Pharmacology

IN NURSING
PREPARED BY:
Mark Joseph V. Liwanag, RN, MSN
Drugs acting on the
Endocrine System
Prepared by:
Mark Joseph V. Liwanag, RN, MSN
OUTLINE:
▪ Adrenocortical Agents
▪ Antidiabetic Agents ▪ Parathyroid Agents
▪ Insulin ▪ Pituitary Drugs
▪ Glucose-Elevating Agents ▪ Thyroid Agents
ADRENOCORTICAL
AGENTS
Glucocorticoids &
Mineralocorticoids
ADRENOCORTICAL AGENTS
▪ are drugs used as short-term treatment to suppress immune
system in patients with inflammatory disorders.

▪ They are also used for replacement therapy to maintain

hormone levels when adrenal glands are not functioning
adequately.

▪ These agents are CLASSIFIED INTO THREE:

▪ glucocorticoids, mineralocorticoids, and androgens.
Glucocorticoids
▪ are agents that stimulate an increase
in glucose levels for energy.
▪ increase the rate of protein breakdown and decrease
the rate of protein formation from amino acids to
preserve energy.
▪ capable of lipogenesis, or the formation and storage
of fat in the body for energy source.

desired and beneficial action of glucocorticoids:

▪ bind to cytoplasmic receptors of target cells to form
complex reactions needed to reduce inflammation
and to suppress immune system.
Indications
▪ Short-term treatment of inflammatory
disorders
▪ Local agents - treat local inflammation.
▪ Systemic use - for treatment of some cancers -
hematological disorders
▪ with mineralocorticoids - used in replacement
therapy for adrenal insufficiency.

Contraindications and Cautions

▪ Acute infection. Can be exacerbated by the blocking effects of the drug on
inflammation and immune system.
▪ Diabetes. Glucose-elevating effect of the drug can disrupt glucose control
These are vital nursing interventions done in
patients who are taking glucocorticoids:
▪ Administer drug daily at 8 to 9 AM to mimic normal peak
diurnal concentration levels
▪ Space multiple doses evenly throughout the day to try to
achieve homeostasis.
▪ Taper doses when discontinuing
▪ Protect patient from unnecessary exposure to infection
▪ Provide comfort measures to help patient cope with drug
effects.
▪ Provide patient education about drug effects and warning
signs
Mineralocorticoids
▪ affect electrolyte levels directly and help
maintain homeostasis.
▪ classic mineralocorticoid is aldosterone.
▪ aldosterone increases sodium reabsorption in
the renal tubules and increases potassium and
hydrogen excretion, leading to water and sodium
retention.
Indications: partial replacement therapy in cortical insufficiency
conditions, treatment of hypotension.

Contraindications and Cautions: Severe hypertension, heart failure, or cardiac

disease. Resultant increased blood pressure
These are vital nursing interventions done in patients
who are taking mineralocorticoids:
▪ Use only in conjunction with appropriate glucocorticoids to
maintain control of electrolyte balance.
▪ Increase dose in times of stress to prevent adrenal insufficiency
and to meet increased demands for corticosteroids under
stress.

▪ Monitor for hypokalemia (weakness, serum electrolytes) to

detect the loss early and treat appropriately.
▪ Discontinue if signs of overdose (excessive weight gain, edema,
hypertension) occur to prevent the development of more severe
toxicity.
 CLASSIFICATION GENERIC NAME BRAND NAME
beclomethasone Beclovent
betamethasone Celestone
budesonide Rhinocort, Entocort EC
Glucocorticoids dexamethasone Decadron
hydrocortisone Cortef
methylprednisolone Medrol
prednisolone Delta-Cortef
fludrocortisone Florinef
Mineralocorticoids
hydrocortisone Cortef
DRUGS AFFECTING
PITUITARY GLANDS
Growth hormones and
Pituitary hormones
Growth Hormones Agonists
are responsible for linear skeletal growth, growth of internal
organs, protein synthesis, and stimulation of processes required
for normal growth.

Therapeutic Action: replacing human GH and stimulate skeletal

growth, growth of internal organs, and protein synthesis.

