ENDOCRINE SYSTEM

• The endocrine system consists of chemical transmitters called hormones and specialized
cell clusters called glands.

PITUITARY GLAND

• Anterior pituitary gland secretes the following hormones:

o Growth hormone (GH)
o Thyroid-stimulating hormone (TSH)
o Adrenocorticotropic hormone (ACTH)
o Prolactin
o Melanocyte-stimulating hormone (MSH)
o Gonadotropins (follicle-stimulating hormone [FSH] and luteinizing hormone
[LH])
• Posterior pituitary gland secretes the following hormones:
o Secretes antidiuretic hormone (vasopressin)
o Oxytocin

PITUITARY MEDICATIONS 1

• Growth hormones and related medications

PITUITARY MEDICATIONS
Growth hormones Indication
• Used to treat pediatric or adult growth hormone
deficiency.
Medication
• Somatropin (Humatrope)
• Mecasermin (Increlex)
Growth hormone receptor Indication
antagonists • Used to treat acromegaly
Medication
• Octreotide acetate (Sandostatin)
• Pegvisomant (Somavert)
Growth hormone releasing Indication
factor • Used to evaluate anterior pituitary function
Medication
• Sermorelin (Geref)
 o Side effects
▪ May vary depending on the medication
▪ Development of antibodies to growth hormone
▪ Headache, muscle pain, weakness, vertigo
▪ Diarrhea, nausea, abdominal discomfort
▪ Mild hyperglycemia
▪ Hypertension
▪ Weight gain
▪ Allergic reaction (rash, swelling), pain at injection site
▪ Elevated aspartate aminotransferase (AST) and alanine aminotransferase
(ALT)
o Nursing care
▪ Assess the child’s physical growth and compare growth with standards.
▪ Recommend annual bone age determinations for children receiving growth
hormones.
▪ Monitor vital signs, blood glucose levels, AST and ALT levels, and thyroid
function tests. 2
▪ Teach the client and family about the clinical manifestations of
hyperglycemia and about other side effects of therapy and the importance
of follow-up regarding periodic blood tests.

ANTIDIURETIC HORMONES

• Mechanism of action
o Enhance reabsorption of water in the kidneys, promoting an antidiuretic effect and
regulating fluid balance.
• Indication
o Used in diabetes insipidus.
• Medications
o Desmopressin acetate (DDAVP, Stimate, Minirin)
o Vasopressin (Pitressin)
• Side effects
o Flushing
o Headache
o Nausea and abdominal cramps
 o Water intoxication
o Hypertension with water intoxication
o Nasal congestion with nasal administration
• Nursing management
o Monitor weight.
o Monitor intake and output and urine osmolality.
o Monitor electrolyte levels.
o Monitor for signs of dehydration, indicating the need to increase the dosage.
o Monitor for signs of water intoxication (drowsiness, listlessness, shortness of breath,
and headache) indicating need to decrease dosage.
o Monitor blood pressure.
o Instruct the client in how to use the intranasal medication.
o Instruct the client to weigh themselves daily to identify weight gain.
o Instruct the client to report signs of water intoxication or symptoms of headache or
shortness of breath.

THYROID HORMONES
3
• Mechanism of action
o Control the metabolic rate of tissues and accelerate heat production and oxygen
consumption
• Indication
o Used to replace the thyroid hormone deficit in conditions such as hypothyroidism
and myxedema.
• Caution
o Enhance the action of oral anticoagulants, sympathomimetics, and antidepressants.
o Decrease the action of insulin, oral hypoglycemics, and digitalis preparations.
o The action of thyroid hormones is decreased by phenytoin (Dilantin) and
carbamazepine (Tegretol).
• Medication
o Levothyroxine sodium (Synthroid, Levothroid, Levoxyl, Thyro-Tabs, Unithroid)
o Liothyronine sodium (Cytomel, Triostat)
o Liotrix (Thyrolar)
o Thyroid (Armour Thyroid, Bio-Thyroid, Nature-Thyroid, Thyroid USP,
Westhroid)
• Side effects
o Nausea and decreased appetite
o Abdominal cramps and diarrhea
o Weight loss
o Nervousness and tremors
o Insomnia
o Sweating and heat intolerance
o Tachycardia, dysrhythmias, palpitations, chest pain
o Hypertension
o Headache
o Toxicity: Hyperthyroidism
• Nursing care
o Thyroid hormones should be given at least 4 hours apart from multivitamins,
aluminum hydroxide and magnesium hydroxide, simethicone, calcium carbonate,
bile acid sequestrants, iron, and sucralfate (Carafate) because these medications
decrease the absorption of thyroid replacements.
o Assess the client for a history of medications currently being taken. 4
o Monitor vital signs.
o Monitor weight.
o Monitor triiodothyronine, thyroxine, and thyroid-stimulating hormone levels.
o Instruct the client to take the medication at the same time each day, in the morning
without food.
o Instruct the client in how to monitor the pulse rate.
o Instruct the client to avoid foods that can inhibit thyroid secretion, such as
strawberries, peaches, pears, cabbage, turnips, spinach, kale, Brussels sprouts,
cauliflower, radishes, and peas.
o Advise the client to avoid over-the-counter medications.
o Instruct the client to wear a Medic-Alert bracelet.
o Advise the client to report symptoms of hyperthyroidism, such as tachycardia, chest
pain, palpitations, and excessive sweating. These indicate signs of toxicity.
ANTITHYROID MEDICATION

