DRUGS ACTING ON THE ENDOCRINE SYSTEM

OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEM

-composed of an interrelated complex of glands (pituitary, adrenals, thyroid, parathyroids, islet of
Langerhans of the pancreas, ovaries and testes) that secrete a variety of hormones directly into the
bloodstream.
-major function, together with the nervous system, is to regulate body functions

HORMONE REGULATION
A. Hormones: chemical substances that act as messengers to specific cells and organs (target organs),
stimulating and inhibiting various processes; two major categories:
1. Local: hormones with specific effect in the area of secretion
2. General: hormones transported in the blood to distant sites where they exert their effect

B. Negative feedback mechanisms: major means of regulating hormone levels

1. Decreased concentration of a circulating hormone triggers production of a stimulating hormone from
the pituitary gland; this hormone in turn stimulates its target organ to produce hormones
2. Increased concentration of a hormone inhibits production of the stimulating hormone, resulting in
decreased secretion of the target organ hormone.

C. Some hormones are controlled by changing blood levels of specific substances (Ca, glucose)

D. Certain hormones follow rhythmic patterns of secretion (female reproductive).

E. ANS and CNS control (P-HA): hypothalamus controls release of the hormones of the APG through
releasing and inhibiting factors that stimulate or inhibit hormone secretion

Structures and Functions

Pituitary Gland (Hypophysis)

A. Located in sella turcica at the base of the brain
B. “Master gland”; 3 lobes:
1. Anterior lobe (adenohypophysis)
a. secretes tropic hormones (hormones that stimulate target glands to produce their hormone):
adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), follicle-stimulating
hormone (FSH), luteinizing hormone (LH)
b. also secretes hormones that have direct effect on tissues: somatotropic or growth hormone,
prolactin
c. regulated by hypothalamic releasing and inhibitin factors and by negative feedback system

2. Posterior lobe (neurohypohysis): does not produce hormones; stores and releases antidiuretic
hormones (ADH) and oxytocin, produces by the hypothalamus

3. Intermediate lobe: secretes melanocyte-stimulating hormone (MSH)

Adrenal Glands
A. two small glands, one above each kidney
B. Consist of two sections:
1. Adrenal cortex (outer portion): produces mineralocorticoids, glucocorticoids, sex hormones
2. Adrenal medulla (inner portion): produces epinephrine, norepinephrine
Thyroid Gland
A. Located in anterior portion of the neck
B. Consists of two lobes connected by a narrow isthmus
C. Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin

Parathyroid Glands
A. Four small glands located in pairs behind the thyroid gland
B. Produce parathormone (PTH)

Pancreas
A. Located behind the stomach
B. Has both endocrine and exocrine functions
C. Islets of Langerhans – involved in endocrine functions
1. Beta cells: produce insulin
2. Alpha cells: produce glucagon

Gonads
A. Ovaries: located in the pelvic cavity, produce estrogen and progesterone
B. Testes: located in the scrotum, produce testosterone

Laboratory/Diagnostic tests

Thyroid Function
A. Serum studies: nonfasting blood studies (no prep)
1. Serum T4 level: measures total serum level of throxine
2. Serum T3 level: measures serum triiodothyronine level
3. TSH: measurement differentiates primary from secondary hypothyroidism

Pancreatic Function
A. Fasting blood sugar: measures serum glucose levels; client fasts from midnight before the test
B. Two-hour postprandial blood sugar: measurement of blood glucose 2 hours after a meal is ingested
1. Fast from midnight before test
2. Client eats a meal consisting of at least 75g CHO or ingests 100g glucose
3. Blood drawn 2 hours after a meal
C. Oral glucose tolerance test: most specific and sensitive test for diabetes mellitus
1. Fast from midnight before test
2. FBG and urine glucose obtained
3. Client ingests 100g glucose; blood sugars are drawn at 30 and 60 minutes and then hourly 3-5 hours;
urine specimens may also be collected
4. Diet for 3 days prior to test should include 200g CHO and atleast 1500 kcal/day
5. During test, assess the client for reactions such as dizziness, sweating and weakness
D. Glycosylated hemoglobin (hemoglobin A1c) reflects the average blood sugar level for the previous
100-120 days. Glucose attaches to a minor hemoglobin (A1c). this attachment is irreversible.
1. Fasting is not necessary
2. Excellent method to evaluate long term control of blood sugar