Indications: long-term treatment of children with growth

failure, AIDS wasting and cachexia, GH deficiency in adults

Somatropin (Nutropin, Saizen, Genotropin,

Serostim) and somatropin rDNA origin (Zorbtive)
These are vital nursing interventions done in patients who
are taking GH agonists:

▪ administer IM or SQ as ordered for appropriate drug

delivery.
▪ Monitor response closely to determine need for dose
adjustment.
▪ Monitor thyroid function, glucose tolerance, and GH
levels periodically to monitor endocrine changes and to
institute treatment as needed.
▪ Provide comfort measures to help patient cope with the
drug effects.
▪ Provide patient education
Growth Hormone Antagonists
▪ used in treating GH hypersecretion (hyperpituitarism) caused
by pituitary tumors.

▪ Therapeutic Action: acting directly on

postsynaptic dopamine receptors in the brain to inhibit GH
secretion

▪ Octreotide and lanreotide are somatostatin analogues

which are more potent in inhibiting GH release with less of
an inhibitory effect on insulin release. They are used
instead of somatostatin.
Drugs Affecting Posterior Pituitary Hormones
posterior pituitary: antidiuretic hormone or vasopressin [ADH] and oxytocin).

ADH possesses antidiuretic, hemostatic, and vasopressor properties.

▪ affected in diabetes insipidus, a condition characterized by production of

a large amount of dilute urine containing no glucose.
Therapeutic Action
increasing water reabsorption and decreasing urine
formation.

Indications: Treatment of neurogenic diabetes insipidus

These are vital nursing interventions done in patients who
are taking posterior pituitary agents:
▪ Monitor patient fluid volume to watch for signs of water
intoxication and fluid excess or excessive fluid loss.
▪ Monitor patient with vascular disease for any sign of
exacerbation to provide for immediate treatment.
▪ Monitor condition of nasal passages if given intranasally to
observe for nasal ulceration, which can occur and could affect
drug absorption.
▪ Provide comfort measures to help patient cope with the drug
effects.
▪ Provide patient education about drug effects and warning
signs to report to enhance patient knowledge and to promote
compliance.
PARATHYROID GLANDS
Therapeutic Action Antihypocalcemic Agents
a vitamin D compound that regulates the absorption of calcium and phosphate
from the small intestine, mineral resorption in bone, and reabsorption of
phosphate from renal tubules, increasing the serum calcium level.

▪ Teriparatide stimulates new bone formation leading to increase in skeletal

mass. It increases serum calcium and decreases serum phosphorus.

Indications
▪ hypocalcemia in patients on chronic renal
dialysis
▪ hypocalcemia associated with
hypoparathyroidism
These are vital nursing interventions
▪ Monitor serum calcium concentration before and
periodically during treatment to allow for adjustment of
dose to maintain calcium levels within normal limit.

▪ Arrange for nutritional consultation if GI effects are

severe to ensure nutritional balance.

▪ Provide patient education about drug effects and

warning signs to report to enhance patient knowledge
and to promote compliance.
Antihypercalcemic Agents
▪ drugs used to treat PRH excess or hypercalcemia.
▪ These agents include bisphosphonates and calcitonin salmon.
▪ act on the serum levels of calcium and do not suppress the parathyroid
gland or PTH.
The desired and beneficial action of antihypercalcemic agents:
1. Bisphosphonates - slow normal and abnormal bone resorption without
inhibiting bone formation and mineralization.
2. Calcitonin - inhibits bone resorption and lowers elevated serum
calcium.
▪ It also increases the excretion of filtered phosphate, calcium, and
sodium by the kidney.
These are vital nursing interventions
▪ Ensure adequate hydration with any of these
agents to reduce risk of renal complications.
▪ Rotate injection sites and monitor for inflammation
if using calcitonins to prevent tissue breakdown
and irritation.
▪ Monitor serum calcium before and periodically
during treatment to allow for dose adjustment.
▪ Arrange for periodic blood tests of renal function to
monitor for renal dysfunction.
▪ Provide comfort measures to help patient cope with
drug effects.
THYROID AGENTS
▪ When thyroid function is low, thyroid hormone
needs to be replaced to ensure adequate
metabolism and homeostasis in the body.

