adenohypophysis)Posterior pituitary (neurohypophysis)

Together, they govern all bodily functionsHormonesNegative feedback loop

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Uses

Replacement therapy when a hormone deficiency is present

Drug therapy to produce a specific hormone response when a hormone deficiency is present

Diagnostic aids to determine hypofunction or hyperfunction of a specific hormonal function

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Indications

Somatropin and somatremRecombinant growth hormone (GH)Stimulate skeletal growth in patients with

deficient GH, such as hypopituitary dwarfism

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Indications (cont’d)Vasopressin and desmopressin

Used in the treatment of diabetes insipidus

Vasopressin: A powerful vasoconstrictor used for hypotensive emergencies, GI bleeding, and pulseless cardiac arrest

Desmopressin: Used for dose-dependent treatment of blood disorders; also used for nocturnal enuresis

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Thyroid GlandSecretes three hormones essential for proper regulation of metabolism

Thyroxine (T4)Triiodothyronine (T3)Calcitonin

Located near the parathyroid glands, which are esponsible for maintaining adequate levels of calcium in the extracellular fluid

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Hypothyroidism: Deficiency in Thyroid Hormones

Primary: abnormality in the thyroid gland itself

Secondary: results when the pituitary gland is dysfunctional and does not secrete TSH

Tertiary: results when the hypothalamus gland does not secrete TRH, which stimulates the release of TSH

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The most common cause of hypothyroidism is Hashimoto's disease. This is an autoimmune disorder in which the body attacks the thyroid gland. The result is damage to the thyroid, preventing it from producing enough hormones. Hashimoto's disease tends to run in families.

Hypothyroidism

CretinismHyposecretion of thyroid hormone during youthLow metabolic rate, retarded growth and sexual

development, possible mental retardation

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Hypothyroidism (cont’d)

MyxedemaHyposecretion of thyroid hormone during adulthoodDecreased metabolic rate, loss of mental and physical

stamina, weight gain, loss of hair, firm edema, yellow dullness of the skin

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Hypothyroidism (cont’d)Common symptoms

Hair lossConstipationLethargyAnorexiaWeight gainBradycardiaEdemaIntolerance to cold

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Hypothyroidism (cont’d)

GoiterEnlargement of the thyroid glandResults from overstimulation by elevated

levels of TSHTSH is elevated because there is little or no

thyroid hormone in circulation

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Thyroid Preparationslevothyroxine (Synthroid, Levothyroid)

Synthetic thyroid hormone T4

liothyronine (Cytomel)Synthetic thyroid hormone T3

liotrix (Thyrolar)Synthetic thyroid hormone T3 and T4 combined

thyroidDesiccated (dried) animal thyroid gland

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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 thyroid hormones

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Indications

To treat all three forms of hypothyroidismLevothyroxine is the preferred drug because its

hormonal content is standardized; therefore, its effect is predictable

“Euthyroid”

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Indications (cont’d)

Also used for thyroid replacement in patients whose thyroid glands have been surgically removed or destroyed by radioactive iodine in the treatment of thyroid cancer or hyperthyroidism

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Adverse Effects

Cardiac dysrhythmia is the most significant adverse effectMay also cause:

Tachycardia, palpitations, angina, hypertension, insomnia, tremors, headache, anxiety, nausea, diarrhea, menstrual irregularities, weight loss, appetite changes, sweating, heat intolerance, others

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Hyperthyroidism: Excessive Thyroid Hormones

Caused by several diseasesGraves’ diseaseMultinodular diseasePlummer’s disease (rare)

Also called toxic nodular diseaseThyroid storm (induced by stress or infection)

Severe and potentially life-threatening

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HyperthyroidismAffects multiple body systems, resulting in an overall

increase in metabolismDiarrheaFlushingIncreased appetiteMuscle weaknessSleep disordersAltered menstrual flowFatiguePalpitationsNervousness / IrritabilityHeat intolerance ExopthalmusIrritability