SPECIFIC DISORDERS OF THE PITUITARY GLAND

Hypopituitarism
- Hypofunction of the APG resulting in deficiencies of both the hormones secreted by the APG and
those secreted by the target glands
 - May be caused by tumor, trauma, surgical removal; may be congenital

Assessment:
1. Tumor, headache
2. Retardation of growth
3. Hormonal disturbances

Medical management: depends on cause

1. Tumor: removal or irradiation
2. Regardless of cause: treatment will include replacement of deficient hormones (cortico-steroids,
thyroid hormones, sex hormones, gonadotropins -> to restore fertility)

Nursing management:
1. Provide care undergoing hypophysectomy or radiation therapy
2. Provide client teaching and discharge planning:
a. Hormone replacement therapy
b. Importance of follow-up care

Hyperpituitarism
- Hyperfunction of the APG resulting in oversecretion of one or more of the anterior pituitary
hormones-> Overproduction of GH -> acromegaly (adults) or gigantism (children)
- Usually caused by a benign adenoma

Assessment:
1. Tumor, headache
2. Hormonal disturbances
3. Acromegaly: enlargement of the bones, features becomes coarse and heavy, lips heavier, tongue
enlarged

Medical management: surgical removal or irradiation of the gland

Nursing interventions:
1. Monitor for hyperglycemia and cardiovascular problems and modify care
2. Provide psychological support and acceptance for alterations in body image
3. Provide care undergoing hypophysectomy or radiation therapy

Diabetes Insipidus
- Hypofunction of the PPG resulting in deficiency of ADH
- Excessive thirst and urination
- Tumor, trauma, inflammation, surgery

Assessment
1. Polydipsia and severe polyuria with low SG (less than 1.004)
2. Fatigue, muscle weakness, irritability, weight loss, signs of DHN
3. Tachycardia, eventual shock -> if fluids not replaced

Nursing interventions
1. Maintain fluid and electrolyte balance (Keep accurate I&O; weigh daily, fluid replacement-IV/oral)
2. Monitor vs and observe for DHN and hypovolemia
3. Administer hormone replacement as ordered
a. vasopressin (Pitressin)
 b. lypressin (Diapid): nasal spray
4. Client teaching: Lifelong hormone replacement therapy; lypressin PRN to control polydipsia/uria

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

- Hypersecretion of ADH from PPG even when the client has abnormal serum osmolality

Assessment
1. concentrated urine
2. Fluid retention and sodium deficiency

Medical management
1. Treat cause
2. Diuretics and fluid restriction

Nursing interventions
1. Administer diuretics (furosemide [Lasix]) as ordered
2. Restrict fluids - to promote fluid loss and gradual increase in serum Na
3. Monitor serum electrolytes
4. Careful intake and output, daily weight
5. Monitor neurologic status
6. Increase Na in diet

DISORDERS OF THE ADRENAL GLAND

Addison’s disease
- Primary adrenocortical insufficiency; hypofunction of the adrenal cortex causes decrease of the
mineralocorticoids, glucocorticoids, and sex hormones
- Rare disease caused by: idiopathic atrophy due to autoimmune process; destruction of the gland
secondary to tuberculosis or infection

Assessment:
1. fatigue, muscle weakness
2. anorexia, nausea, vomiting, abdominal pain, weight loss
3. history of hypoglycemic reactions
4. Hypotension, weak pulse
5. Bronze-like pigmentation of the skin
6. decreased capacity to deal with stress
7. low cortisol levels, hyponatremia, hyperkaliemia, hypoglycemia
Nursing interventions
1. Administer hormone replacement therapy as ordered
a. Glucocorticoids (cortisone, hydrocortisone): to stimulate diurnal rhythm of cortisol release, give 2/3
dose in early morning and 1/3 dose in the afternoon
b. Mineralocorticoids: fludrocortisone acetate (Florinef)
2. Monitor VS
3. decrease stress in the environment
4. prevent exposure to infection
5. Provide rest periods; prevent fatigue
6. Monitor I&O
7. Weigh daily
8. provide small, frequent feedings of diet high in CHO, Na and CHON to prevent hypoglycemia and
hyponatremia and proper nutrition
9. client teachings:
a. disease process/signs and symptoms
b. medications for lifelong replacement therapy; never omit meds
c. avoid stress, trauma, infections
d. diet modification -> high in protein, carbohydrates, sodium