▪ When thyroid function is too high, the resultant systemic effects can be
serious, and the thyroid will need to be removed or destroyed
pharmacologically, and then the hormone normally produced by the gland will
need to be replaced with thyroid hormone.

▪ Thyroid agents include THYROID HORMONES AND ANTITHYROID DRUGS,which

are further classified as thioamides and iodine solutions
THYROID AGENTS: Thyroid Hormones
▪ thyroid replacement hormones increase the metabolic rate of body
tissues
▪ for replacement therapy in hypothyroid states, suppression of TSH in the
treatment and prevention of goiters, and management of thyroid
cancer.
▪ In conjunction with antithyroid drugs,
they also are indicated to treat thyroid
toxicity, prevent goiter formation during
thyroid overstimulation, and treat
thyroid overstimulation during
pregnancy
NURSING RESPONSIBILITIES:
▪ Administer a single daily dose before breakfast each day to ensure
consistent therapeutic levels.
▪ Administer with a full glass of water to help prevent difficulty
swallowing.
▪ Monitor response carefully when beginning therapy to adjust dose
according to patient response.
▪ Monitor cardiac response to detect cardiac adverse effects.
▪ Assess patient carefully to detect any potential drug–drug interactions
if giving thyroid hormone in combination with other drugs.
▪ Arrange for periodic blood tests of thyroid function to monitor the
effectiveness of the therapy.
THYROID AGENTS: Antithyroid Agents
▪ Drugs used to block the production of thyroid
hormone and to treat hyperthyroidism include the
thioamides and iodide solutions

▪ Thioamides - lower thyroid hormone levels by

preventing the formation of thyroid hormone in the
thyroid cells, which lowers the serum levels of
thyroid hormone.
▪ partially inhibit the conversion of T4 to T3 at the
cellular level.
THYROID AGENTS: ANTITHYROID AGENTS
Iodine Solutions
▪ Low doses of iodine are needed in the body for the
formation of thyroid hormone.
▪ High doses, however, block thyroid function.
▪ Therefore, iodine preparations are sometimes used
to treat hyperthyroidism but are not used as often
as they once were in the clinical setting
▪ iodine solutions cause the thyroid cells to become
oversaturated with iodine and STOP producing thyroid
hormone.
GLUCOSE - ELEVATING
AGENTS
Glucose-Elevating Agents:
Classification Generic Name Brand Name
Glucose- Proglycem,
DIAZOXIDE
elevating Hyperstat
agents GLUCAGON GlucaGen
Therapeutic Action
Increasing blood glucose by decreasing insulin
release and accelerating the breakdown of
glycogen in the liver to release glucose.

Indications
▪ Diazoxide is an oral management of
hypoglycemia; intravenous use for
management of severe hypertension.

▪ Glucagon is used to counteract severe

hypoglycemic reactions
Nursing Implementation with Rationale
▪ Monitor blood glucose levels to evaluate the
effectiveness of the drug.
▪ Have insulin on standby during emergency use to treat
severe hyperglycemia if it occurs as a result of overdose.
▪ Monitor nutritional status to provide nutritional
consultation as needed.
▪ Monitor patients receiving diazoxide for potential
cardiovascular effects, including blood pressure, heart
rhythm and output, and weight changes, to avert serious
adverse reactions.
 DISEASE SPOTLIGHT: DIABETES mellitus

DIABETES MELLITUS - a metabolic

diseases characterized by increased
levels of glucose in the blood
(hyperglycemia) resulting from defects
in insulin secretion, insulin action, or
both (American Diabetes Association,
2009a).
 TYPES OF DM
▪ Type 1 - Viral infections, environmental conditions, and genetic factors
contribute to the onset
▪ Type 2 - is the most common type of
diabetes.
▪ sources suggest that heredity and
obesity are the major factors that cause
T2 DM
▪ GDM - Gestational Diabetes Mellitus
▪ Secondary diabetes (medications,
hormonal changes)
 DIAGNOSIS
Several tests may be employed:
1. Fasting Plasma glucose (FPG) or;
• Fasting Blood Sugar (FBS)
2. Oral Glucose Tolerance Test (OGTT)
3. Random Plasma Glucose Test or;
• Random Blood Sugar (RBS)
4. Haemoglobin A1C (HbA1C)
5. Capillary blood glucose (CBG)
 CRITERIA FOR THE Diagnosis Of Diabetes
Mellitus
▪ Fasting plasma glucose ≥ 126
mg/dL