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Treatment of HyperthyroidismRadioactive iodine (I131) works by destroying the thyroid

glandSurgery to remove all or part of the thyroid gland

Lifelong thyroid hormone replacement will be needed

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Treatment of Hyperthyroidism (cont’d)

Antithyroid drugs: thioamide derivativesmethimazole (Tapazole)propylthiouracil (PTU)

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Antithyroid Drugs

Used to palliate hyperthyroidism and to prevent the surge in thyroid hormones that occurs after surgical treatment or during radioactive iodine treatment for hyperthyroidism

May cause liver and bone marrow toxicity

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Nursing Implications

Assess for drug allergies, contraindications, potential drug interactions

Obtain baseline vital signs, weight

Cautious use advised for those with cardiac disease, hypertension, and pregnant women

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Nursing Implications (cont’d)During pregnancy, treatment for hypothyroidism

should continue

Fetal growth may be retarded if maternal hypothyroidism is untreated during pregnancyAdjust dosage every 4 weeks to keep TSH at the

lower end of the normal range

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Nursing Implications (cont’d)

Teach patient to take thyroid drugs once daily in the morning to decrease the likelihood of insomnia if taken later in the day

Teach patient to take the medications at the same time every day and not to switch brands without physician approval

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Nursing Implications (cont’d)Teach patients to report any unusual symptoms, chest pain, or heart palpitations

Teach patients not to take over-the-counter medications without physician approval

Teach patients that therapeutic effects may take several months to occur

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Nursing Implications (cont’d)

Teach patients the importance of alerting health care providers of thyroid medication useMay enhance activity of anticoagulantsDiabetic patients may need increased dosages of hypoglycemic medsMay decrease serum digoxin levels

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Nursing Implications (cont’d)

Antithyroid medications Better tolerated when given with foodGive at the same time each day to maintain consistent blood levelsNever stop these medications abruptlyAvoid eating foods high in iodine (seafood, soy sauce, tofu, and iodized salt)

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Nursing Implications (cont’d)

Monitor for therapeutic responseMonitor for adverse effects

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Diabetes Mellitus

Two typesType 1Type 2

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Diabetes Mellitus (cont’d)Signs and symptoms

Elevated fasting blood glucose (higher than 126 mg/dL)

PolyuriaPolydipsiaPolyphagiaGlycosuriaUnexplained weight lossFatigueHyperglycemia

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Type 1 Diabetes MellitusLack of insulin production or production of defective

insulinAffected patients need exogenous insulinFewer than 10% of all diabetes cases are type 1Complications

Diabetic ketoacidosis (DKA)Peripheral vascular neurological deterioation

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Type 2 Diabetes Mellitus

Most common type: 90% of all cases

Caused by insulin deficiency and insulin resistance

Many tissues are resistant to insulinReduced number of insulin receptorsInsulin receptors less responsive

Complications: Hyperosmolar nonketotic syndrome

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Type 2 Diabetes Mellitus (cont’d)Several comorbid conditions

ObesityCoronary heart diseaseDyslipidemiaHypertensionMicroalbuminemia (protein in the urine)Increased risk for thrombotic (blood clotting)

eventsThese comorbidities are collectively referred to as

metabolic syndrome or insulin-resistance syndrome or syndrome X

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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

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Major Long-Term Complications of DM (Both Types)

Macrovascular (atherosclerotic plaque)Coronary arteriesCerebral arteriesPeripheral vessels

Microvascular (capillary damage)RetinopathyNeuropathyNephropathy

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Screening for DMFasting plasma glucose (FPG) levels higher than or

equal to 110 mg/dL but less than 126 mg/dL may indicate “prediabetes”

Impaired glucose tolerance test (oral glucose challenge)

Screening recommended every 3 years for all patients 45 years and older

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Treatment for DM

Type 1Insulin therapy

Type 2Lifestyle changesOral drug therapyInsulin when the above no longer provide

glycemic control

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Types of Antidiabetic DrugsInsulinOral hypoglycemic drugs

Both aim to produce normal blood glucose states

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InsulinFunction as a substitute for the endogenous hormoneEffects are the same as normal endogenous insulin Restores the diabetic patient’s ability to:

Metabolize carbohydrates, fats, and proteinsStore glucose in the liverConvert glycogen to fat stores

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Insulin (cont’d)Human-derived, using recombinant DNA technologiesRecombinant insulin produced by bacteria and yeastGoal: tight glucose control

To reduce the incidence of long-term complications

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Human-Based InsulinRapid-acting

Most rapid onset of action (5 to 15 minutes) Shorter duration Patient must eat a meal after injection

Insulin lispro (Humalog) Similar action to endogenous insulin

Insulin aspart (NovoLog) Insulin glulisine (Apidra)

NewestMay be given SC or via continuous SC infusionpump (but not IV)

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Human-Based Insulin (cont’d)

Short-actingRegular insulin (Humulin R)Onset 30 to 60 minutes

The only insulin product that can be given by IV bolus, IV infusion, or even IM

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Human-Based Insulin (cont’d)

Intermediate-actingIsophane insulin suspension (also called NPH)

Cloudy appearanceSlower in onset and more prolonged in duration than

endogenous insulin

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Human-Based Insulin (cont’d)Long-acting

glargine (Lantus), detemir (Levemir)Clear, colorless solutionReferred to as basal insulin

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Human-Based Insulin (cont’d)Combination insulin products

NPH 70% and regular insulin 30% (Humulin 70/30, Novolin 70/30, Novolog 70/30)

NPH 50% and regular insulin 50% (Humulin 50/50)

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Sliding-Scale Insulin Dosing• SC short-acting or regular insulin doses adjusted

according to blood glucose test results• Typically used in hospitalized diabetic patients or

those on TPN or enteral tube feedings• Subcutaneous 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

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SLIDING SCALE INSULINCHECK FINGER STICK GLUCOSE AC AND HS

BLOOD GLUCOSE 0 – 120 0 INSULINBG 121 – 250 4U REG INSULINBG 251 – 350 6U REG INSULINBG 351 – 400 8U REG INSULINBG > 400 CALL MD

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Oral Antidiabetic DrugsUsed for type 2 diabetesTreatment for type 2 diabetes includes lifestyle modifications

Diet, exercise, smoking cessation, weight lossOral antidiabetic drugs may not be effective unless the patient

also makes behavioral or lifestyle changes

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Oral Antidiabetic Drugs (cont’d)Stimulate insulin secretion from the beta

cells of the pancreas, thus increasing insulin levels

Beta cell function must be presentImprove sensitivity to insulin in tissuesResult in lower blood glucose levelsFirst-generation drugs not used as

frequently now

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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 diabetes

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Oral Antidiabetic Drugs:Mechanism of Action

Biguanides - metformin (Glucophage)Decrease production of glucose by the liverDecrease intestinal absorption of glucoseIncrease uptake of glucose by tissuesDo not increase insulin secretion from the pancreas

(does not cause hypoglycemia)

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Oral Antidiabetic Drugs: Adverse Effects

MetforminPrimarily affects GI tract: abdominal bloating,

nausea, cramping, diarrhea, feeling of fullnessMay also cause metallic taste, reduced vitamin

B12 levelsLactic acidosis is rare but lethal if it occursDoes not cause hypoglycemia

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Oral Antidiabetic Drugs:Mechanism of Action (cont’d)

SulfonylureasStimulates the release of insulin Decreases secretion of glucagon

First generation: chlorpropamide (Diabinese), tolazamide (Tolinase)

Second generation: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Micronase)

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Oral Antidiabetic Drugs: Interactions

SulfonylureasHypoglycemic effect increases when taken with

alcohol, anabolic steroids, many other drugsAdrenergics, corticosteroids, thiazides, others

may reduce hypoglycemic effectsAllergic cross-sensitivity may occur with loop

diuretics and sulfonamide antibioticsMay interact with alcohol, causing a disulfiram-

type reaction

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Oral Antidiabetic Drugs (cont’d)Glinides

Repaglinide (Prandin), Nateglinide (Starlix)