Cushing’s Syndrome
- Condition resulting from excessive secretion of corticosteroids, particularly the glucocorticoid
cortisol; usually females (30-60 y/o)
- Caused by adrenocortical tumors or hyperplasia; neoplasms secreting ACTH, causing increased
glucocorticoids
- Iatrogenic: prolonged use of corticosteroids

Assessment:
1. Muscle weakness, fatigue, obese trunk with thin arms and legs, muscle wasting
2. Irritability, depression, frequent mood swings
3. Moon face, buffalo hump, pendulous abdomen
4. Purple striae on trunk, acne, thin skin
5. Signs of masculinization in women, menstrual dysfunction, decrease libido
6. Osteoporosis, decreased resistance to infection
7. Hypertension, edema
8. cortisol levels increased, slight hypernatremia, hyponatremia, hypokalemia, hyperglycemia

Nursing interventions
1. Maintain muscle tone
2. Prevent accidents or falls and provide adequate rest
3. Protect client from exposure to infection
4. Maintain skin integrity
5. Minimize stress
6. Monitor vs: hypertension, edema
7. Monitor I&O and daily weights
8. Provide diet low in calories and sodium and high in protein, potassium, calcium, vitamin D
9. Monitor urine for glucose and acetone: administer insulin
10.

DISORDERS OF THE THYROID GLAND

Hypothyroidism (Myxedema)
- Slowing of metabolic processes caused by hypofunction of the thyroid glnd with decreased
thyroid hormone secretion -> myxedema(adults); cretinism(children); often with women(30-60)
- Primary: atrophy; secondary: decreased stimulation from pituitary TSH; Iatrogenic: surgical
removal of the gland or overtreatment of hyperthyroidism
- In severe cases, myxedema coma may occur-> hypothyroidism, neurologic impairment-> coma

Assessment:
1. Fatigue, lethargy, slowed mental processes, dull, slow clumsy movements
2. Anorexia, weight gain, constipation
3. Intolerance to cold, dry scaly skin, sparse hair, brittle nails
4. Menstrual irregularities; generalized non-pitting edema
5. Bradycardia, cardiac complications (CAD, angina pectoris, MI, CHF)
6. Increased sensitivity to sedatives, narcotics, anesthetics
7. Low T3 and T4 levels
8. Exaggeration of these findings in myxedema coma: weakness, lethargy, syncope, bradycardia,
hypotension, hypoventilation, subnormal temperature

Medical management
1. Drug therapy: levothyroxine (Synthroid), thyroglobulin (Proloid), liothyronine (Cytomel)
2. Myxedema coma is a medical emergency
a. IV thyroid hormones
b. correction of hypothermia
c. maintenance of vital functions
d. treatment of precipitating causes

Interventions:
1. Monitor vs, I&O, daily weights, observe edema, signs of cardiovascular complications
2. Administer thyroid hormone replacement as ordered and monitor effects
a. Observe for thyrotoxicosis (tachycardia, palpitations, nausea, vomiting, diarrhea, sweating, tremors,
agitation, dyspnea)
b. Increase dosage gradually
3. Provide a comfortable warm environment
4. Provide low-calorie diet
5. Avoid the use of sedatives; reduce by half
6. Institute measures to prevent skin breakdown
7. Provide increased fluids and fiber to prevent constipation; stool softeners
8. Observe for signs of myxedema coma
9. client teachings: take daily dose in the morning (insomnia); protection for cold weather; prevent
constipation

Hyperthyroidism (Grave’s disease)

- Secretion of excessive amounts of thyroid hormone in the blood causes an increase in metabolic
process; thyroid gland changes and overactivity may be present; unknown cause
- Most often seen in women (30-50)