• Mechanism of action
o Inhibit the synthesis of thyroid hormone.
• Indication
o Used for hyperthyroidism or Graves’ disease.
• Medications
o Methimazole (Tapazole)
o Propylthiouracil (PTU)
o Strong iodine solution (Lugol’s solution)
o Potassium iodide
o Iodide I 131 (Iodotope)
• Side effects
o Nausea and vomiting
o Diarrhea
o Drowsiness, headache, fever
o Hypersensitivity with rash
o Agranulocytosis with leukopenia and thrombocytopenia
5
o Alopecia and hyperpigmentation
o Toxicity: Hypothyroidism
o Iodism
▪ Characterized by vomiting, abdominal pain, metallic or brassy taste in the
mouth, rash, and sore gums and salivary glands
• Nursing care
o Monitor vital signs.
o Monitor triiodothyronine, thyroxine, and thyroid-stimulating hormone levels.
o Monitor weight.
o Instruct the client to take medication with meals to avoid gastrointestinal upset.
o Instruct the client in how to monitor the pulse rate.
o Inform the client of side effects and when to notify the physician.
o Instruct the client in the signs of hypothyroidism.
o Instruct the client regarding the importance of medication compliance and that
abruptly stopping the medication could cause thyroid storm.
 o Instruct the client to monitor for signs and symptoms of thyroid storm (fever,
flushed skin, confusion and behavioral changes, tachycardia, dysrhythmias, and
signs of heart failure).
o Instruct the client to monitor for signs of iodism.
o Advise the client to consult physician before eating iodized salt and iodine-rich
foods.
o Instruct the client to avoid acetylsalicylic acid (aspirin) and medications containing
iodine.
o Propylthiouracil (PTU) causes agranulocytosis. Advise the client to contact the
physician if a fever or sore throat develops.

PARATHYROID MEDICATIONS

• Mechanism of action
o Regulates serum calcium levels.
o Low serum levels of calcium stimulate parathyroid hormone release.
o Hyperparathyroidism
▪ High serum calcium level and bone demineralization; medication is used to
6
lower the serum calcium level.
o Hypoparathyroidism
▪ Low serum calcium level, which increases neuromuscular excitability;
treatment includes calcium and vitamin D supplements.
o Oral calcium salts
▪ Mechanism of action
• Reduce the absorption of tetracycline hydrochloride.

MEDICATION TO TREAT CALCIUM DISORDERS

Oral calcium supplements
Vitamin D Supplements
• Calcium acetate (PhosLo)
• Calcium carbonate (Rolaids, Tums, others)
• Calcium chloride
• Calcium citrate (Citracal)
• Calcium glubionate (Calcionate, calciquid)
• Calcium gluconate
• Calcium lactate (Cal-lac)
• Tribasic calcium phosphate (Posture)
• Cholecalciferol (Vitamin D3)
 • Ergocalciferol (Vitamin D2)
Biphosphonates and Calcium • Alendronate sodium (Fosamax)
Regulators • Calcitonin salmon (Calcimar, Cibacalcin, Fortical)
• Etidronate disodium (Didronel)
• Ibandronate (Boniva)
• Pamidronate disodium (Aredia)
• Risedronate sodium (Actonel)
• Tiludronate disodium (Skelid)
• Zoledronate (Reclast)
• Zoledronate (Zometa)
Medications to Treat • Cinacalcet hydrochloride (Sensipar)
Hypercalcemia • Doxercalciferol (Hectorol)
• Gallium nitrate (Ganite)
• Paricalcitol (Zemplar)