Similar MOA as SulfonureasIncreace insulin secretionShort duration of action

Must be taken with each meal

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Oral Antidiabetic Drugs (cont’d)Thiazolidinediones

pioglitazone (Actos), rosiglitazone (Avandia)Also known as glitazones

Regulates genes involved in glucose and lipid metabolismDecreases cellular resistanceSlow onset of action

Make take months to see adequate response

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Oral Antidiabetic Drugs:Mechanism of Action (cont’d)

ThiazolidinedionesDecrease insulin resistance“Insulin sensitizing drugs”Increase glucose uptake and use in skeletal

muscleInhibit glucose and triglyceride production in

the liver

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Oral Antidiabetic Drugs: Adverse Effects (cont’d)

ThiazolidinedionesModerate weight gain, edema, mild anemia Hepatic toxicity—monitor ALT levels

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Oral Antidiabetic Drugs:Mechanism of Action (cont’d)

Alpha-glucosidase inhibitorsReversibly inhibit the enzyme alpha-glucosidase

in the small intestineResult in delayed absorption of glucoseMust be taken with meals to prevent excessive

postprandial blood glucose elevations (with the “first bite” of a meal)

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Oral Antidiabetic Drugs (cont’d)Alpha-glucosidase inhibitors

acarbose (Precose), miglitol (Glyset)

Adverse effectsFlatulence, diarrhea, abdominal painDoes not cause hypoglycemia, hyperinsulinemia,

or weight gain

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New Antidiabetic Drugs Amylin mimetics

Slows gastric emptyingSuppresses glucogon secretion and

hepatic glucose productionIncreases the feeling of “fullness”

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Oral Antidiabetic Drugs: Mechanism of Action (cont’d)

Amylin mimeticMimics the natural hormone amylinpramlintide (Symlin)Slows gastric emptyingSuppresses glucagon secretion, reducing hepatic glucose

outputCentrally modulates appetite and satietyUsed when other drugs have not achieved adequate

glucose controlSubcutaneous injection

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Oral Antidiabetic Drugs:Interactions

Amylin mimeticsConcurrent insulin doses need to be reducedTake one hour before other medications

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New Antidiabetic Drugs

Incretin mimeticsexenatide (Byetta)sitagliptin (Januvia)

SC injectionGiven before meals

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Oral Antidiabetic Drugs: Mechanism of Action (cont’d)

Incretin mimeticMimics the incretin hormonesEnhances glucose-driven insulin secretion from

beta cells of the pancreasOnly used for Type 2 diabetesExenatide: Injection pen device

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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 carbs—to prevent rebound postprandial hypoglycemia

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Hypoglycemia SymptomsEarly

Confusion, irritability, tremor, sweatingLate

Hypothermia, seizuresComa and death will occur if not treated

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Glucose-Elevating DrugsOral forms of concentrated glucose

Buccal tablets, semisolid gel50% dextrose in water (D50W)Glucagon

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Nursing Implications

Before giving drugs that alter glucose levels, obtain and document:A thorough historyVital signsBlood glucose level, A1c levelPotential complications and drug

interactions

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Nursing Implications (cont’d)Before giving drugs that alter glucose levels:

Assess the patient’s ability to consume foodAssess for nausea or vomitingHypoglycemia may be a problem if antidiabetic

drugs are given and the patient does not eatIf a patient is NPO for a test or procedure,

consult physician to clarify orders for antidiabetic drug therapy

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Nursing Implications (cont’d)Keep in mind that overall concerns for any diabetic patient increase

when the patient:Is under stressHas an infectionHas an illness or traumaIs pregnant or lactating

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Nursing Implications (cont’d)Thorough patient education is

essential regarding:Disease processDiet and exercise recommendationsSelf-administration of insulin or

oral drugsPotential complications

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Nursing Implications (cont’d)

When insulin is ordered, ensure:Correct routeCorrect type of insulinTiming of the doseCorrect dosage

Insulin order and prepared dosages are second-checked with another nurse

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Nursing Implications (cont’d)Insulin