Assessment
1. Irritability, agitation, restlessness, hyperactivity, tremor, sweating, insomnia
2. Increased appetite, hyperphagia, weight loss, diarrhea, intolerance to heat
3. Exophthalmos, goiter
4. Warm, smooth skin; fine, soft hair, pliable nails
5. Tachycardia, increased systolic BP, palpitations
6. Increased T3 and T4 levels

Medical management
a. Antithyroid drugs (propylthiouracil and methimazole [Tapozole]): block synthesis of thyroid hormone
b. Adrenergic blocking agents (propranolol [Inderal]): used to decrease sympathetic activity and
alleviate symptoms

Nursing interventions
1. Monitor vs, daily weights
2. Administer antithyroid medications as ordered
3. Provide uninterrupted rest: (private room, meds)
4. Provide cool environment
5. Minimize stress
6. Encourage quiet, relaxing diversional activities
7. Diet: high in carbohydrates, protein, calories, vitamins, minerals
8. Exophthalmos:( protect eyes; artificial tears); thyroid storm

ANTERIOR PITUITARY HORMONES

- Used to antagonize the effects of specific pituitary hormones
- May be used as replacement therapy or diagnostic purpose

GROWTH HORMONE
- Responsible for growth and CHON synthesis
- Indicated for growth failure (dwarfism)
- Somatotropin (Nutropin, Saizen, Humatrope)
- A: IV; D: wide; M: liver; E: urine and feces
- Contraindicated for allergy, closed epiphysis and obesity
- Serious adverse effect: DM (if prolonged used)

POSTERIOR PITUITARY HORMONES

- ADH (synthetic) – antidiuretic, hemostatic, vasopressor properties
- promote water reabsorption from the renal tubules -> stops diuresis
- reduction in urine output -> measure for effectiveness
- vasopressin (Pitressin) – parenteral/nasal; desmopressin (DDAVP)
- DI, hemophilia A, nocturnal enuresis, abdominal distention
- D: wide; M: liver; E: urine
- CI: allergy, severe renal dysfunction; Caution: epilepsy, pregnancy
- AE: water intoxication, tremor, sweating, headache

DRUGS USED TO TREAT THYROID DISEASES

Thyroid: TSH
Goal: To return the patient to a normal thyroid (euthyroid) state.
Hypothyroidism: replacement of thyroid hormones
Hyperthyroidism: thyroidectomy, radioactive iodine, antithyroid medications
- Treated out-patient unless for surgery

Two general classes of drugs used to treat thyroid hormones:

1. Replacement thyroid hormones – levothyroxine (T4), liothyronine (T3), liothyronine, USP
2. Antithyroid agents –suppress synthesis of thyroid hormones (radioactive iodides, propylthiouracil,
methimazole)

THYROID REPLACEMENT HORMONES (wt gain s/sy vs hyper)

- Primary goal: normal thyroid state (euthyroid)
- Natural and synthetic sources

COMMON THYROID HORMONES

Ethyroxine Synthroid, Synthetic T4 Drug of choice

Levoxyl
liothyronine Cytomel Synthetic T3 Rapid than
levothyroxine;
not indicated
with CVD
liotrix Thyrolar Synthetic levothyroxine+liothyronin
 e
4:1
thyroid, USP From pig, beef,
sheep; oldest;
least expensive;
lack purity,
uniformity and
stability

NOTE: initial dosage depends on age of patient, severity of hypothyroidism and other medical
conditions.
-Hypothyroid patients are sensitive to replacement therapy -> monitor closely for adverse effects
-PO: initiated in low dosages of levothyroxine (0.05 to 0.1 mg daily; ave: 0.1 mg to 0.2 mg) and gradually
increased
-same time of the day
- taken on empty stomach (at least 45 minutes before ingestion of food; commonly after breakfast)

ADVERSE EFFECTS:
Signs of hyperthyroidism Tachycardia, anxiety, wt loss, abdominal cramping,
diarrhea, palpitations, angina, heat intolerance

- Dose-related; may occur after 1-3wks

- Reduction of dosage or discontinuation

DRUG INTERACTIONS:
Warfarin: requires increased dosage of anticoagulants; assess also for signs of bleeding; reduce after
four weeks
Digoxin: requires decrease dosage if with hypothyroidism, but with therapy, gradual increase may be
necessary
Estrogen: may require increase dosage of thyroid hormone
Hyperglycemia: monitor for development of hyperglycemia, specially early weeks-> assess; adjust
dosage

