Farmakoterapi Penyakit Gangguan Endokrin: Disampaikan Oleh: Dewi Oktavia Gunawan, M.Farm.,Apt Prodi Farmasi Unpak, 2019

FARMAKOTERAPI
PENYAKIT GANGGUAN
ENDOKRIN
Disampaikan oleh:
Dewi Oktavia Gunawan,
M.Farm.,Apt
Clinical Terms Related to the
Endocrine System
• adrenalectomy—surgical removal of an adrenal gland
• diabetus insipidus—caused by a decreased secretion of an
antidiuretic hormone from the posterior pituitary gland; does
not involve blood sugar, but is marked by a large output of
dilute urine
• diabetes mellitus—a disorder of carbohydrate metabolism
caused by an insulin deficiency or the inability to respond to
insulin; marked by excessive urine production, excessive
amounts of sugar in the blood and urine, thirst, hunger and
weight loss
• exophthalmos—abnormal protrusion of the eyes
• gestational diabetes—high blood glucose levels that develop
during pregnancy in some women
• goiter—an enlarged thyroid gland usually resulting from
Clinical Terms Related to the
Endocrine System
• hyperglycemia—too much glucose in the blood
• hypoglycemia—too little glucose in the blood
• parathyroidectomy—surgical removal of a parathyroid
gland
• thyroiditis—inflammation of the thyroid gland
• thymectomy—surgical removal of the thymus gland
• thyroidectomy—surgical removal of the thyroid gland
• thyroiditis—inflammation of the thyroid gland
• Type I diabetes—usually occurring in childhood, blood
sugar levels are high due to the body making little or no
insulin
• Type II diabetes—usually occurring in adults, higher than
normal blood glucose levels due to the pancreas not making
KONSEP DASAR
BIOMEDIK –KLINIK
ENDOKRIN
Scenario
Your patient is an obese, 55-year-old, insulin-
dependent diabetic woman. She presents
confused, anxious, tachycardic, and hypotensive.
Her family says that she also has thyroid disease.
Your partner administers oxygen and sets up an
IV as you continue your assessment.
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Discussion
• What additional assessments should
you perform?
• How can you determine whether this is

related to the diabetes or the thyroid
condition?
• What thyroid emergencies could

present in this manner?
• Which interventions will you consider?

Endocrine System
• Consists of ductless glands and tissues that
produce and secrete hormones
Major Endocrine Glands
Endocrine Gland Functions
• Secrete hormones into blood
– Regulatory effect on metabolic
functions
– Hormones exert effects at many
sites
• Often at distance from origin
Hormone Receptors
• Hormones categorized
as:
– Proteins
– Polypeptides
– Derivatives of amino
acids
– Lipids
• Hormone may affect

specific organ or tissue
or have general effect
on entire body
Hormones
• Steroid hormones
– Manufactured from cholesterol
• Cortisol, aldosterone, estrogen, progesterone, and
testosterone
• Nonsteroid hormones
– Synthesized from amino acids
• Insulin, parathyroid hormone, and others
Regulation of Hormone Secretion
• All hormones operate within

feedback systems (either positive or
negative) to maintain an optimal
internal environment
Regulation of Hormone Secretion
• Negative feedback
– Most common mechanism
– Usually, increase in serum level of hormone or related
substance suppresses further hormone output
– Hormone production is stimulated when serum levels
fall
Negative Feedback Mechanism
Specific Disorders of the
Endocrine System
• Endocrine disorders arise from:
– Imbalance in production of hormones
– Alteration in body’s ability to use
hormones produced
• Effects of disturbances of
endocrine gland function relate to:
– Degree of dysfunction
– Age and gender of affected person
1. DIABETES MELLITUS
Diabetes Mellitus
• Systemic disease of endocrine system
• Usually pancreatic dysfunction
• Disorder of fat, carbohydrate, and protein