• Nursing care
o Calcium salts administered with digoxin (Lanoxin) increases the risk of digoxin
7
toxicity.
o Monitor electrolyte and calcium levels.
o Assess for signs and symptoms of hypocalcemia and hypercalcemia.
o Assess for symptoms of tetany in the client with hypocalcemia.
o Assess for renal calculi in the client with hypercalcemia
o Instruct the client in the signs and symptoms of hypercalcemia and hypocalcemia.
o Instruct the client to check over-the-counter medication labels for the possibility of
calcium content.
o Instruct the client receiving oral calcium supplements to maintain an adequate
intake of vitamin D because vitamin D enhances absorption of calcium.
o Instruct the client receiving calcium regulators such as alendronate sodium
(Fosamax) to swallow the whole tablet with water at least 30 minutes before
breakfast and not to lie down for at least 30 minutes.
o Instruct the client using nasal spray of calcitonin (Calcimar) to alternate nares.
o Instruct the client using antihypercalcemic agents to avoid foods rich in calcium
such as green, leafy vegetables, dairy products, shellfish, and soy.
 o Instruct the client not to take other medications within 1 hour of taking a calcium
salt.
o Instruct the client to increase fluid and fiber in diet to prevent constipation
associated with calcium supplements.

CORTICOSTEROIDS (MINERALOCORTICOIDS)

• Mechanism of action
o Steroid hormones that enhance the reabsorption of sodium and chloride
o Promote the excretion of potassium and hydrogen from the renal tubules, thereby
helping maintain fluid and electrolyte balance.
• Indication
o Used for replacement therapy in primary and secondary adrenal insufficiency in
Addison’s disease.
• Medication
o Fludrocortisone acetate
• Side effects
o Sodium and water retention (hypernatremia and edema), hypertension
o Hypokalemia 8
o Hypocalcemia
o Osteoporosis, compression fractures
o Weight gain
o Heart failure
• Nursing care
o Monitor vital signs.
o Monitor intake and output and weight and for edema.
o Monitor electrolyte and calcium levels.
o Instruct the client to take medication with food or milk.
o Instruct the client to consume a high-potassium diet.
o Instruct the client to report illness, such as severe diarrhea, vomiting, and fever.
o Instruct the client to notify the physician if low blood pressure, weakness, cramping,
palpitations, or changes in mental status occur.
o Instruct the client to wear a Medic-Alert bracelet.
o Instruct the client taking a corticosteroid not to stop the medication abruptly
because this could result in adrenal insufficiency.
CORTICOSTEROIDS (GLUCOCORTICOIDS )

• Mechanism of action
o Affect glucose, protein, and bone metabolism, alter the normal immune response
and suppress inflammation, and produce anti-inflammatory, antiallergic, and anti-
stress effects.
• Indication
o Used as a replacement in adrenocortical insufficiency.
• Contraindications and cautions
o Contraindicated in clients with hypersensitivity, psychosis, and fungal infections.
o Should be used with caution in clients with diabetes mellitus.
o Used with extreme caution in clients with infections because they mask the signs
and symptoms of an infection
o Increase the potency of medications taken concurrently, such as aspirin, and
nonsteroidal anti-inflammatory drugs, thus increasing the risk of gastrointestinal
bleeding and ulceration.
o Use of potassium-wasting diuretics increases potassium loss, resulting in
hypokalemia.
9
o Dexamethasone decreases the effects of orally administered anticoagulants and
antidiabetic agents.
o Barbiturates, phenytoin (Dilantin), and rifampin (Rifadin) decrease the effect of
prednisone.
• Medications
o Betamethasone
o Cortisone acetate
o Dexamethasone
o Hydrocortisone
o Methylprednisolone
o Prednisolone
o Prednisone
o Triamcinolone
• Side effects
o Hyperglycemia
o Hypokalemia
 o Hypocalcemia, osteoporosis
o Sodium and fluid retention
o Weight gain
o Mood swings
o Moon face, buffalo hump, truncal obesity
o Increased susceptibility to infection and masking of the signs and symptoms of
infection
o Cataracts
o Hirsutism, acne, fragile skin, bruising
o Growth retardation in children
o Gastrointestinal (GI) irritation, peptic ulcer, pancreatitis
o Seizures, psychosis
• Nursing care
o Monitor vital signs.
o Monitor serum electrolyte and blood glucose levels.
o Monitor for hypokalemia and hyperglycemia.
o Monitor intake and output and weight and for edema. 10
o Monitor for hypertension.
o Assess medical history for glaucoma, cataracts, peptic ulcer, mental health disorders,
or diabetes mellitus.
o Monitor the older client for signs and symptoms of increased osteoporosis.
o Assess for changes in muscle strength.
o Prepare a schedule for the client with information on short-term tapered doses.
o Instruct the client that it is best to take medication in the early morning.
o Advise the client to eat food high in potassium.
o Instruct the client to avoid individuals with respiratory infections.
o Advise the client to inform all health care providers of the medication regimen.
o Instruct the client to report signs and symptoms of a medication overdose or
Cushing’s syndrome, including a moon face, puffy eyelids, edema in the feet,
increased bruising, dizziness, bleeding, and menstrual irregularities.
o Note that the client may need additional doses during periods of stress, such as
surgery.
 o Instruct the client not to stop the medication abruptly because abrupt withdrawal
can result in severe adrenal insufficiency.
o Advise the client to consult with the physician before receiving vaccinations.
o Advise the client to wear a Medic-Alert bracelet.