Check blood glucose level before giving insulinRoll vials between hands instead of shaking them to mix suspensionsEnsure correct storage of insulin vialsONLY use insulin syringes, calibrated in units, to measure and give insulinEnsure correct timing of insulin dose with meals

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Nursing Implications (cont’d)

Insulin (cont’d)When drawing up two types of insulin in one syringe, always withdraw

the regular or rapid-acting insulin firstProvide thorough patient education regarding self-administration of

insulin injections, including timing of doses, monitoring blood glucose levels, and injection site rotations

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Nursing Implications (cont’d)

Oral antidiabetic drugsAlways check blood glucose levels before givingUsually given 30 minutes before mealsAlpha-glucosidase inhibitors are given with the first

bite of each main mealMetformin is taken with meals to reduce GI effectsMetformin will need to be discontinued if the patient

is to undergo studies with contrast dye because of possible renal effects—check with the prescriber

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Nursing Implications (cont’d)Assess for signs of hypoglycemiaIf hypoglycemia occurs:

If the patient is conscious, give oral form of glucose 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 sandwichIf the patient is unconscious, give D50W or glucagon, intravenouslyMonitor blood glucose levels

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Nursing Implications (cont’d)Monitor for therapeutic response

Decrease in blood glucose levels to the level prescribed by physician

Measure hemoglobin A1c to monitor long-term compliance with diet and drug therapy

Monitor for hypoglycemia and hyperglycemia

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Adrenal GlandAdrenal cortexAdrenal medullaEach portion has different functions and secretes different

hormonesFeedback process of hormone regulation

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Adrenal Gland (cont’d)Adrenal medulla secretes catecholamines

EpinephrineNorepinephrine

Adrenal cortex secretes corticosteroidsGlucocorticoidsMineralocorticoids (primarily aldosterone)All adrenal cortex hormones are steroid hormones

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Adrenocortical HormonesOversecretion leads to Cushing’s syndromeUndersecretion leads to Addison’s disease

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Adrenal DrugsCan be either synthetic or naturalMany different drugs and formsGlucocorticoids

Topical, systemic, inhaled, nasalMineralocorticoid

SystemicAdrenal steroid inhibitors

Systemic

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Adrenocortical Hormones (cont’d)Glucocorticoids

beclomethasone (several formulations)fluticasone propionatehydrocortisone (several formulations)cortisonemethylprednisoloneprednisoneMany others

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Adrenocortical Hormones (cont’d)Mineralocorticoid

fludrocortisone acetateAdrenal steroid inhibitor

aminoglutethimide

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Mechanism of ActionMost exert their effects by modifying enzyme activity

Different drugs 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

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IndicationsWide variety of indications

Adrenocortical deficiencyCerebral edemaCollagen diseasesDermatologic diseasesGI diseasesExacerbations of chronic respiratory illnesses, such as asthma and COPD

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Indications (cont’d)Wide variety of indications (cont’d)

Organ transplant (decrease immune response)Palliative management of leukemias and lymphomasSpinal cord injuryMany other indications

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Indications (cont’d)Glucocorticoids administration

By inhalation for control of steroid-responsive bronchospastic statesNasally for rhinitis and to prevent the recurrence of polyps after

surgical removalTopically for inflammations of the eye, ear, and skin

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Indications (cont’d)Antiadrenals (adrenal steroid inhibitors)aminoglutethimide

Used in the treatment of Cushing’s syndrome, metastatic breast cancer, and adrenal cancer

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ADRENAL INSUFFICIENCY

DESTRUCTION OF THE ADRENAL CORTEX BY DISORDERS SUCH AS:TBADDISON’S DISEASEPROLONGED ADMINISTRATION OF EXOGENOUS

CORTICOSTEROIDSSURGICAL REMOVAL OF ADRENAL GLANDS

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ADDISONIAN CRISIS

TRIGGERED BY STRESSFUL EVENTSURGERYACUTE ILLNESSTRAUMAABRUPT WITHDRAWAL OF CORTICOSTEROID THERAPY

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ADDISONIAN CRISISSIGNS AND SYMPTOMS