▪ Oral glucose tolerance test (OGTT):

2-hr plasma glucose ≥ 200 mg/dL

▪ Haemoglobin A1C 6.5% or higher

 OVERVIEW OF TREATMENT
ORAL AND INJECTABLE DRUGS - Standards of Care recommends a four-step
approach:
▪ STEP 1. At diagnosis, initiate lifestyle changes
▪ plus metformin.

▪ STEP 2. continue lifestyle changes plus metformin, and add a second drug.

▪ STEP 3. Progress from step 2 to a three-drug combination (inclusive of

METFORMIN).
▪ STEP 4. If three-drug combination therapy that includes basal insulin fails to
achieve treatment goals after approximately 3 months - combination
injectable regimen inclusive of insulin and possibly a GLP-1 receptor agonist.
ANTIDIABETIC
AGENTS
Therapeutic Action
▪ Alpha-glucosidase inhibitors acarbose and
miglitol inhibit alpha-glucosidase, an enzyme
that breaks down glucose for absorption.

▪ Therefore, they delay the absorption of glucose.

▪ They have only a mild effect on glucose levels and

do not enhance insulin secretion.

▪ They are associated with severe hepatic toxicity and

GI distress.
Therapeutic Action
▪ Biguanide metformin decrease the production
and increases the uptake of glucose.
▪ It is effective in lowering blood glucose and
does not cause hypoglycemia as the
sulfonylureas do.

▪ Meglitinides nateglinide and repaglinide are

newer agents that act like sulfonylureas to
increase insulin release.

▪ Sulfonylureas stimulate insulin release from the

beta cells in pancreas.
Therapeutic Action
▪ Synthetic human amylin - (pramlintide)
works to modulate gastric emptying after a
meal to cause a feeling of fullness or satiety.
▪ prevents the postmeal rise in glucagon

▪ Incretin mimetics (exenatide and liraglutide)

mimic the effects of GLP-1: enhancement of
glucose-dependent insulin secretion by the
beta cells in the pancreas,
▪ depression of elevated glucagon
secretion
Therapeutic Action
▪ DPP-4 inhibitors lina-, saxa-, and
sitagliptin slow the breakdown of GLP-1 to
prolong the effects of increased insulin
secretion,
▪ decreased glucagon secretion, and
slowed GI emptying.

▪ Thiazolidinediones pioglitazone and

rosiglitazone - decrease insulin resistance.
 Classifications Generic Name Brand Name
Alpha-glucosidase acarbose miglitol Precose, Glyset
inhibitors miglitol Glyset
Biguanide metformin Glucophage
linagliptin Tradjenta
Dipeptidyl peptidase-4-
saxagliptin Onglyza
inhibitors
sitagliptin Januvia
 Classifications Generic Name Brand Name
Human amylin pramlintide acetate Symlin
exenatide Baraclude
Incretin mimetics
liraglutide Victoza
nateglinide Starlix
Meglitinides
repaglinide Prandin
pioglitazone Actos
Thiazolidinediones
rosiglitazone Avandia
Sulfonylureas
Classification Generic Name Brand Name
chlorpropamide Diabinese
First-generation tolazamide Tolinase
tolbutamide Orinase
glimepiride Amaryl
Second-generation glipizide Glucotrol
glyburide DiaBeta, Micronase
Indications
▪ Biguanide - (metformin) is approved for use in children 10
years of age and older; polycystic ovarian syndrome (PCOS).

▪ Meglitinides - (nateglinide and repaglinide) are used to lower

postprandial glucose levels; taken just before meals.

