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Medications and the Endocrine System. RN2 Medication Course School of Nursing & Health Studies Victoria University. Endocrine System. Consists of ductless glands Produce hormones that regulate and control the metabolic activities of the body, thus maintaining homeostasis

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medications and the endocrine system

Medications and the Endocrine System

RN2 Medication Course

School of Nursing & Health Studies

Victoria University

endocrine system
Endocrine System
  • Consists of ductless glands
  • Produce hormones that regulate and control the metabolic activities of the body, thus maintaining homeostasis
  • Participates in the regulation of
    • Digestion, use and storage of nutrients
    • Growth and development
    • Electrolyte and water metabolism
    • Reproductive functions
endocrine system overview
Endocrine System Overview
  • The nervous system coordinates rapid and precise responses to stimuli using action potentials
  • The endocrine system maintains homeostasis and long-term control using chemical signals (hormones)
  • The endocrine system works in parallel with the nervous system to control growth and maturation along with homeostasis.
endocrine system overview6
Endocrine System Overview
  • A gland is a group of cells that produces and secretes chemicals in response to a stimulus
  • Exocrine glands, e.g. sweat and salivary glands, release secretions in the skin or inside the mouth via ducts (ex = outside)
  • Endocrine glands release more than 20 major hormones directly into the bloodstream where they can be transported to cells in other parts of the body (endo = inside)
endocrine system overview7
Endocrine System Overview
  • Hormone enters blood & extracellular fluid
  • Arrives at target cell which has a protein membrane ‘receptor’. Hormone (‘key’) will only enter & ‘unlock’ a target cell ‘matched’ to that hormone;
  • Entry of hormone then alters the cell’s function
major endocrine glands
Pineal Gland

Hypothalamus

Pituitary Gland

Anterior

Posterior

Thyroid Gland

Parathyroid Glands

Adrenal Glands

Cortex

Medulla

Thymus Gland

Pancreas

Gonads

Ovaries

Testes

Major Endocrine Glands
slide9

Endocrine control

  • Feedback Mechanisms
    • Controls and prevents the over production and underproduction of a hormone thus ensuring homeostasis
  • Conditions may occur due to:
    • A gland enlarging or shrinking in size resulting in either:
        • Hyper-secretion or
        • Hypo-secretion
endocrine control
Endocrine control
  • Hypothalamus & Pituitary.
    • Together they control many endocrine functions
  • Hypothalamus
    • When stimulated by feedback produces releasing factors (RF) that stimulates the pituitary to release hormones
  • Pituitary gland
    • The master gland of the body
pituitary gland
Pituitary Gland
  • The hypothalamus exerts hormonal control
  • Pituitary gland
    • Size of a grape
    • Hangs by a stalk from the hypothalamus
    • Protected by the sphenoid bone
  • Has two functional lobes
    • Anterior pituitary – glandular tissue
    • Posterior pituitary – nervous tissue
growth hormone
Growth hormone
  • General metabolic hormone
  • Major effects are directed to growth of skeletal muscles and long bones
  • Causes amino acids to be built into proteins
  • Causes fats to be broken down for a source of energy
anterior pituitary disorders
Anterior Pituitary disorders

Hyperpituitarism: Increased Growth Hormone

  • Gigantism - during childhood or
  • Acromegaly - adulthood
    • Usually due to a slow growing adenoma
    • Skeletal overgrowth
  • Treatment
    • Surgery
    • Chemotherapy
    • Bromocryptine (Parlodel)
anterior pituitary disorders20
Anterior Pituitary disorders

Hypopituitarism: Insufficient supply of hormones

    • metabolic dysfunction
    • sexual immaturity
    • growth retardation - dwarfism
  • Due to congennital causes, trauma, a tumour of the pituitary or hypothalamus
  • Replacement of hormones
    • Corticosteroids, thyroid & sex hormones
    • Growth hormone:
      • Somatotropin (Genotropin, Humatrope)
posterior pituitary hormones
Posterior Pituitary Hormones
  • Oxytocin: stimulates contractions of the uterus & milk let-down
  • Antidiuretic hormone (ADH)
    • Can inhibit urine production
    • In large amounts, causes vasoconstriction leading to increased blood pressure (vasopressin)
posterior pituitary diabetes insipidus
Posterior Pituitary: Diabetes Insipidus
  • Deficiency of Anti Diuretic Hormone (ADH)
  • Causes: congenital, surgery, trauma, infection
  • Replacement
  • Vasopressin:
    • Pitressin: IMI/S.C/ intranasal
  • Desmopressin
    • Minirin nasal spray
    • Minirin, Octostim
      • injection IV/IMI
thyroid gland
Thyroid Gland
  • Two lobes & a connecting isthmus
  • Controlled by hypothalamus & pituitary gland
  • Produces two hormones
    • Thyroid hormone & Calcitonin
  • Thyroid Hormone
    • Major metabolic hormone
    • Requires iodine
  • Composed of two hormones
    • Thyroxine (T4) – precursor
    • Triiodothyronine (T3) – active hormone
thyroid disorders27
THYROID DISORDERS
  • Hyperthyroidism

