Endocrine system, Uncategorized

Endocrine basics




Endocrine System
Endocrine system regulates essential activities of the body
Metabolism of nutrients
Reproduction
Growth and development
Adapting to change in internal and external environments

Generally used
As replacement drug therapy to make up for hormone deficiency
As a diagnostic aid to determine if there is hypo or hyper function of a gland
Anterior Pituitary Drugs

An excess of GH can cause gigantism, while a lack of GH can cause dwarfism


Inadequate Growth Hormone (aka – somatotropin or somatropin)

Don’t miss the big picture here –
GH is synthesized, stored, and secreted by somatotropic cells within the 
lateral wings of the anterior pituitary gland.

Dwarfism
Somatrem (protropin)
Somatotropin (hymatrope)
Both are similar to endogenous growth hormone
Side effects include:
*  Pain
*  Redness at injection site
Dwarfism
somatrem (Protropin®)
somatotropin
Excessive Growth Hormone
Acromegaly
Gigantism
Surgical removal 1º
octreotide (Sandostatin®)
Acromegaly & Gigantism
Treatment of choice is surgical removal of the tumor
Octreotide (sandostatin)
*  Synthetic drug similar to somatostatin.
*  Inhibits the release of growth hormone
*  Side effects include:  bradycardia, diarrhea and stomach distress
Posterior Pituitary Drugs
Oxytocin
ADH

– Diabetes insipidus
– Nocturnal enuresis
vasopressin (Pitressin®)
desmopressin (Stimate®)
lypressin (Diapid®)
Two posterior hormones are oxytocin and antidiuretic hormone.
Antidiuretic analogues are used to treat diabetes insipidus, nocturnal enuresis (bedwetting).
ADH can cause vasoconstriction and increased BP.
Other names: Vasopressin (pitressin), desmopressin (stimate), lypressin (diapid) 
Thyroid and Anti-thyroid Drugs
Thyroid gland is responsible for the secretion of three hormones essential for proper regulation of metabolism.
– Thyroxine (T4)
– Triodothyronine (T3)
– Calcitonin 
T3 and T4

– Both produced in the thyroid gland through the iodination and coupling of the amino acid tyrosine. 
– Body needs about 1 mg of iodine per week from the diet. 
Iodine Rich Foods
Kelp, Yogurt, Cow’s milk, Strawberries, Mozzarella Cheese
Thyroid-Stimulating Hormone

TSH is released from the anterior pituitary and is stimulated when the blood levels 
of T3 and T4 are low. 
Hypothyroidism
Laboratory value to look at:
– TSH – thyroid stimulating hormone will be increased – it is working hard to 
stimulate the production of T3 and T4
– T3 and T4 levels would be low

A condition characterized by diminished production of the thyroid hormone.
Primary hypothyroidism stems from an abnormality in the gland itself.
Secondary hypothyroidism begins at the level of the pituitary gland and results from reduced levels of TSH (thyroid stimulating hormone).
Tertiary type is caused by reduction in the amount of TRH of thyrotropin releasing hormone by the hypothalamus. 
Hypothyroidism – Adults
Presenting clinical manifestations
Weight gain
Constipation
Fatigue
Irregular menstrual cycle in women
Edema
More common in females than males
Down Syndrome have high incidence
Newborns
– All newborns are tested at birth for thyroid function
– If untreated can lead to retardation due to effects on brain development
How is Hypothyroid Treated?
Thyroid drugs such as levothyroxine – Synthroid or Levothroid 
Take on empty stomach in the morning
Do  not take with antacids or iron preparations
Do not stop when feeling better
Dosage of other drugs may need to be reduced due to slow metabolism 
in liver and excretion in urine  
Hyperthyroidism
Excessive secretion of thyroid hormones.
Causes:
Graves’ disease

Plummer’s disease or toxic nodular disease.

