Adrenal Agents

Glucocorticoids
  • Prednisone – preferred oral glucocorticoid for anti-inflammatory or immunosuppressant purposes
  • Cortisone
  • Methylpredinisolone
  • Many others
Mineralocorticoid
  • fludrocortisone acetate – Used to treat Addison’s Disease

Adrenal steroid inhibitors
  • Aminoglutethimide (Cytadren) – used to treat Cushing’s syndrome, breast cancer and adrenal cancer
  • ketoconazole

Indications

Adrenocortical deficiency, collagen diseases, dermatologic diseases, GI diseases, exacerbations of chronic respiratory illnesses, organ transplant (decrease immune response), spinal cord injury, cerebral edema
Glucocorticoids given:
  • by inhalation for control of steroid-responsive bronchospastic states
  • nasally for rhinitis and to prevent the recurrence of polyps after surgical removal
  • topically for inflammation of the eye, ear, and skin
Antiadrenals (adrenal steroid inhibitors)
  • used in the treatment of Cushing's syndrome

Mechanism of action:

  • modifying enzyme activity
  • salt and fluid retention (dependent on type; potency)
  • Glucocorticoids inhibit or help control inflammatory and immune responses

Contraindications

  • drug allergies
  • serious infections: septicemia, systemic fungal infections, and varicella
In TB and meningitis, glucocorticoids may be used to prevent inflammatory CNS damage

Side Effects

  • Cardiovascular
    • heart failure, cardiac edema, hypertention
  • CNS
    • convulsions, HA, vertigo, mood swings, nervousness
  • Endocrine
    • growth suppression, Cushing's syndrome, heryglycemia
  • GI
    • peptic ulcers with possible perforation, pancreatitis
  • Integumentary
    • fragile skin, petechiae, ecchymosis, facial erythema, poor wound healing, hirsutism, uticaria
  • Musculoskeletal
    • muscle weakness, loss of muscle mass, osteoperosis
  • Ocular
    • increased intraocular pressure, glaucoma

Adverse effects

  • weight gain
  • increased bp
  • aggression
  • depression
  • psychosis
  • electrolyte imbalances
  • elevated blood glucose levels
  • decreased healing time


Corticosteroid Interactions

  • Non-potassium sparing diuretics: thiazide and loop diuretics
    • can lead to severe hypocalcemia and hypokalemia
  • Aspirin and other NSAIDs
    • additive GI effects
  • Anticholinergic drugs
    • weakness in patients with myasthenia gravis
  • Immunizing biologicals
    • Cortiocosteroids lower the immune response

Nursing Implications

• Perform a physical assessment to determine baseline weight, height, intake and output status, vital signs (especially BP), hydration status, immune status
• Assess for edema and electrolyte imbalances
• Assess for contraindications to adrenal agents
• Oral forms should be given with food or milk to minimize GI upset
• Assess for drug allergies and potential drug interactions
• Clear nasal passages before giving a nasal corticosteroid
• After using an 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
• Teach patients to take all adrenal medications at the same time every day, usually in the morning, with meals or food
• Sudden discontinuation of these agents can precipitate an adrenal crisis caused by a sudden drop in serum levels of cortisone
• Doses are usually tapered before the agent is discontinued
• Monitor for therapeutic responses
• Monitor for side/adverse effects





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Antidiabetics



Diabetes Overview


Diabetes- a chronic disorder of metabolism
Insulin- transports glucose
  • Type 1: Juvenile Onset, Insulin Dependent Diabetes Mellitus (10% of cases)
    • absence of insulin production
      • complications- diabetic ketoacidosis (DKA); body breaks down fatty acids for fuel- can lead to coma and death
      • risk factors- overweight, inactivity, family history, race (increased risk for Asians, African Americans, Native Americans and Hispanics), increased risk in those over 45, gestational diabetes
      • treatments- insulin therapy
  • Type 2: Adult Onset, Non-Insulin Dependent Diabetes Mellitus (90% of cases)
    • insulin deficiency and insulin resistance
      • treatments- lifestyle changes, oral drug therapy; insulin is used when these two no longer provide control
  • Gestational: in pregnancy, 4%
    • Hyperglycemia development in pregnancy
    • Typically subsides after delivery however, 30-60% may develop Type 2 within 10 to 15 years


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Normoglycemia- normal blood sugar (60 mg/dL-110 mg/dL)

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Hyperglycemia- elevated blood sugar (>126 mg/dL)

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Hypoglycemia- low blood sugar (<50 mg/dL)