metabolism
• Potentially lethal
• Predisposes patient to several medical

emergencies
Pancreas
• Important in absorption and use of carbohydrates,
fat, and protein
– Principal regulator of blood glucose concentration
Pancreas
• Exocrine and endocrine functions
– Exocrine portion consists of acini (glands that produce
pancreatic juice) and
– Duct system that carries pancreatic juice to small
intestine
– Endocrine portion has pancreatic islets (islets of
Langerhans)
• Produce hormones
Islets of Langerhans
• Composed of:
– Beta cells secrete insulin
• Daily average of 0.6 units/kg of body weight
– Alpha cells secrete glucagon
– Other cells
• Some are delta cells that secrete somatostatin (inhibiting the
secretion of growth hormone)
• Sel A = alpha  glucagon  menghasilkan gula bila
tubuh kekurangan gula
• Sel B = beta  insulin  menguraikan gula bila
berlebihan mjd glikogen dlm otot
• Sel D = delta  somatostatin  tergantung dr kebutuhan
tubuh  membantu sel A bila kekurangan gula &
membantu sel B bila kelebihan gula
• Sel F = pankreopeptide  membantu dlm proses
pencernaan makanan terutama protein
Islets of Langerhans
• Two pancreatic islets (of Langerhans) or hormone-producing
areas among pancreatic cells
Insulin
• Protein released by beta cells
when blood glucose levels rise
• Primary functions
– Increase glucose transport into cells
– Increase glucose metabolism by cells
– Increase liver glycogen levels
– Decrease blood glucose
concentration toward normal levels
Glucagon
• Protein released by alpha cells
when blood glucose levels fall
• Major effects
– Increase blood glucose levels by
stimulating liver to release glucose
stores from glycogen and other
storage sites
– Stimulate gluconeogenesis (glucose
formation) by breakdown of fats and
fatty acids
Growth Hormone (GH)
• Polypeptide hormone produced and secreted by anterior
pituitary gland
• Secretion triggered by many physiological stimuli
• Antagonizes insulin by decreasing insulin actions on cell

membranes
– Reduces capacity of muscles, adipose, and liver cells to
absorb glucose
Regulation of Glucose Metabolism
• Normal serum glucose concentration: 60-
120 mg/dL
• Three components of food
– Carbohydrates
– Fats
– Proteins
• Process of digestion
• Carbohydrate metabolism
• Fat metabolism
• Protein metabolism
Regulation of Insulin
and Glucagon Secretion
Glucagon and Its Functions
• Functions are opposite to insulin
• Most important is to increase blood glucose

concentration
• Effects on glucose metabolism

– Breakdown of liver glycogen
– Increased gluconeogenesis
Glucagon and Its Functions
Glucose, amino acids, and Absorption from intestinal tract decreases,
blood levels of glucose, amino acids,
fatty acids stimulate insulin
secretion and fatty acids decrease
Pathophysiology of Diabetes Mellitus
• Deficiency of insulin or inability to
respond to insulin
• Signs
– Increased intake of fluid (polydipsia)
– Large quantities of urine that
contains glucose (polyuria,
glucosuria)
– Weight loss
• TypeCopyright
1 or type
© 2007, 2 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
2006, 2001,
Type 1 Diabetes Mellitus
• Inadequate production of biologically
effective insulin by pancreas
• Incidence
• Morbidity/mortality
• Occurs any time after birth

– Often in teenagers and young adults
• Lifelong treatment with insulin

injections, exercise, and diet regulation
Type 1 Diabetes Mellitus—S/S
• Usually present suddenly
– Polyuria
– Polydipsia
– Dizziness
– Blurred vision
– Rapid, unexplained weight loss
Type 2 Diabetes Mellitus
• Decreased production of insulin by beta cells of pancreas
and diminished tissue sensitivity to insulin
• Incidence
• Morbidity/mortality
• Risk factors
• Often oral hypoglycemic medications, exercise, and