ANDROGENS

• Indication
o Used to replace deficient hormones or to treat hormone-sensitive disorders
o Can cause decreased serum glucose concentration, thereby reducing insulin
requirements in the client with diabetes mellitus.
• Caution
o Can cause bleeding if the client is taking oral anticoagulants (increase the effect of
anticoagulants)
o Hepatotoxic medications are avoided with the use of androgens because of the risk
of additive damage to the liver.
o Androgens usually are avoided in men with known prostate or breast carcinoma
because androgens often stimulate growth of these tumors.
• Medications 11
o Fluoxymesterone
o Methyltestosterone (Testred)
▪ Testosterone preparations
▪ Testosterone, pellets (Testopel)
▪ Testosterone, transdermal (Androderm)
▪ Testosterone cypionate (Depo-Testosterone)
▪ Testosterone enanthate (Delatestryl)
▪ Testosterone buccal system (Striant)
• Side effects
o Masculine secondary sexual characteristics (body hair growth, lowered voice,
muscle growth)
o Bladder irritation and urinary tract infections
o Breast tenderness
o Gynecomastia
o Priapism
o Menstrual irregularities
 o Virilism
o Sodium and water retention with edema
o Nausea, vomiting, or diarrhea
o Acne
o Changes in libido
o Hepatotoxicity, jaundice
o Hypercalcemia
• Nursing care
o Monitor vital signs.
o Monitor for edema, weight gain, and skin changes.
o Assess mental status and neurological function.
o Assess for signs of liver dysfunction, including right upper quadrant abdominal pain,
malaise, fever, jaundice, and pruritus.
o Assess for the development of secondary sexual characteristics.
o Instruct the client to take medication with meals or a snack.
o Instruct the client to notify the physician if priapism develops.
o Instruct the client to notify the physician if fluid retention occurs. 12
o Instruct women to use a nonhormonal contraceptive while on therapy.
o For women, monitor for menstrual irregularities and decreased breast size.

ESTROGENS AND PROGESTINS

• Mechanism of action
o Both may be used to stimulate the endogenous hormones to restore hormonal
balance
• Indication
o Treat hormone sensitive tumors (suppress tumor growth) or for contraception.

ESTROGENS AND PROGESTINS

Estrogens Mechanism of action
• Esterified estrogens • Steroids that stimulate female reproductive tissue.
Contraindications and cautions
(Menest)
• Contraindicated in clients with breast cancer,
• Estradiol (Estrace,
endometrial hyperplasia, endometrial cancer, history
Femtrace)
of thromboembolism, known or suspected pregnancy,
or lactation.
 • Estrogens, conjugated • Use with caution in clients with hypertension,
(Premarin, Cenestin, gallbladder disease, or liver or kidney dysfunction.
Enjuvia) • Can increase the risk of toxicity when used with
• Ethinyl estradiol hepatotoxic medications.
(Estinyl) • Barbiturates, phenytoin (Dilantin), and rifampin
(Rifadin) decrease the effectiveness of estrogen.
Progestins Mechanism of action
• Estradiol/drospirenone • Steroids that specifically stimulate the uterine lining.
Contraindications
(Angeliq)
• Contraindicated in clients with thromboembolic
• Estradiol/norgestimate
disorders and should be avoided in clients with breast
(Prefest)
tumors or hepatic disease.
• Estradiol/northindrone
(Femhrt)
• Medroxyprogesterone
acetate (Depo-
Provera, Provera)
• Medroxyprogesterone
and conjugated 13
estrogens (Premphase,
Prempro)
• Megestrol acetate
(Megace)
• Norethindrone acetate
(Aygestin)
• Norgestrel (Ovrette)
• Progesterone
(Prometrium)

• Side effects
o Breast tenderness, menstrual changes
o Nausea, vomiting, and diarrhea
o Malaise, depression, excessive irritability
o Weight gain
o Edema and fluid retention
 o Atherosclerosis
o Hypertension, stroke, myocardial infarction
o Thromboembolism (estrogen)
o Migraine headaches and vomiting (estrogen)
• Nursing care
o Monitor vital signs.
o Monitor for hypertension.
o Assess for edema and weight gain.
o Advise the client not to smoke.
o Advise the client to undergo routine breast and pelvic examinations.