ANTITHYROID MEDICATIONS (for Grave’s/hyperfuction; s/sy-tachy, nervousness,heat int)

Propylthiouracul (PTU, Propasil); methimazole (Tapazole)

- Antithyroid agents by blocking synthesis of T3 and T4 in the thyroid gland
- Do not destroy any T3 and T4 already produced

USES: long-term treatment of hyperthyroidism or short-term treatment before subtotal thyroidectomy

- 1-2 years

Note: PTU, PO; 100-150 mg q 6-8 hrs daily(initial); 50 mg 2-3times daily;

Methimazole, PO; 5-20 mg q 8 hrs daily (initial); 5-15 mg (maintenance)

ADVERSE EFFECTS:
Purpuric rash/puritus (most common), bone marrow suppression, hepatotoxicity, nephrotoxicity
ADRENOCORTICAL AGENTS

GLUCOCORTICOIDS
- enter target cells and bind to cytoplasmic receptors, initiating many complex reactions -> anti-
inflammatory and immunosuppressive effects

ACTIONS: suppresses hypersensitivity and immune response (allergy and anti-inflammatory reactions)

USES: short-term treatment of inflammatory disorders, to relieve discomfort, and give the body a
chance to heal from inflammatory effects
: replacement therapy for patients with adrenocortical insufficiency; immunosuppression;
reduction of inflammation and its effects

COMMON GLUCOCORTICOIDS:
Bethametasone Celestone Long-acting steroid; parenteral or oral; inflammation
Cortisone Cortone Acetate One of the first corticosteroids; orally and parenteral for
adrenal insufficiency and acute inflammation
Dexamethasone Decadron, etc. Dermatologic, ophthalmologic, parenteral, inhalation; can
last 2-3 days
Hydrocortisone Cortef Powerful; both M & G; replacement therapy in patients
with adrenal insufficiency
Methylprednisolone Medrol Little mineralocorticoid; drug of choice for inflammatory
and immune disorders; oral, parenteral, enema
prednisolone Delta-Cortef Intermediate corticosteroid; oral, topical, intralesional
and intra-articular injections, oral, topical
Prednisone Deltasone, etc Oral; adrenal insufficiency; inflammation; TAPERED

PHARMACOKINETICS:
ABSORPTION Many sites
DISTRIBUTION Well-distributed; crosses placenta and BM
METABOLISM Liver
EXCRETION Urine

CONTRAINDICATIONS AND CAUTIONS:

- Allergy; lactation; diabetes (glucose-elevating effects); pregnancy; ulcers

ADVERSE EFFECTS:
- fluid retention, potential CHF, increased appetite and weight gain; fragile skin and loss of hair;
muscle weakness and atrophy, Cushing’s syndrome
- fluid overload and HPN

NURSING RESPONSIBILITIES:
- Take drugs at meal time or with food.
- Eat foods high in potassium, low in sodium.
- Instruct client to avoid individuals with RTI.
- Instruct client not to stop medication abruptly, it should be tapered to prevent adrenal insufficiency
- Avoid taking NSAID while taking steroids.
- Take inhaled bronchodilators first before taking inhaled steroids, and rinse mouth after using.
- Teach the client the signs and symptoms of excess use of glucocorticoids

ANTIDIABETIC AGENTS: Normal serum glucose = 70-110/80-120 mg/dl

Type 1 –early inlife; Type2 – later in life
Oral Hypoglycemic Agents (OHA)

1. Sulfonylureas
- stimulate insulin secretions and increase tissue sensitivity to insulin.
First Generation :
chlorpropamide (Diabenese)
- most frequently used
- disulfiram precautions
tolbutamide (Orinase)
- more easily cleared from the body
- congenital defect
tolazamide
Second Generation : safer to patients with renal dysfunction; do not interact with as many CHON-drugs;
longer duration; same action as 1st gen
glypizide, glimepiride (Glucotrol)-less expensive