dietary regulation needed to control illness
– Some require insulin injections
Management
• Drug therapy (insulin or oral
hypoglycemic agents)
• Diet regulation
• Exercise
• Insulin
– Genetically engineered human insulin
(Humulin) available in rapid-,
intermediate-, and long-acting
Oral Hypoglycemic Agents
• Stimulate insulin release from pancreas
– Effective in patients who have functioning beta cells
Oral Hypoglycemic Agents
• Commonly prescribed oral
hypoglycemic agents
– Chlorpropamide (Diabinese)
– Metformin (Glucophage)
– Tolbutamide (Orinase)
– Acetohexamide (Dymelor)
– Glipizide (Glucotrol)
– Glyburide (Diabeta, Micronase)
– Glimepiride (Amaryl)
Diabetic Emergencies
• Three life-threatening conditions:
– Hypoglycemia (insulin shock)
– Hyperglycemia (diabetic ketoacidosis [DKA])
– Hyperosmolar hyperglycemic nonketotic (HHNK) coma
Hypoglycemia
• Syndrome; blood glucose levels <80
mg/dL
– Symptoms usually at levels <60 mg/dL
or higher if the fall has been rapid
– May occur in nondiabetic patients
• Causes
• Predisposing factors
• Signs and symptoms
Diabetic Ketoacidosis (DKA)
• Absence of or resistance to insulin
• Pathophysiology
• Management
• Protokol manajemen terapi KAD
Fase Uraian Terapi
Fase I 1. Rehidrasi : NaCl 0,9% atau RL 2 L/2jam pertama, lalu 80 tt/m selama 4 jam, lalu
30 tt/m selama 18 jam
(4-6 L/24 jam), diteruskan sampai 24 jam berikutnya (20 tt/m)
2. IDRIV (Insulin Dosis Rendah IntraVena) : 4 unit/jam iv (rumus minus satu)
3. Infus K+ per 24 jam : 25 mEq (bila K+ = 3,0-3,5 mEq/l), 50 mEq (bila K+ = 2,5-
3,0), 75 mEq (bila K+
= 2,0-2,5 dan 100 mEq (bila K+ = 2,0 mEq)
4. Infus BIK : bila pH ≤ 7,2-7,3 atau BIK <12 mEq/l : 50-100 mEq drip dlm 2 jam
(bolus BIK 50-100 mEq
diberikan bila pH ≤ 7,0
5. Antibiotika : dipilih yg up to date dan dosis adekuat
Glukosa Darah ± 250 mg/dl atau reduksi ±
Fase II 1. Rumatan : NaCl 0,9% atau pot.R (IR/Insulin Reguler 4-8 unit), maltose 10% (IR
6-12 u) bergantian : 20 tt/m (dimulai perlahan, berjalan perlahan dan diakhiri
perlahan)
Hyperosmolar Hyperglycemic
Nonketotic (HHNK) Coma
• Life-threatening emergency
• Older patients with type 2 diabetes or

undiagnosed diabetics
• Causes
• Precipitating factors
• SignsCopyright
and symptoms
© 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Pathophysiology of HHNK Coma
Assessment of the Diabetic
Patient
• Diabetic emergency may mimic
other conditions
– Maintain a high degree of suspicion
– Be alert for:
• Medical identification tag
• Insulin syringes
• Diabetic medications (often in refrigerator)
History
• Onset of symptoms
• Food intake
• Insulin or oral hypoglycemic use
• Alcohol or other drug consumption
• Predisposing factors
– Exercise, infection, illness, stress
• Associated symptoms
Management
• Conscious diabetic
patient
• Unconscious diabetic
patient
2. PENYAKIT KELENJAR
TIROID/GONDOK
Thyrotoxicosis = Hyperthyroid
• Any toxic condition resulting from thyroid
hyperfunction
– Hyperthyroidism and thyrotoxicosis are designations
for common, milder forms of disease
• Thyroid storm is a life-threatening manifestation

of thyroid hyperfunction
– Rare condition
Grave’s Disease
• Excessive thyroid activity with enlargement of the
gland (goiter)
• Leads to swollen neck
• Protruding eyes (exophthalmos)