Thyroid storm: caused by stress or infection



Signs and symptoms of thyroid crisis or thyroid storm
Tachycardia and cardiac arrhythmias
Fever
Heart failure
Flushed skin
Confusion / apathetic attitude / behavioral changes
Hypotension –baroreflex
Clinical Manifestations of hyperthyroidism
Diarrhea
Flushing
Increased appetite
Muscle weakness
Fatigue
Heart palpitations
Irritability
Nervousness
Sleep disturbances
Heat intolerance
Altered menses

Laboratory Values for Hyperthroidism 
SUMMARY

TSH would be low because it is not needed…
T3 and T4 would be high
Anti-thyroid Drugs
Methimazole and propylthioracil (PTU) act by inhibiting the incorporation 
of iodine molecules into the amino acid tyrosine.

Propylthioracil has the added ability to inhibit the conversion of T4 to T3 in the 
peripheral circulation.
Propylthioracil or PTU
Most common drug used by hyperthyroidism.
Will take about two weeks before the client will see change.
Side Effects: maculopapular skin rash, arthralgias, neutropenia –  
abnormally low count of neutrophils

Patient Education
Never discontinue the drugs abruptly 
Drug therapy is life-long
Follow-up is important to monitor dosing and therapeutic effects of the drug therapy.

Antidiabetic Drugs

Pancreas
Pancreas is both an endocrine and an exocrine gland, in that it functions to produce endocrinic hormones released into the circulatory system (such as insulin, andglucagon), to control glucose metabolism, and also to secrete digestive/exocrinic pancreatic juice, which is secreted eventually via the pancreatic duct into duodenum. Digestive or exocrine function of pancreas is as significant to the maintenance of health as its endocrine function.


The pancreas has two main functions:

[1] to produce pancreatic endocrine hormones (e.g., insulin & glucagon) which help
regulate many aspects of our metabolism and

[2], to produce pancreatic digestive enzymes.

Glucose

Primary source of energy for cell in the body.
Excess glucose is stored in the liver as glycogen.

When circulating glucose is needed the glycogen stored in the liver is broken
down in a process called glycogenolysis.

Glucagon starts this process.

Glucagon is released by the alpha cells of the pancreas.

Blood Sugar Levels 
Normal range is from 80 to 100 mg / dL
Diabetes is typically diagnoses when fasting blood 
sugar is 126 mg / dL or higher

Diabetes Mellitus
A complex disorder of carbohydrate, fat and protein metabolism resulting from 
lack of insulin secreted by the beta cells of the pancreas or a defect in the insulin receptors.
WIKI:
Diabetes mellitus (DM) or simplydiabetes, is a group of metabolic diseases in which a person has highblood sugar. This high blood sugar produces the symptoms of frequent urinationincreased thirst, andincreased hunger. Untreated, diabetes can cause many complications. Acutecomplications include diabetic ketoacidosis and nonketotic hyperosmolar coma. Serious long-term complications include heart disease,kidney failure, and damage to the eyes.
Diabetes is due to either the pancreasnot produce enough insulin, or becausecells of the body do not respond properly to the insulin that is produced.[2] 
Diabetes – long term complications
Related to blood vessel disease
– Small blood vessels
– Eyes (retinopathy), 
kidneys (nephropathy), 
nerves (microvascular)
– Large blood vessels
– Heart and blood vessels: coronary artery disease, stokes, lower 
extremity pain and impaired healing due to lack of blood flow 
Two Types of Diabetes (Mellitus)
Diabetes Mellitus Type I
Often called insulin-dependent diabetes or juvenile diabetes.
Diabetes type I
Auto-immune component.
Autoimmune reaction gradually destroys the insulin-producing beta cells.
Lack of insulin production or production of defective insulin.

Diabetic Ketoacidosis 

– When body cannot utilize glucose it will break down fatty acids 
for fuel producing ketones as metabolic by-products. 
– This produces a state of ketoacidosis.
– Untreated can lead to coma and death.