CONTRACEPTIVES

• Description
o Contain a combination of estrogen and a progestin or a progestin alone
o Medications that only contain progestins are less effective than the combined
medications.
• Mechanism of action
o Estrogen-progestin combinations suppress ovulation and change the cervical 14
mucus, making it difficult for sperm to enter.
• Indication
o Useful in controlling irregular or excessive menstrual cycles.
o Provide reversible prevention of pregnancy.
• Contraindication and caution
o Contraindicated in women with hypertension, thromboembolic disease,
cerebrovascular or coronary artery disease, estrogen-dependent cancers, and
pregnancy.
o Contraceptives interfere with the activity of bromocriptine mesylate (Parlodel) and
anticoagulants and increase the toxicity of tricyclic antidepressants.
o Contraceptives should be avoided with the use of hepatotoxic medications.
o Contraceptives may alter blood glucose levels.
o Antibiotics may decrease the absorption and effectiveness of oral contraceptives.
• Side effects
o Breakthrough bleeding
o Excessive cervical mucus formation
 o Breast tenderness
o Hypertension
o Nausea, vomiting
• Nursing care
o Usually are taken for 21 consecutive days and stopped for 7 days; the administration
cycle is then repeated.
o Risk factors associated with the development of complications related to the use of
contraceptives include smoking, obesity, and hypertension.
o Monitor vital signs and weight.
o Instruct the client in the administration of the medication (it may take up to 1 week
for full contraceptive effect to occur when the medication is begun).
o Instruct the client with diabetes mellitus to monitor blood glucose levels carefully.
o Instruct the client to report signs of thromboembolic complications.
o Instruct the client to notify the physician if vaginal bleeding or menstrual
irregularities occur or if pregnancy is suspected.
o Advise the client to use an alternate method of birth control when taking antibiotics
because these may decrease absorption of the oral contraceptive. 15
o Instruct the client to perform breast self-examination monthly and about the
importance of annual physical examinations.
o Contraceptive patches
▪ Designed to be worn for 3 weeks and removed for a 1-week period
▪ Applied on clean, dry, intact skin on the buttocks, abdomen, upper outer
arm, or upper torso
▪ Instruct the client to peel away half of backing on patch, apply the sticky
surface to the skin, remove the other half of the backing, and then press
down on the patch with the palm for 10 seconds.
▪ Instruct the client to change the patch weekly, using a new location for each
patch.
▪ If the patch falls off and remains off for less than 24 hours (such as when
the client is sleeping or is unaware that it has fallen off), it can be reapplied
if still sticky, or it can be replaced with a new patch.
▪ If the patch is off for more than 24 hours, a new 4-week cycle must be started
immediately.
 o Vaginal ring
▪ Inserted into the vagina by the client, left in place for 3 weeks, and removed
for 1 week.
▪ The medication is absorbed through mucous membranes of the vagina.
▪ Removed rings should be wrapped in a foil pouch and discarded, not flushed
down the toilet.
o Implants and depot injections
▪ Provide long-acting forms of birth control, from 3 months to 5 years in
duration.
o If the client decides to discontinue the contraceptive to become pregnant,
recommend that the client use an alternative form of birth control for 2 months
after discontinuation to ensure more complete excretion of hormonal agents before
conception.

FERTILITY MEDICATIONS

• Mechanism of action
o Act to stimulate follicle development and ovulation in functioning ovaries and are
combined with human chorionic gonadotropin to maintain the follicles once 16
ovulation has occurred.
• Contraindication and caution
o Contraindicated in the presence of primary ovarian dysfunction, thyroid or adrenal
dysfunction, ovarian cysts, pregnancy, or idiopathic uterine bleeding.
o Should be used with caution in clients with thromboembolic or respiratory disease.
• Medication
o Chorionic gonadotropin (Profasi)
o Clomiphene citrate (Clomid)
o Follitropin alfa (Gonal-f)
o Follitropin beta (Follistim AQ)
o Menotropins (Pergonal, Repronex, Menopur)
o Urotropin alfa (Bravelle, Fertinex, Metrodin)
o Lutropin alfa (Luveris)
• Side effects
o Risk of multiple births and birth defects
o Ovarian overstimulation (abdominal pain, distention, ascites, pleural effusion)
 o Headache, irritability
o Fluid retention and bloating
o Nausea, vomiting
o Uterine bleeding
o Ovarian enlargement
o Gynecomastia
o Rash
o Orthostatic hypotension
o Febrile reactions
• Nursing care
o Instruct the client regarding administration of the medication.
o Provide a calendar of treatment days and instructions on when intercourse should
occur to increase therapeutic effectiveness of the medication.
o Provide information about the risks and hazards of multiple births.
o Instruct the client to notify the physician if signs of ovarian overstimulation occur.
o Inform the client about the need for regular follow-up for evaluation.
17
MEDICATIONS FOR ERECTILE DYSFUNCTION