▪ Thiazolidinediones - (pioglitazone and rosiglitazone) are used

in combination with insulin, metformin, and sulfonylureas in
patients with insulin resistance.

▪ Sulfonylureas are used as adjunct to diet and exercise for the

treatment of type 2 diabetes older than 10 years of age
These are vital nursing interventions
▪ Administer the drug as prescribed in the appropriate relationship to
meals to ensure therapeutic effectiveness.
▪ Ensure that patient has dietary and exercise regimen and using good
hygiene practices to improve the effectiveness of the insulin and
decrease adverse effects of the disease.

▪ Monitor response carefully; blood glucose monitoring is the most

effective way to evaluate dose. Obtain blood glucose levels as ordered
to monitor drug effectiveness.

▪ Monitor patients during times of trauma, pregnancy, or severe stress,

and arrange to switch to insulin coverage as needed.
▪ Provide patient education about drug effects and warning signs to
report to enhance patient knowledge and to promote compliance.
 INSULIN THERAPY: Indication

• Insulin is used to treat all patients with type 1

diabetes and many patients with type 2
diabetes.
1. TYPE 1 - must be administered for life
2. TYPE 2 - necessary on a long-term basis to
control glucose levels if other treatments
are ineffective.
• injections are administered two or more times
daily to control the blood glucose level.
 TYPES OF INSULIN

1. SHORT: Rapid acting

2. SHORT: Slow acting
3. Intermediate acting
CLEAR CLOUDY
4. Long acting and combinations
Based on appearance
5. Ultra long acting

Based on action
 SHORT DURATION: RAPID ACTING
▪ administered in association with meals to control
the postprandial (or after meal) rise in blood
glucose.
▪ Insulin Lispro, Aspart, and Glulisine
▪ to provide glycemic control between meals and at
night
▪ used in conjunction with an intermediate- or
long-acting agent.
▪ formulated as clear solutions
▪ for routine therapy, all three are given subQ and
rarely used IV
 SHORT DURATION: RAPID ACTING

Generic name Brand Onset (min) Peak (hr) Duration (hr)

Insulin lispro Humalog 15 – 30 0.5 – 2.5 3–6
Insulin aspart NovoLog 10–20 1–3 3–5
Insulin glulisine Apidra 10–15 1–1.5 3–5
 SHORT DURATION: SLOW ACTING
▪ unmodified human insulin.
▪ example: Regular Insulin
▪ administered by subQ injection and through IV
therapy.
▪ For IV therapy, ONLY the U-100 formulation should
be used.
▪ Regular insulin is supplied as a clear solution.
 SHORT DURATION: SLOW ACTING
Two concentrations are available: U-100 (100
units/mL) and U-500 (500
For routine treatment of diabetes, regular
insulin can be:
1. injected before meals to control
postprandial hyperglycemia
2. infused subQ to provide basal glycemic
control.
 SHORT DURATION: SLOW ACTING
Generic name Brand Onset (min) Peak (hr) Duration (hr)
Regular insulin Humulin R, 30–60 1–5 6–10
Novolin R
 INTERMEDIATE DURATION
▪ Neutral Protamine Hagedorn (NPH) Insulin
Suspension.
▪ also known as isophane insulin
▪ prepared by conjugating regular insulin with
protamine (a large protein).
▪ Protamine - decreases the solubility of NPH
insulin and thus delays absorption.
▪ onset is delayed, NPH insulin cannot be administered at mealtime to control
postprandial hyperglycemia.
▪ drug is injected two or three times daily to provide glycemic control between
meals and during the night.
 INTERMEDIATE DURATION
Generic name Brand Onset (min) Peak (hr) Duration (hr)
NPH insulin Humulin N, 60–120 6–14 16–24
Novolin N
 INTERMEDIATE DURATION
▪ NPH insulin is the only one suitable for
mixing with short-acting insulins. SUITABLE FOR MIXING

▪ allergic reactions are possible.

▪ are supplied as cloudy suspensions that

must be agitated before administration.

▪ Administration is by subQ injection only.

ALLERGIC REACTIONS
 LONG DURATION
▪ Insulin Glargine (U-100). is a modified
human insulin with a prolonged duration of
action (up to 24 hours).