– Characteristic: fruity smell to breath 

Clinical Manifestations: DM I

– Polyuria (excess urination)
– Polydipsia (excessive thirst)
– Polyphagia (excess appetite)
Glucosuria (high blood glucose levels)
Weight loss
Fatigue

Vaginal yeast infection (females)

Treatment
Type 1 diabetes always requires insulin therapy.

Insulin
Primary treatment for diabetes type I.
Insulin functions as a substitute for the endogenous hormone.

It replaces the insulin that is either not made or is made defectively in the body.

Action of Insulin


It restores the ability to metabolize carbohydrates, fats and protein; 
to store glucose in the liver, and covert glycogen to fat stores. 

Side Effects of Insulin therapy

Too much insulin can result in hypoglycemia.

Insulin overdose can result in shock and possible death.

WHY DOES INSULIN CAUSE HYPOKALEMIA???

Insulin results in Hypokalemia just by increasing the activity of H*K ATPase pump. 
So insulin only shifts the K+ from the extracellular compartment to the intracellular compartment, it doesn’t decrease the total K+ content of the body……..
remember it……that’s why during management of Hyperkalemia 1st initial therapy is 
done by giving Insulin + Glucose combination which usually needs 30 minutes to come into action……..

Hypoglycemia

Abnormally low blood glucose level (generally below 50 mg/dL)

Hypoglycemic Signs and Symptoms

Shakiness
Dizziness
Sweating
Hunger
Headache
Pale skin
Sudden moodiness or behavior changes
Confusion or difficulty paying attention
Tingling sensation around the mouth

What to do?
Give sugar!
Orange juice
Glucagon: sublingual, IM

The Challenge:
To balance glucose and insulin levels in the body.

Types of Insulin

Four major classes of insulin:
– Rapid acting
– Short acting (regular)
– Intermediate acting

– Long-acting

Rapid Acting Insulin: Lispro /aspart


– Onset: 15 minutes
– Peak: 1-3 hours
– Duration: 3-5 hours
Used to cover extra carbohydrates 
Dosage adjusted according to number of carbohydrates ingested.

Best given 15 minutes before a meal.

Short Acting: regular / Humalin R / Novolin R


Onset of action: 30 to 60 minutes
Peak action: 2-4 hours
Duration: 8-12 hours

Best given 30 to 60 minutes before a meal.

* Only insulin that can be given intravenous in cases of severe DKA.

Intermediate Acting: NPH / Novalin

Lente or NPH insulin
Combination of long-acting 70% and rapid-acting 30%.
Effect is slower and more prolonged.
Onset: 1 – 1.5 hours
Peak: 4 – 12 hours

Duration: 24 hours

Long-Acting Insulin: Lantus
Combination: 70/30 or 50/50
Each contains rapid-acting and slower-acting insulin. 
Sliding Scale
Rapid-acting or short-acting given based on blood glucose levels.
Typically used in treating hospitalized diabetics and newly diagnosed (especially children)
Diabetes Type II


Non-insulin dependent or adult onset diabetes.
Note: if the blood glucose levels cannot be managed with oral anti-diabetic
drugs the client may need to use insulin

Obesity is one of the major risk factors for the development of type 2 diabetes.

– African Americans, Hispanic Americans, and Native Americans
are all at higher risk than whites.
10% have circulating anti-bodies that suggest an autoimmune origin 
of the disease.

Laboratory Values
Elevated blood glucose (higher than 126 mg/dL)
Impaired fasting glucose level (110 mg/dL or higher but less than 126 mg/dL)

A1c: screening blood value (higher than 6)

Hemoglobin A1c

Glycated hemoglobin 
Used to monitor glucose control of diabetes over time.
ADA recommends that this test be done 4 times a year in a known diabetic
(in addition to blood glucose tests).

Has become a screening tool to detect diabetes.
A1c

Healthy level should be 4 – 5.9
Blood glucose would be 60 to 100.