An over production of thyroxine causing a metabolic imbalance causing thyrotoxicosis

  • Hypothyroidism

an underproduction of thyroxine leading to a slowing of the metabolic process causing myxoedema

  • Euthyroid State Normal thyroid hormone production
hyperthyroidism versus hypothyroidism
Tachycardia

Pyrexia

Hyperactivity

Anxiety

Moist skin

Exophthalmos

Possible goitre

Weight loss

Increased appetite

Bradycardia

Hypopyrexia

Hypoactivity

Fatigue

Dry Skin

Hair Loss

Oedema

Weight Gain

Poor Memory

Hyperthyroidism versus Hypothyroidism
enlarged thyroid goitre
Enlarged thyroid - GOITRE
  • Euthyroid – thyroid follicles/cysts
  • Iodine deficiency
  • Toxic: overproduction of thryoxin
  • Signs & Symptoms
    • neck enlargement
    • dysphagia
    • respiratory distress
  • Treatment depends on cause
slide31

Hyperthyroidism

  • Hyperthyroidism (Grave’s Disease)
    • Multi system autoimmune disorder characterised by pronounced hyperthyroidism, and usually associated with an enlarged thyroid gland.
  • Origin is unknown but may be familial.
  • 5 times more common in women than in men
  • Can arise after an infection or physical or emotional stress.
  • Usually occurs between 30 to 60 years of age
      • Treatment:
        • Antithyroid agents
        • Surgery
exopthalmos
Exopthalmos
  • This is an abnormal condition marked by protrusion of the eyeballs.
anti thyroid medications
Anti-Thyroid Medications
  • Carbimazole (Neo-Mercazole)
    • Decreases thyroid hormone synthesis. High dose initially then decreased to maintenance
  • Propylthiouracil
    • As above but also prevents conversion of T4 to T3
  • Sodium Iodide (1311) (Radioactive)
    • used to reduce the production of thyroid hormones by destroying thyroid cells.
    • Generally used in patients who are not good surgical candidates (cardiac dysfunctions, elderly & debilitated)
    • Specific nursing considerations are required
hypothyroidism
Hypothyroidism
  • Decreased activity of the thyroid gland
  • Caused by:
    • Congenital (cretinism)
    • Surgical removal
    • Decrease of thyroid stimulating hormone (Myxoedema)
    • Atrophy of the thyroid gland
hashimoto s disease
An auto immune thyroid disorder characterised by the production of antibodies in response to thyroid antigens.

The disease shows a marked hereditary pattern.

It is 20 times more common in women than in men

The goitre is usually asymptomatic.

Treatment: thyroxin

Prognosis: good with treatment

Hashimoto’s disease
myxoedema
Myxoedema
  • Signs & Symptoms
    • Weight gain
    • Mental and physical lethargy
    • Dryness of the skin
    • Constipation
    • Slow metabolism
    • Coma / death
thyroid medications
Thyroid Medications
  • Thyroxine
    • Slow in onset but long-acting
    • Usually for maintenance therapy
  • Liothyronine (Tertroxin)
    • Rapidly absorbed from GIT; short-acting
    • Usually used for emergency therapy.
  • Adverse Effects
    • Usually decrease with time
    • Tremor, headache & tachycardia & Arrhythmias
    • GIT disturbances, weight loss
thyroxin
Thyroxin
  • Oroxine, Eutrosig
  • Correct storage & use essential
    • Unstable in light, heat, humidity
    • Keep in original packaging
    • Recommended to keep in fridge
    • Check expiry date
  • Bioavailability varies from 40-80%
    • Take on an empty stomach 30-60 mins pre-breakfast
    • Or in the evening pre bed on an empty stomach
    • Or with breakfast but dose will be higher & must be taken the same way each day
    • Decreased absorption with iron, antacids, calcium, milk, soy etc
thyroxin42
Thyroxin
  • Half-life
    • 6-7 days Euthyroid
    • 3-4 days Hyperthyroid
    • >7 days Hypothyroid
  • Duration of action 7-21 days
  • Takes 3-4 weeks for full therapeutic effect
  • Levels every 6 weeks initially then 6 monthly when stable
  • Interactions
    • Increased effect - warfarin, phenobarb
    • Decreased effect – steroids, digoxin, hypoglycaemics
parathyroid glands
Parathyroid Glands
  • Tiny masses on the posterior of the thyroid
  • Secrete parathyroid hormone
    • Raise calcium levels in the blood
    • Stimulate osteoclasts to remove calcium from bone
    • Stimulate the kidneys and intestine to absorb more calcium
calcitonin
Calcitonin
  • Produced by C cells(parafollicular) in the thyroid gland
  • Decreases blood calcium levels by causing its deposition on bone
  • Antagonistic to parathyroid hormone
parathyroid disorders
Parathyroid disorders
  • Hyperparathyroidism: an excess production of parathyroid hormone which may be due to tumours, hereditary factors or secondary to renal disease.
  • Causes bone decalcification and renal calculi due to an hypercalcemia
  • Treatment:
    • Calcitonin SC or IMI
    • Surgery
parathyroid disorders46
Parathyroid disorders
  • Hypoparathyroidism: leads to a hypocalcaemia causing neuromuscular excitability, cardiac irregularities, and digital paraesthesia
  • Acute ; IV calcium
  • Replacement: Calcium Supplements, Vit D
rn2 medication course school of nursing health services victoria university
RN2 Medication Course