▪ indicated for once-daily subQ dosing to

treat adults and children with type 1
diabetes and adults with type 2 diabetes.

▪ Dosing may be done any time of day (morning, afternoon, or

evening), but should be done at the same time every day.
 LONG DURATION
▪ Insulin Detemir - is a human insulin analog with
a slow onset.
▪ At low doses (0.2 units/kg), effects persist
about 12 hours
▪ At higher doses (0.4 units/kg), effects
persist for up to 20 to 24 hours.

▪ used to provide basal glycemic control.

▪ It is not given before meals to control postprandial hyperglycemia.
▪ Compared with NPH insulin, insulin detemir has a slower onset and
longer duration.
 LONG DURATION
Generic name Brand Onset (min) Peak (hr) Duration (hr)
Insulin glargine (U- Lantus 70 18–24
100) NONE
Insulin detemir Levemir 60–120 12–24
 LONGER DURATION (> 24 HOURS)
▪ Insulin Glargine (U-300) and Insulin Degludec
▪ U-300 insulin glargine is similar to U-100
insulin glargine
▪ except that it is three times concentrated,
which prolongs its duration of action to be in
excess of 24 hours.
▪ indicated for once-daily subQ dosing to treat both type 1 and type 2
diabetes.
▪ supplied as a clear solution in pre-filled pens only.
▪ product is dosed once daily
 LONGER DURATION (> 24 HOURS)
Generic name Brand Onset (min) Peak (hr) Duration (hr)
Insulin glargine Toujeo 360
(U-300) NONE > 24
Insulin degludec Tresiba 30–90
 PREMIXED INSULINS
1. Humulin 70/30 - 70% of human insulin isophane
(intermediate-acting insulin, NPH) and 30% regular
(fast-acting) insulin.
2. Humulin 50/50 - 50% isophane (NPH) insulin and
50% regular insulin.
3. Humalog 75/25 - 75% lispro protamine insulin and
25% lispro “rapid” insulin.
• helps prevent hypoglycemia
• helps control hyperglycemia more effectively
▪ Measure units of insulin not the volume of solution
▪ Calibrated in 1 or 2 units increments
Example: 30 units
MIXING OF INSULIN
 STORAGE OF INSULIN
▪ Unopened insulin vials are refrigerated until needed.
▪ Once an insulin vial has been opened, it may be kept:
▪ at room temperature for 1 month
▪ in the refrigerator for 3 months.
▪ should not be put in the freezer.
▪ Prefilled syringes - stored in the refrigerator and
should be used within 1 to 2 weeks.
▪ Opened insulin vials lose their strength after
approximately 3 months
Complications of Insulin Treatment
HYPOglycemia (generally defined clinically as a blood glucose
below 70 mg/dL)
Rapid treatment of hypoglycemia is mandatory:
▪ If persist, irreversible brain damage or even death may result.
▪ In conscious patients, glucose levels can be restored with a
fast-acting oral sugar (e.g., glucose tablets, orange juice, sugar
cubes, honey, corn syrup, non diet soda).
▪ if the swallowing reflex or the gag reflex is suppressed,
nothing should be administered by mouth.
▪ In cases of severe hypoglycemia, IV glucose is the preferred
treatment.
▪ Parenteral glucagon is an alternative treatment.
Complications of Insulin Treatment
Morning Hyperglycemia - An elevated
blood glucose level on arising in the
morning
▪ caused by an insufficient level of
insulin
▪ may be caused by several factors:
1.Dawn phenomenon
2.Somogyi effect
3.Insulin waning
Complications of Insulin Treatment
▪ Hypokalemia - Insulin promotes
uptake of potassium by cells - can
lower blood levels of potassium.

▪ Lipoatrophy (tissue atrophy) is a

depression under the skin surface
that primarily occurs in women and
children.
▪ Lipohypertrophy (tissue hypertrophy) is a raised lump or knot on the
skin surface that is more common in men.
REFERENCES:

McCuistion, L., et al (2018) Pharmacology: A Patient Centered

Nursing Process Approach 9th ed. Saunders