Oral Antidiabetic Drugs
Used in Diabetes type II along with 
life style modifications:
Diet
Exercise
Smoking cessation
Monitoring of blood glucose levels
Therapy with one or more drugs
Sulfonylureas
Drugs that stimulate insulin secretion from the beta cells of the pancreas.
Helps to transport glucose out of the blood into the cells.
Adverse effects: 
Hemtologic system: anemia, thrombocytopenia
Gastrointestinal: nausea, epigastric fullness and heartburn
Meglitinides
Have similar mechanism of action as sulfonylureas: 
increase insulin secretion from the pancreas. 
Adverse effects: 
headache, 
hypoglycemic episodes, 
weight gain, 
joint pain
Biguanide
Generic name: Metformin
Most commonly used oral drug in treating diabetes type II.
Action: works by decreasing the production of glucose 
as well as increasing its uptake.
Decreases glucose production by the liver
Decreased intestinal absorption of glucose
Improves insulin receptor sensitivity 
Alert: use of metformin with iodine containing radiologic contrast can lead 
to acute renal failure.
*Client should be off drug at least 48 hours before undergoing any radiologic 
study that requires contrast materials
Thiazolidinediones
– Part of the newer generation of drugs
– Action: works to decrease insulin resistance by enhancing the 
sensitivity of insulin receptors in liver, skeletal muscle and adipose tissue.
– Side effect: can increase LDL and HDL


Adrenal Drugs
Adrenal glucocorticoids: group of steroids

Corticosteroids
– Produced by the adrenal cortex
– Involved in stress response, immune response and regulation of inflammation, 
carbohydrate metabolism, protein catabolism, blood electrolyte levels and behavior.
Uses of Corticosteroids
Use to treat a number of different disorders 
especially inflammatory or immunologic disorders 
Arthritis
Dermatitis
Allergic reactions
Asthma
Hepatitis
Lupus erythematosus
Inflammatory bowel disease: ulcerative colitis and Crohn’s disease
Uveitis – inflammation of eye
Use in Orthopedics
Cortisone can be injected directly into a joint to reduce inflammation
Medrol dose pack is often prescribed for chronic back pain 
When not to use Corticosteroids
Fungal infections – thrush – vaginal yeast infections
Clients who are high risk for infection
– Diabetes
– Peptic ulcer
– Hypertension
– CHF

– Renal Failure

How Administered?
Topical – skin rashes – hydrocortisone
Eye drops / ear drops: cortisone ear drops or Prednisolone Ophthalmic suspension
Nasal – Nasonex
Tablet or liquid form – prednisone, Decadron
IV – methyl prednisone or Solu-medrol

Inhaled  – asthmatic or COPD 

Goals of Therapy
To reduce symptoms to a tolerable level
Total suppression of symptoms may require excessive dosages

Avoid serious side effects

Pharmacology Classification: corticosteroids
Action: suppress inflammation and the normal immune response.
Adverse reaction and side effects: 
depression, euphoria, hypertension, PEPTIC ULCER, 
THROMBOEMBOLISM, cushingoid appearance
Administration of PO Prednisone
Prednisone is a syntheticcorticosteroid drug that is particularly effective as an immunosuppressant drug. It is used to treat certain inflammatory diseases (such as moderate allergic reactions) and (at higher doses) some types of cancer, but has significant adverse effects. Because it suppresses the immune system, it leaves patients more susceptible to infections.