School of Nursing & Health Services

Victoria University

Steroid Therapy
objectives
Objectives
  • State the functions of natural steroids
  • List the indications for steroid therapy
  • Outline the side effects of steroid therapy
  • Explain why steroid therapy must be gradually withdrawn
  • Discuss how side effects may be minimised with inhaled, topical and oral steroid therapy
  • Describe the patient education required for a client on steroid therapy
adrenal glands
Adrenal glands
  • The medulla secretes
    • Adrenaline
      • epinephrine
    • Noradrenaline
      • Norepinephrine
  • The cortex secretes
    • Glucocorticoids
    • Mineralocorticoids
    • Androgens
corticosteroids
Corticosteroids
  • Glucocorticoids
    • or corticosteroids or steroids
    • Metabolic, anti-inflammatory & immunosupressant effects
  • Mineralocorticoids(principally aldosterone)
    • Electrolyte & fluid balance via
      • Sodium & water retention
      • Potassium excretion
  • Androgens
    • Development of sex organs
    • Regulation of reproduction
natural corticosteroids
Natural Corticosteroids

1. Resistance to stress

  • Work synergistically with adrenaline to maintain homeostasis
  • Potentiate the vasoconstriction action of nor-adrenaline, therefore assist to increase BP
  • Natural surges during stress e.g. infection, surgery
natural corticosteroids54
Natural Corticosteroids

2. Metabolic effects:

  • Increase blood glucose by
    • Gluconeogenesis in liver from fats & AA
    • Increases plasma Amino Acids
    • Mobilises fatty acids for energy
    • Decreases cell uptake of glucose
natural corticosteroids55
Natural Corticosteroids

3. Anti-inflammatory

  • Decreases inflammatory mediators
  • Decreases movement of neutrophils
  • ↓antigen/antibody response

4. Immunosupression

  • Decreases thymic activity
  • Decreases lymphocyte activity
natural corticosteroids56
Natural Corticosteroids
  • No major stores in body, produced when required i.e. stimulated by ACTH from anterior pituitary
  • Produced from cholesterol
  • Cortisone is hydroxylated in the liver to prednisone and then activated to prednisilone
  • Blood cortisol levels kept within very narrow limits
  • The normal effects of cortisol do not produce the effect of steroid drugs used at high doses/for prolonged periods
corticosteroids uses
Corticosteroids: Uses
  • Replacement therapy
    • in conditions where adrenal insufficiency has occurred.
  • Anti-inflammatory/allergic action
    • Asthma, hay fever, eczema
    • Inflammatory bowel disease, Lupus, Rheumatoid Arthritis
  • Suppression of immunity
    • Prevent rejection of organ transplants
  • Anti-tumour action
    • Anti-lymphocytic action: Lymphomas, leukaemias
    • Decrease tumour size, decrease cerebral oedema
adverse effects of therapy
Adverse effects of therapy

Effects carbohydrate metabolism

  • Increased blood glucose:
    • Mainly an issue in diabetics
    • Decrease sensitivity to insulin

Electrolyte & fluid balance

Steroids cross react with aldosterone receptors in kidney and lead to the retention of sodium, water and excretion of potassium

  • Hypertension
  • Oedema
  • Hypokalaemia
adverse effects of therapy59
Adverse effects of therapy