– Often young women
– May be autoimmune process
Thyroid Gland
• Anterior neck, just below

larynx
– Two lobes
• One on each side of the
trachea
• Thyroid hormones
– Important role in metabolism
Disorders of the Thyroid Gland
• May result from:
– Defects in gland
– Disruption of hypothalamic-pituitary hormonal
control system
• Causes of thyroid gland disorders
• Thyroid storm
• Management
• Penyebab kelainan kelenjar Tiroid:
 Diduga oleh karena produksi TSH (Thyroid-
stimulating hormone) yg berlebihan oleh
kelenjar hipofisis/pituitary anterior
 “Autonomous hyperfunction” dr kelenjar tiroid
itu sendiri
 Long Acting Thyroid Stimulator (LATS) : efek
thd kelenjar tiroid hampir sama dgn TSH, tetapi
jauh lbh lama
 Thyroid Stimulating Immunoglobulin (TSI) :
• Thyroid Storm = Krisis Tiroid
 Keadaan gawat yg tjd jika gejala-gejala
hipertiroid mendadak meningkat dgn hebat, tjd pd
penderita yg tdk terkontrol dgn baik dan ada factor
pemicu (infeksi dan trauma fisik/psikis)
• Gejala klinik Hipertiroid:
1. Umur penderita:
 Muda: nervositas yg lbh menonjol
 Tua: kardiovaskuler yg lbh menonjol
2.Ada/tidaknya kelainan organ-organ lain sebelumnya.
Gejala a.l:
 Tremor halus (terutama jari dan lidah)
 Nervous
 Goiter
 Emotional irritability (mudah tersinggung)
 Von Muller;s Paradox (makan banyak tp badan tambah
kurus)
 Tak tahan udara panas
 Kulit banyak berkeringat dan hangat
 Palpitasi (berdebar-debar) sinus takikardia, atrial
fibrilasi dan kadang-kadang dekompensasi cordis
 Rambut jarang, halus, dan mudah rontok
 Hiperdefekasi (sehari BAB beberapa kali
 Lekas Lelah (terutama otot-otot paha)
3. Dermopati
4. Gejala pada mata: (sympathetic over stimulation)
spastis, a.l:
 Mobius sign (sukar mengadakan konvergensi)
 Von Grave’s sign (sclera antara limbus & kelompok
mata bagian atas terlihat)
 Joffrey sign (dahi tak dpt berkerut)
 Stellwag’s sign (mata jarang berkedip)
 “Lid lag” (palpebra superior tertinggal waktu melirik
ke bawah
 Oleh karena factor mekanis: pendesakan retro orbital
 Exophthalamus dan akibatnya:
 Konjungtivitis
 Ulkus cornea
 Palpebra bengkak
 Optik neuritis
 Optik atrofi
• Lab :
1. BMR – jarang dipakai
2. I-131 uptake yg meningkat: >60%/24jam
3. Thyroid scaning = sidikan kelanjar tiroid “hot nodule”
4. Kadar kolesterol rendah (< 160 mg%)
5. T3 dan T4 serum yg meningkat, FT4 meningkat,
TSH3 menurun
6. Uric acid sering menurun
7. Tes toleransi glukosa oral kadang terganggu
8. X-foto dada dan leher: mencari adanya Struma
aberrant
9. FT4 dan TSH3 yg terpenting untuk diagnose
• Management :
1. Konservatif
1) Obat-obat yg menekan produksi hormone tiroid:
a. PTU = Prophylthiouracil dosis 200-600 mg/hari
b. Methimazole (mis. Neomercazole) dosis 1/10-nya
PTU
2) Obat-obat yg menekan pengaruh “sympathetic over
stimulation”:
a. Beta-bloker: Propanolol
b. Sedative/minor tranquilizer
3) Riborantia: multivitamin dgn mineral
2. Pembedahan
Indikasi :
1) Relaps
2) Struma yg besar
3) Tidak dpt diobati secara konservatif
4) Evaluasi pengobatan konservatif sukar
5) kosmetik
3. Radioaktif : memakai Iodium-131 (I-131)
Indikasi :
1) Umur tua
2) Menolak pembedahan
3) Karena kondisinya tdk dapat dibedah
• Pengobatan Exopthalmus:
Bila ada exopthalmus:
a. Hindari iritasi pd cornea (+salep mata)
b. Kalau perlu kortikosteroid injeksi retro oculli
dan per oral
• Pengobatan Dermopati:
a. Kortikosteroid local dan per oral
Hypothyroidism = Hipotiroid
Keadaan klinik yg diakibatkan oleh karena kekurangan
hormone tiroid.
• Penyebab :
1. Thyroidal:
a. Thyroprivic (kelenjar tiroid tidak ada): kongenital,
pastablasi.
b. Goitrous : kekurangan iodium, obat-obatan (PAS,
Phenylbutazon), chronic thyroiditis.
2. Supra Thyroid:
a. Gangguan fungsi hipofisis/pituitary
b. Gangguan fungsi hipotalamus
• Gejala Klinis:
Anak-anak:
 Perkembangan mental dan fisik terganggu
Dewasa:
 Mula-mula tdk khas (a.l konstipasi, malaise, “cold
intolerance”), kemudian
 Reflek menurun
 Nafsu makan turun tp BB naik
 Kulit kering dan kaku – myxedema
 Dapat terjadi cardiomegaly – effusion
 Dapat terjadi A-dynamic megacolon
 Bradikardial (+)
• Lab:
1. BMR negative besar (<20%)
2. Kolesterol meningkat (400 mg% atau lebih)
3. T3 dan T4 menurun, FT4 menurun
4. TSH meningkat – diagnostic, EKG: bradikardia,
amplitude rendah T datar/terbaik
• Management terapi
1. Ekstrak Tyroid : 120-180 mg/hari
2. Levothyroxin : 0,2-0,3 mg/hari
Myxedema
• Severe hypothyroidism
• Results from thyroid hormone