Take with meal or snack to decrease intestinal tract upset

Avoid consuming grapefruit juice

If once a day dosing – take in am before 9am
If more than once daily be sure to evenly space time medication is taken
In long term usage may need to take every other day in the morning so natural production is not totally suppressed 

Side Effects of Prednisone
Moon face, buffalo hump, 
obese trunk (love handles), acne, 
hirsutism, 
weight gain
Impaired healing or bruising 
CNS: nervousness, insomnia, depression, aggravation of pre-existing mental disorders
Musculoskeletal: long term use can cause osteoporosis, muscle weakness and atrophy
GI: peptic ulcer, increased appetite
Cardiovascular: fluid retention
Ocular: increased intraocular pressure, glaucoma, cataracts 
High-dose
corticosteroid therapy
produces a characteristic 
“moon face” appearance
Let’s also look at:
Drugs Affecting the Adrenal Cortex
Drugs Affecting the Parathyroid
Reproductive Drugs

Parathyroid Diseases
Hypoparathyroidism
Inadequate calcium levels

TX: increased dietary calcium

Hyperparathyroidism

Excessive calcium levels
TX: surgical removal

NAP TIME (yes, I get burned our too, 
and need to take many naps!!!)

NAP TIME (yes, I get burned our too, 
and need to take many naps!!!)

ok..let’s get back with the program, Moji.
Wake up! Already awake? Ok, sorry!

Adrenal Cortex
Adrenocorticotropic hormone(ACTH), also known as corticotrophin, is a polypeptide tropic hormone produced and secreted by the anterior pituitary gland. It is an important component of the hypothalamic-pituitary-adrenal axis and is often produced in response to biological stress (along with its precursor corticotropin-releasing hormone from the hypothalamus). Its principal effects are increased production and release of corticosteroids
Wiki:

 Primary adrenal insufficiency, also called Addison’s disease, occurs when adrenal gland production of cortisol is chronically deficient, resulting in chronically elevated ACTH levels

– when a pituitary tumor is the cause of elevated ACTH (from the anterior pituitary) this is known as Cushing’s Disease and the constellation of signs and symptoms of the excess cortisol (hypercortisolism) is known as Cushing’s syndrome.

ACTH Hypersecretion

Cushing’s Disease (pituitary tumor)

Surgical removal of tumor
Inhibit adrenal secretion HOW??????????????
ketoconazol (Nizoral ®)

Symptomatic tx:
Antihypertensives

ACTH Hyposecretion
Addison’s Disease
Replacement therapy
Cortisone (Cortistan®)
Hydrocortisone (SoluCortef®)

Fludrocortisone (Florinef Acetate®)

ACTH Hyposecretion
Addison’s Disease
Replacement therapy
Cortisone (Cortistan®)
Hydrocortisone (SoluCortef®)

Fludrocortisone (Florinef Acetate®)

Estrogens & Progestins

Estrogens used for post-menopausal hormone replacement therapy.
estradiol (Estrace®)
conjugated estrogens (Premarin®)
estropipate (Ogen®)

Progestin
Diminish side effects of estrogen therapy
Nausea, fluid retention, breast tenderness
medroxyprogesterone acetate (Provera®)
norethindrone acetate (Aygestin®)
Oral Contraceptives
Combination of estrogen and progestin
Loestrin®, Levora®, Nordette®, Ovocon®, Norinyl® plus many others
Minipill: progestin only
Micronor®, Nor-Q.D.®, Orvette®

Prime side effect:  risk of thromboembolism
Uterine Stimulants & Relaxants
Stimulants (Oxytocics)
  uterine contraction
Indication:
Induce labor
Postpartum hemorrhage
oxytocin (Pitocin®)
ergonovine (Ergotrate®)
Relaxants (tocolytics)
Relax uterine smooth muscle
Beta2 agonists
terbutaline (Brethine®)
ritodrine (Yuptopar®)
Infertility Agents
Promote maturation of ovarian follicles
clomiphene (Clomid®)
urofollitropin (Metrodin®)

Male Reproductive Agents
Testosterone Replacement
methyltestosterone (Metandren®)
fluoxymesterone (Halotestin®)

Benign Prostatic Hypertrophy
Surgery
finasteride (Proscar®)
Sexual Behavior

Most are side effects from other medications
Antihypertensives & psychoactive drugs
sildenafil (Viagra®)

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