2. Biguanides
- facilitates insulin action on the peripheral receptor site.
Metformin and Glucophage (Glucovance)
- acts by decreasing hepatic production of glucose from stored glycogen. As the result of this
action, metformin:decreases the serum glucose levels following a meal
– inhibits glycogenolysis, reduces absorption of glucose, increases insulin sensitivity improving glucose
uptake; decrease in FBG
- adjunct to diet to lowe blood glucose (Type 2 DM)
- does not cause hypoglycemia and weight gain, decreases cholesterol
- side effect is lactic acidosis

3. Alpha-glucosidase inhibitors
- antihyperglycemic agent; enzyme inhibitor (alpha-amylase, alpha-glucoside hydrolase)
- This agent is prescribed for clients who cannot control blood sugar by diet because:
- delay carbohydrate absorption in the intestinal system/ it inhibits the digestive enzyme for
carbohydrates in the small intestine
- adjunct to Type 2 DM which exercise and diet cannot control
- does not cause hypoglycemia
Acarbose (Precose) – side effect is diarrhea

4. Thiazolinidine (TZD)
- increase tissue sensitivity of insulin. -> allowing more glucose to enter the cells in the presence of
insulin for metabolism
- do not stimulate the release of insulin, rather, insulin must be present to be effective
- effective in Type 2 DM
-can be used alone or in combination
Rosiglitazone (Avandia)

5. Meglitinides
- stimulate insulin release in pancreatic B-cells.
- effective in type 2 DM not controlled by diet or exercise (pancreas still ha capacity to secrete insulin);
not effective in type 1DM
- can be used with metformin
-short duration of action – lesser risk for having hypoglycemic effects
 Repaglinide (Prandin)

Nursing considerations :
- Effective only for type II DM.
- Contraindicated to pregnant & breastfeeding.
- Given before meals.
- Monitor for signs of hypoglycemia.

INSULIN
- hormone produced in the beta cells of the pancreas -> key regulator of metabolism
- required for the entry of glucose into skeletal and heart muscle and fat
- if insulin is deficient, the transport of glucose into the cells is reduced -> hyperglycemia
- hyperlipidemia, ketosis, acidosis

USES:
-

Insulin Onset Peak Duration

Immediate-acting (lispro) 0.15h (ave: 5 mins) 0.5–1h 5h
Short-acting(regular-IV, semilente, human) 0.5-1 h 2-4 h 5-7h
Intermediate-acting (NPH, lente) 1-3 h 8-12 h 18-24 h
Long-acting (ultralente, Lantus – no peak) 4-6h 10-30 h 24-36 h
Mixed Humulin (regular 30%, NPH 70%) 0.5 h 4-8 h 25 h

Nursing considerations :
- The insulin that has fewer antigenic, allergic, and insulin resistance effects is: human insulin (Humulin)
- Usually given before meals.
- Roll the bottle in palm of hands, don’t shake.
- insulin syringe (100-unit insulin syringe)
- Inject amount of air that is equal to each dose into the bottle – short acting last (clear).
- The client is to receive regular and NPH insulins. In preparing the syringe(s), the nurse or client would
use: one injection: draw up regular insulin first
- Aspirate short acting first, then long or intermediate (cloudy).
- Alcohol is recommended for cleansing bottle but not with skin.
- Pinch skin, avoid I.M, don’t aspirate (SC).
- Rotate the injection site an inch a part.
- Prefilled syringes are stored vertically, needle-up.
- May increase dose during illnesses.
- Used bottles stored in room temperature, unused bottle stored in refrigerator.
Combination insulins that are commercially premixed, such as Humulin 70/30, are primarily for clients:
who can use the prepared amount of regular and NPH units
- insulin pump: regular insulin -> maintain glucose level
-in case of infection/s: increase dosage
- assesses signs and symptoms of hypoglycemic reaction (insulin shock):nervousness and tremors
- Monitor for acute hypoglycemia :
a. 3-4 commercially prepared glucose tablet
b. 4-6 ounce of fruit juice or regular soda
c. 2-3 teaspoon or honey
d. Glucagon 1 gm SQ or IM
e. D50-50 IV.
- give glucagon as first aid on collapsed person