Protein & calcium changes

  • Muscle weakness & wasting
  • Delayed wound healing
  • Osteoporosis & Bone thinning
    • Decreased bone production
    • Calcium absorption from gut and  excretion in kidneys
    • Osteoporosis if prolonged therapy
  • Inhibits growth in children
adverse effects of therapy60
Adverse effects of therapy

Suppression of inflammation & immunity

  • Suppression of immune tissues & cells
  • ↓inflammatory response
  • Masks signs of infection

Other

  • Gastric ulceration
    • Increased gastric acidity
  • Cataracts & glaucoma
  • Psychological effects
    • Euphoria, insomnia, depression, psychosis
adverse effects of therapy62
Adverse effects of therapy
  • Redistribution of fat
    • Buffalo hump, moon face
  • Skin changes
    • Skin thinning
    • Susceptible to bruising
    • Striae
    • Tendency to acne
    • Hirsuitism
corticosteroids64
Corticosteroids
  • Adverse Reactions:
    • Generally due to prolonged use
    • Cushing’s syndrome
  • To maximise benefits and limit side effects steroids should be ordered at lowest dose possible, for as short a time as possible to be effective
adverse effects of therapy68
Adverse effects of therapy

Atrophy of adrenal cortex

  • Doses >5mg/day/prolonged
  • Suppression of stress responses
  • Adrenal gland unable to respond with increased cortisol levels as cortex suppressed
  • Leads to Addison’s Crisis
synthetic steroids
Synthetic Steroids
  • Available as:
    • inhaled steroids
      • nasal sprays
      • metered-dose inhalers
    • rectal
    • topical
    • oral (pills or syrups)
    • injections for
    • IMI
    • IVI
    • intraarticular
topical steroids
Topical Steroids
  • Anti-inflammatory drugs applied to the site where response required.
  • Usually prescribed to treat inflammatory skin conditions
  • Fewer adverse effects than from oral or parental administration.
  • Available as:
    • Lotions, creams, ointments, gel
topical steroids71
Topical Steroids
  • How they work
    • Suppress inflammatory response at the site of application.
    • Minimally absorbed by normal skin
    • Absorption dependant on the site of application (thickness of skin)
    • Absorption increased where the natural barriers have been compromised
      • inflammed skin
      • wound sites
topical steroids72
Topical Steroids
  • Side effects:
    • Dry, irritated skin
    • Erythema
    • Unusual hair growth
    • Atrophy of skin
    • Striae
    • Tendency to bacterial & fungal infections
  • Systemic effects may occur after prolonged use
topical steroids classified according to potency
Topical steroids: Classified according to potency
  • Mild
    • Hydrocortisone 0.5-1%
      • Never use anything stronger than hydrocortisone on the face
      • Egocort, Dermaid, Anusol, Cortaid, Hydrocortone
  • Potent
    • Betamethasone 0.02%, 0.05% & 1%
      • Betnovate,Celestone, Diprosone
    • Mometasone 0.1%
      • Elocon, Novasone
    • Triamcinolone
      • Aristocort
topical steroids74
Topical Steroids
  • Usually only daily or twice day applications ordered
  • Wear gloves to apply
  • Thin smear only
  • Wash hands post – easily absorbed through skin
  • Do not apply occlusive dressing unless ordered – increases absorption
  • Should not be used alone when there is a bacterial/fungal infection as may cause spread of infection
inhaled steroids
Inhaled Steroids
  • Inhaled steroids are synthetic in origin.
  • Generally prescribed as a long-term control medication, to be used daily.
  • Act to reduce inflammation in either
    • lungs (asthma) or
    • nose (nasal allergies)
  • makes them less sensitive and possibly decreases mucus production
inhaled steroids76
Inhaled Steroids
  • Inhaled (MDI etc)
    • Used primarily to treat and/or prevent lung inflammation (asthma)
  • Nasally Inhaled Steroids
    • Reduce inflammation form nasal allergies
      • Beclomethasone: Beconase, Vancenase, Vanceril, Fluticase: Flovent, Flonase
      • Triamcinolone: Azmacort
  • Common side effects:
      • Coughing, hoarseness, dry mouth, throat irritation, flushing, loss of taste or unpleasant taste.
      • Thrush (causing discolouration of the tongue)
      • Burning & irritation inside the nose
      • Headache, runny nose, sneezing, watery eyes, nosebleeds
  • How could side effects be minimised?
parental steroids
Parental steroids
  • Intravenous
  • Intramuscular
  • Intra-articular
    • Hydrocortisone
    • Dexamethasone
synthetic corticosteroids
Synthetic Corticosteroids
  • Similar to natural cortisol
    • Regulation of cortisol occurs in the brain but brain is unable to tell difference between naturally occurring and synthetic medication
  • Normal steroid circadian rhythm higher in the morning, reaches a peak after waking then falls slowly to low levels in the evening & early phases of sleep
  • Sustained high doses leads to adrenal suppression
    • Dosage should be reduced gradually to allow the adrenal gland to recover and increase cortisol production at a normal level again
synthetic steroids79
Synthetic steroids