MEDICATIONS FOR ERECTILE DYSFUNCTION

Alprostadil (Caverject, Edex) Mechanism of action
• A prostaglandin that relaxes smooth muscle and
promotes blood flow when injected directly into the
corpus cavernosum.
Side effect
• Pain at the injection site, infection, priapism, penile
fibrosis, rash
Administration
• Injected intra-cavernously
Sildenafil (Viagra), tadalafil Mechanism of action
(Cialis), and vardenafil • Cause smooth muscle relaxation and allow blood flow

(Levitra) into the corpus cavernosum.

Contraindication
• Cannot be administered to clients taking nitrates,
nitroprusside, or b-blockers.
Caution
• Used cautiously in clients with coronary artery disease,
 active peptic ulcer disease, bleeding disorders, or
retinitis pigmentosa.
Side effects
• Headache, flushing, dyspepsia, urinary tract infection,
diarrhea, hypotension, dizziness, rash, neuralgia,
insomnia
Administration
• Taken orally

• Contraindication and caution

o Contraindicated in the presence of any anatomical obstruction or condition that
might predispose to priapism and in clients with penile implants.
o Use cautiously in clients with bleeding disorders.
• Side effects
o Blurred vision and changes in color vision
• Nursing care
o Perform a thorough assessment of health and medication history.
o Instruct the client regarding administration of the medication.
18
o Inform the client of side effects necessitating the need to notify the physician.

MEDICATIONS FOR DIABETES MELLITUS

INSULIN AND ORAL HYPOGLYCEMIC MEDICATION
Insulin Mechanism of action
• Increases glucose transport into cells
• Promotes conversion of glucose to glycogen
• Decreasing serum glucose levels
Contraindication
• Clients with hypersensitivity
Oral hypoglycemic Mechanism of action
medications • Stimulate the pancreas to produce more insulin
• Increase the sensitivity of peripheral receptors to insulin
• Decrease hepatic glucose output
• Delay intestinal absorption of glucose
• Decreasing serum glucose levels
Indication
• Clients with type 2 diabetes mellitus
 Contraindication
• Type 1 diabetes mellitus

• Caution
o Beta-Adrenergic blocking agents may mask signs and symptoms of hypoglycemia
associated with hypoglycemic medications.
o Anticoagulants, chloramphenicol (Chloromycetin), salicylates, propranolol
(Inderal), monoamine oxidase inhibitors, pentamidine (Pentam 300), and
sulfonamides may cause hypoglycemia.
o Corticosteroids, sympathomimetics, thiazide diuretics, phenytoin (Dilantin),
thyroid preparations, oral contraceptives, and estrogen compounds may cause
hyperglycemia.

ORAL HYPOGLYCEMIC MEDICATIONS

SULFONYLUREAS AND NONSULFONYLUREAS

MEDICATION NURSING CONSIDERATIONS
Sulfonylureas Classification
• Acetohexamide • Sulfonylureas may be classified as first- or second-
generation sulfonylureas. 19
(Dymelor)
Mechanism of action
• Chlorpropamide
• Stimulate the beta cells to produce more insulin.
(Diabinese)
Caution
• Glimepiride (Amaryl) • Sulfonylureas can cause a disulfiram (Antabuse) type of
• Glipizide (Glucotrol) reaction when alcohol is ingested.
• Glyburide (DiaBeta, Side effects
Micronase) • Gastrointestinal symptoms and dermatological
• Tolazamide reactions; hypoglycemia can occur when an excessive
(Tolinase) dose is administered or when meals are omitted or
• Tolbutamide delayed, food intake is decreased, or activity is increased.
(Orinase)
Biguanides Description
• Metformin • May be used alone or in combination with a sulfonylurea
Mechanism of action
(Glucophage)
• Suppresses hepatic production of glucose and increases
insulin sensitivity
Side effects
• Diarrhea (most common), lactic acidosis (most serious)
Alpha-glucosidase inhibitors Mechanism of action
• Acarbose (Precose) • Delay absorption of ingested carbohydrates (sucrose