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DRUGS

· Insulins (Human-Based Insulins)


o Rapid-Acting
§ Most rapid onset of action 5-15 minutes
§ Shorter duration
· Ex. NovoLog
· Ex. Humalog
· Ex. Apidra
May be given SC or via continuous SC infusion pump
BUT NOT IV
o Short-Acting
§ Onset 30-60 minutes
· Ex. Humulin R, Novolin R
Only insulin product that can be given by IV bolus, IV infusion, or IM
o Intermediate-Acting
§ Ex. Humulin N, Novolin N
§ Ex. Humulin L, Novolin L
· Both have cloudy appearance
· Slower in onset and more prolonged duration than endogenous insulin
o Long-Acting
§ Used to maintain basal rate of insulin
§ Dosed 1-2 times per day
· Ex. Lantus
o Clear, colorless solution
· Ex. Ultralente, Humulin U
o White, opaque solution
o Combination Insulin Products
§ Ex. Humulin 70/30, Novolin 70/30
§ Ex. Humulin 50/50
§ Ex. Humalog Mix 75/25

· Oral Antidiabetic Agents
o Used for Type 2 Diabetes
o Treatment includes lifestyle changes

§ Sulfonylureas, 1st oral agents stimulate insulin secretion from the beta cells of the pancreas, thus increasing insulin levels
· Ex. Diabinese, Tolinase, Orinase, Amaryl, Glucotrol, DiaBeta
o S/E include hypoglycemia, hematologic effects, nausea, epigastric fullness

§ Biguanides decrease production of glucose, increase uptake of glucose by tissues but do not increase insulin secretion from the pancreas
· Ex. Glucophage
o S/E include abdominal bloating, nausea, cramping, diarrhea, metallic taste, reduced vitamin B12 levels

§ Meglitinides stimulate insulin secretion from pancreas. Should be taken before meals to prevent spike in blood sugar after eating.
· Ex. Prandin

§ Alpha-glucosidase inhibitors delay absorption of glucose by inhibiting the enzyme in the small intestine. Should be taken with meals to prevent excessive postprandial blood glucose elevations
· Ex. Precose, Glyset
o S/E include flatulence, diarrhea, abdominal pain

§ Thiazolidinediones decrease insulin resistance, increase glucose uptake and use in skeletal muscle, inhibit glucose and triglyceride production in liver
· Ex. Actos, Avandia
o S/E include moderate weight gain, edema, mild anemia, hepatic toxicity, heart failure, cardiac issues




SLIDING SCALE
· No insulin for blood glucose less than 140 mg/dL
· 2 units for blood glucose 141-199 mg/dL
· 4 units for blood glucose 200-249 mg/dL
· 6 units for blood glucose 250-299 mg/dL
· 8 units for blood glucose 300 mg/dL or greater


Nursing Implications
Clarify orders for antidiabetic drug therapy if the patient is NPO, hypoglycemia can result from antidiabetic agent use with no food intake
Ensure- route, type, timing, dosage and ALWAYS check with a second RN!
Always withdraw regular insulin first when drawing up two types of insulin in one syringe
Role vials instead of shaking in order to prevent the formation of air bubbles and ensuring the correct dosage is drawn
Provide patient education on disease process, diet/ exercise recommendations, self-administration of insulin or oral agents, rotating injection sites, timing of dosages, monitoring blood glucose
Requires long term compliance
Watch for symptoms of hypoglycemia
· Early symptoms- altered CNS: confusion, irritability, sweating
· Later symptoms- tremors, hypothermia, seizures (no intervention can lead to coma and death)






====Quiz====

1. Name 2 disorders that affect the Adrenalcortical hormones.

2. List 3 indications of Glucocorticoids.

3. Of the choices below, which is a side effect of adrenal cortical hormones.

a. increased energy

b. anorexia

c. weight gain

d. euphoria

4.The main action of insulin is to:

a. push glucose from the blood into the cells so it can be used.

b. push glucose from the cells into the blood so it can be used.

c. excrete excessive glucose.

d. stimulate liver to release stored glucose for use when needed.

5. Name 2 symptoms of Diabetes Mellitus.

6. _% of all diabetic cases are Type 1 and _% of all diabetic cases are Type 2.



Answers:
1. Cushing's syndrome and Addison's syndroms
2. Cerebral edema,deficiency, collagen diseases, organ transplant, spinal cord injury, and GI diseases
3. c
4. a
5. polyuria, polydipsia, polypahgia, glycosuria, fatigue, weight loss, and hyperglycemia
6. 10% and 90%

References

Petges, N. (2011). Adrenal Agents, Pharmacological Conecepts, Aurora, IL

Petges, N. (2011). Antidiabetic Agents, Pharmacological Concepts, Aurora, IL

Lilly, L., Harrington, S., and Snyder, J. (2011). Pharmacology and the nursing process. (6th ed.). St. Louis: Mosby