HIGH FEVER, WEAKNESSSEVERE ABDOMINAL PAINLOWER BACK AND LEG PAINVOMITING, DIARRHEAHYPOTENSIONCIRCULATORY COLLAPSE, SHOCK, COMA, DEATH

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ADDISONIAN CRISIS

TREATMENTRAPID REPLACEMENT OF FLUIDSGLUCOCORTICOIDS

FLUDROCORTISONE

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ADVERSE EFFECTS OF CORTICOSTEROIDSSEE COMPLETE LIST p. 512 TABLE 33-4

CUSHING’S SYNDROMEMOON FACE, BUFFALO HUMP

ELECTROLYTE IMBALANCEMOOD SWINGS, NERVOUSNESS, INSOMNIAPEPTIC ULCERSHYPERGLYCEMIAFRAGILE SKINFLUID RETENTIONWEIGHT GAIN

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ENDOCRINE DISORDERS

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CUSHING’S DISEASE AND SYNDROMESIGNS AND SYMPTOMS

OBESITYFAT PADS UNDER CLAVICLE AND UPPER BACK

(BUFFALO HUMP), REDISTRIBUTION OF FAT IN THE CENTRAL (TRUNK) REGIONS, “MOON” FACE

MUSCLE WEAKNESS RELATED TO CHANGES IN PROTEIN METABOLISM

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CUSHING’S SIGNS AND SYMPTOMS

LOSS OF COLLAGEN AND CONNECTIVE TISSUE

THINNING OF SKIN – ABDOMINAL STRIAE

EASY BRUISING

POOR WOUND HEALING

ALTERED GLUCOSE METABOLISM

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SIGNS AND SYMPTOMS, CONT.

ELECTROLYTE IMBALANCE

OSTEOPOROSIS

DEPRESSION – PSYCHOSIS

INCREASING FACIAL HAIR IN WOMEN

ALTERATIONS OF THE MENSTRUAL CYCLE

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ContraindicationsDrug allergies

Serious infections, including septicemia, systemic fungal infections, and varicella

However, in the presence of tuberculous meningitis, glucocorticoids may be used to prevent inflammatory CNS damage

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Contraindications (cont’d)Cautious use in patients with

Gastritis, reflux disease, ulcer diseaseDiabetesCardiac/renal/liver dysfunction

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Adverse EffectsPotent effects on all body systemsCardiovascular

Heart failure, cardiac edema, hypertension—all caused by electrolyte imbalances (hypokalemia, hypernatremia)

CNSConvulsions, headache, vertigo, mood swings, nervousness, insomnia, “steroid

psychosis,” others

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Adverse Effects (cont’d)Potent effects on all body systemsEndocrine

Growth suppression, Cushing’s syndrome, menstrual irregularities, carbohydrate intolerance, hyperglycemia, others

GIPeptic ulcers with possible perforation,

pancreatitis, abdominal distention, others

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Adverse Effects (cont’d)Potent effects on all body systemsIntegumentary

Fragile skin, petechiae, ecchymosis, facial erythema, poor wound healing, hirsutism, urticaria

MusculoskeletalMuscle weakness, loss of muscle mass, osteoporosis

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Adverse Effects (cont’d)Potent effects on all body systemsOcular

Increased intraocular pressure, glaucoma, othersOther

Weight gain

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Nursing ImplicationsSystemic forms may be given by oral, IM, IV, or rectal routes

(not SC)Prepare and administer according to manufacturer’s directionsOral forms should be given with food or milk to minimize GI

upset

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Nursing Implications (cont’d)For topical applications, follow instructions

about use and type of dressing, if any, to applyClear nasal passages before giving a nasal

corticosteroid

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Nursing Implications (cont’d)After using an orally inhaled corticosteroid, instruct patients to rinse

their mouths to prevent possible oral fungal infections

Teach patients on corticosteroids to avoid contact with people with infections and to report any fever, increased weakness, lethargy, or sore throat

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Nursing Implications (cont’d)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

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Nursing Implications (cont’d)

Monitor for therapeutic responsesMonitor for adverse effects

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