• Miglitol (Glyset) and complex carbohydrates), resulting in smaller

Thiazolidinediones
• Pioglitazone (Actos)
increase in blood glucose level after meals.
• Do not increase insulin production
• Will not cause hypoglycemia when given alone
Nursing care
• Given with first bite of meal
• Can be given alone or in combination with Sulfonylureas
Mechanism of action
• Insulin-sensitizing agents that lower blood glucose by

• Rosiglitazone decreasing hepatic glucose production and improving

(Avandia) target cell response to insulin

Caution
• May cause liver toxicity
Meglitinides Mechanism of action
• Nateglinide (Starlix) • Stimulate pancreatic insulin secretion
Description
• Repaglinide
• Quicker and shorter duration of action; therefore, less
(Prandin) 20
chance of hypoglycemia because blood glucose–lowering
effect wears off quickly
• Very fast onset of action allows client to take the
medication with meals and skip a dose when a meal is
skipped

• Nursing care
o Assess the client’s knowledge of diabetes mellitus and the use of oral antidiabetic
agents.
o Obtain a medication history regarding the medications that the client is taking
currently.
o Assess vital signs and blood glucose levels.
o Instruct the client to recognize the signs and symptoms of hypoglycemia and
hyperglycemia.
o Instruct the client to avoid over-the-counter medications unless prescribed by the
health care provider.
 o Instruct the client not to ingest alcohol with sulfonylureas.
o Inform the client that insulin may be needed during stress, surgery, or infection.
o Instruct the client in the necessity of compliance with prescribed medication.
o Instruct the client on how to take each specific medication, such as with the first
bite of the meal for meglitinides and alpha-glucosidase inhibitors.
o Advise the client to wear a Medic-Alert bracelet.

INSULIN

• Mechanism of action
o Acts primarily in the liver, muscle, and adipose tissue by attaching to receptors on
cellular membranes and facilitating the passage of glucose, potassium, and
magnesium.
• Indication
o Prescribed for clients with type 1 diabetes mellitus and type 2 diabetes mellitus in
clients whose blood glucose level is not controlled with oral hypoglycemic agents.
o Storing of insulin
▪ Avoid exposing insulin to extremes in temperature.
▪ Insulin should not be frozen or kept in direct sunlight or a hot car. 21
▪ Before injection, insulin should be at room temperature.
▪ If a vial of insulin will be used up in 1 month, it may be kept at room
temperature; otherwise, the vial should be refrigerated.
o Insulin injection sites
▪ The main areas for injections
• Abdomen, arms (posterior surface), thighs (anterior surface), and
hips.
▪ Insulin injected into the abdomen
• May absorb more evenly and rapidly than at other sites.
▪ Systematic rotation within one anatomical area is recommended to prevent
lipodystrophy.
o Nursing care
▪ Client should be instructed not to use the
same site more than once in a 2- to 3-week
period.
▪ Injections should be 1½ inches apart
 within the anatomical area.
▪ Heat, massage, and exercise of the injected area can increase absorption
rates and may result in hypoglycemia.
▪ Injection into scar tissue may delay absorption of insulin.