Duration of action

  • Short acting (8-12 hours)
    • Cortisone
    • Hydrocortisone
  • Intermediate (1-3 days)
    • Prednisone
    • Prednisilone
  • Long acting (2-3 days)
    • Dexamethasone
    • Betamethasone
comparison of corticosteroid strengths
Comparison of Corticosteroid strengths

Representation of relative potencies of some corticosteroids for equivalent anti-inflammatory action

corticosteroids81
Corticosteroids
  • Readily absorbed
    • 90% bound to plasma proteins
    • Metabolized in liver & body tissues
    • Excreted in kidneys
  • Prednisone vs Prednisolone
    • Prednisone is an inactive drug which is metabolised by the liver, whereas prednisolone is active
    • Clients with hepatic dysfunction must be given prednisolone.
  • Dosage
    • Usually commenced with lowest possible dose which is increased until improvement is achieved
    • Under normal circumstances treatment does not extend longer than 4-6 weeks
addison s crisis
Addison’s Crisis
  • Any stress can increase requirements
  • Natural cortisol production suppressed therefore body cannot supply the extra surge needed
  • Addison’s crisis – shock-like state
    • Collapse, vomiting, low BP
      • Hydrocortisone IV
      • IV fluids & glucose
  • Increased steroid dosage required for
    • Infection, surgery, stress
tapering dosage
Tapering dosage
  • When dose is to be discontinued, decrease gradually to enable adrenal cortex to produce cortisol
  • It can take the adrenal cortex up to 2 years to recover from prolonged treatment
  • Long term therapy ceased gradually over days, weeks, months to allow return of adrenal function
  • Report any vomiting, weakness or fainting
oral steroids
Oral Steroids
  • Available as
    • solution, syrup or tablet
  • Commonly a form of prednisone.
    • Prednisone, prednisolone, methylprednisolone
  • Used both for short & long term therapy
  • Used to treat a multitude of diseases
    • Asthma,
    • Systemic lupus erythematosus (SLE)
    • Prevention of transplant rejection
    • And other inflammatory-based diseases
oral steroids85
Oral Steroids
  • Steroid Burst
    • A burst may last 2 to 7-days and not require a reducing dose or several weeks with a reducing dose  steroid taper
    • Common side effects include:
      • Loss of appetite, fluid retention, moodiness and stomach upset
  • Routine Steroids
    • Used in clients with chronic lung disease. Client usually under a pulmonologist or allergist
administration oral
Administration (oral)
  • Simulate normal circadian rhythm to minimise adrenal suppression
    • Avoid evening doses
    • Administer mane or
    • Mane (2/3 dose) and evening (1/3 dose)
  • Give with food
  • Alternate day dosing
    • Minimises suppression
    • Often in children to minimise growth suppression
interactions
Interactions
  • Effects increased by:
    • OCP, ketaconazole
  • Effects decreased by:
    • Phenytoin, barbiturates, antacids
  • Other:
    • Counteracts effects of oral hypoglycaemics
    • Increases risk of gastric ulcer if NSAIDs
    • Increased risk of digoxin toxicity (K)
    • Not given with live virus immunisations
client education
Client Education
  • Take medication as ordered at the advised time
  • Do not stop taking suddenly
  • Medic alert bracelet if oral steroids (prolonged)
  • Take with food to decrease gastric irritation
  • Well balanced diet, adequate protein
    • Decrease refined sugars
    • Limit salt intake,
    • Add foods high in potassium & calcium
  • Avoid alcohol, NSAIDs & aspirin
client education89
Client Education
  • Eye check annually, alert dr - steroid use
  • Keep skin well moisturised
  • Routine exercise to minimise muscle wasting
  • Avoid exposure to infections
    • Especially varicella & measles
    • Annual flu immunisation
  • Monitor
    • Blood pressure
    • BGL may need checking
  • For inhaled
    • Check technique, use spacer, rinse mouth
client education90
Client Education
  • Steroids used for treatment of conditions such as asthma are not the same as the anabolic steroids used illegally by athletes or in body-building.
  • Corticosteroids do not affect the liver or cause sterility.