TIME ACTIVITY OF PHARMACOLOGICAL INSULIN

PREPARATION BRAND ONSET PEAK DURATION
(HR) (HR) (HR)
RAPID-ACTING INSULIN
Insulin aspart NovoLog 0.25 1-3 3-5
Insulin glulisine Apidra 0.3 0.5-1.5 3-4
Human lispro injection Humalog 0.25 0.5-1.5 5
SHORT-ACTING INSULIN
Regular human insulin injection Humulin R 0.5 2-4 5-7
Novolin R 0.5 2.5-5 8
ReliOn R
Humulin R (concentrated U-500) Humulin R (U 500) 1.5 4-12 24
INTERMEDIATE -ACTING INSULIN
Isophane insulin NPH injection Humulin N 1.5 4-12 16-24+
22
Novolin N 1.5 4-12 16-24+
ReliOn N
Insulin detemir injection Levemir 1 6-8 5.7-24
70% human insulin isophane Humulin 70/30 0.5 2-12 24
suspension/30% human insulin Novolin 70/30
injection ReliOn 70/30
50% human insulin isophane Humulin 50/50 0.5 3-5 24
suspension/50% human insulin
injection
70% insulin aspart protamine NovoLog Mix 70/30 0.25 1-4 24
suspension/30% insulin aspart
injection
75% insulin lispro protamine Humalog Mix 75/25 0.25 1-2 24
suspension/25% insulin lispro injection
LONG-ACTING INSULIN
Insulin glargine injection Lantus 2-4 None 24
• Precaution
o Insulin glargine cannot be mixed with any other types of insulin.
o Regular insulin is the only type of insulin that can be administered intravenously.
• Administering insulin
o To prevent dosage errors, be certain that there is a match between the insulin
concentration noted on the vial and the calibration of units on the insulin syringe;
the usual concentration of insulin is U 100 (100 units/mL).
o Most insulin syringes have a 27- to 29-gauge needle that is about ½-inch long.
o Before use, swirl insulin vial gently or rotate between palms to ensure that the
insulin and ingredients are mixed well; otherwise, an inaccurate dose will be drawn;
vigorously shaking the bottle will cause bubbles to form.
o Premixed insulins (NPH and regular insulin) are available as 70/30 (most
commonly used) and 50/50 (premixed insulin lispro protamine and insulin lispro
75/25 are also available).
o Inject air into the insulin bottle (a vacuum makes it difficult to draw up the insulin).
o When mixing insulins, draw up the regular (shorter acting) insulin first (Fig. 55-2).
o Regular insulin may be mixed with NPH or Lente insulin. 23
o Lispro insulin may be mixed with Humulin N or Humulin-U (Ultralente)
o Insulin aspart protamine may be mixed with NPH insulin only.
o Insulin zinc suspensions may be mixed only with each other and regular insulin, not
with other types of insulin.
o Administer a mixed dose of insulin within 5 to 15 minutes of preparation; after this
time, the regular insulin binds with the NPH insulin and its action is reduced.
o Aspiration generally is not recommended with self-injection of insulin.
o Administer insulin at a 45- to 90-degree angle in clients with normal subcutaneous
mass and at a 45- to 60-degree angle in thin persons or those with a decreased
amount of subcutaneous mass.
• Steps for mixing insulins
1. Wash hands.
2. Gently rotate NPH insulin bottle.
3. Wipe off tops of insulin vials with alcohol sponge.
4. Draw back amount of air into the syringe that equals total dose.
5. Inject air equal to NPH dose into NPH vial. Remove syringe from
 vial.

6. Inject air equal to regular dose into regular vial.

7. Invert regular insulin bottle and withdraw regular insulin dose.

8. Without adding more air to NPH vial, carefully

withdraw NPH dose.

EXENATIDE (BYETTA)

• Description
o A synthetic hormone classified as an incretin mimetic that is administered
subcutaneously.
• Mechanism of action
o Restores first-phase insulin response (first 10 minutes after food ingestion)
o Lowers the production of glucagon after meals 24

o Slows gastric emptying (which limits the rise in the blood glucose level after a meal)
o Reduces fasting and postprandial blood glucose levels
o Reduces caloric intake, resulting in weight loss
• Indication
o Used for clients with type 2 diabetes mellitus (not recommended for clients taking
insulin nor should clients be taken off of insulin and given exenatide)
• Nursing care
o Packaged in premeasured doses (pen) that require refrigeration (cannot be frozen)
o Administered as a subcutaneous injection in the thigh, abdomen, or upper arm
within 60 minutes before morning and evening meals
o Not taken after meals
o If a dose is missed, the treatment regimen is resumed as prescribed with the next
scheduled dose.
o Can cause mild to moderate nausea that abates with use.
PRAMLINTIDE (SYMLIN)

• Mechanism of action
o Synthetic form of amylin, a naturally occurring hormone secreted by the pancreas
• Indication
o Used for clients with types 1 and 2 diabetes mellitus who use insulin.
• Side effect
o Nausea
• Caution
o Associated with an increased risk of insulin-induced severe hypoglycemia,
particularly in clients with type 1 diabetes mellitus
• Nursing care
o Given before meals to lower blood glucose level after meals, leading to less
fluctuation during the day and better long-term glucose control
o Unopened vials are refrigerated; opened vials can be refrigerated or kept at room
temperature for up to 28 days.

GLUCAGON

• Hormone secreted by the alpha cells of the islets of Langerhans in the pancreas. 25
• Mechanism of action
o Increases blood glucose level by stimulating glycogenolysis in the liver.
• Indication
o Used to treat insulin-induced hypoglycemia when the client is semiconscious or
unconscious and is unable to ingest liquids.
• Nursing care
o Can be administered subcutaneously, intramuscularly, or intravenously
o The blood glucose level begins to increase within 5 to 20 minutes after
administration.
o Instruct the family in the procedure for administration.