deficiency
• May be associated with:

– Inflammation of thyroid gland
– Atrophy of thyroid gland
– Treatment for hyperthyroidism
• Incidence
• SignsCopyright
and symptoms
© 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
• Sign & Symptoms (primary symptoms) :
 Altered mental status
 Low body temperature
 Low blood sugar
 Low bloodpressure
 Hyponatremia
 Hypercapnia
 Hypoxia
 Slowed heart rate and hypoventilation
• Cardiac :
 Bradicardia/hipotensi
 CHF
 Kardiomegali
 Perikardial effusion
 Low voltage EKG
• Neck :
 Thyroidectomy scar
 Goiter (uncommon)
• Dermatologic :
 Dry, scaly, yellow skin
 Loss of lateral of eye brow
 Non-pitting waxy edema of face
Myxedema Coma
• Rare illness characterized by:
– Hypothermia
– Mental obtundation
– Myxedema
• Medical emergency
• Management
• Management :
 ICU  monitoring kontinyu status cardiovascular dan
pulmonary
 Supprotive care
 Treat Hypothermia  Passive rewarming
 Treat hyponatremia  normal saline dan free water
restriction
 Hormon thyroid treatment
 Levothyroxine (T4)  loading dose 300-400 µg iv, then
50-100 µg iv dayli sampai oral medication bias
diberikan
 Jika respon suboptimal, consider concurrent iothyronin
(T3): 5 µg iv setiap 8 jam
 Kortikosteroid terapi
 Baseline cortisol level dan mulai hidrokortison 100 mg
iv, dilanjutkan 50 mg iv setiap 6-8 jam
 Follow up steroid terapi
3. PENYAKIT KELENJAR ADRENAL
Cushing’s Syndrome
• Abnormally high circulating level of
corticosteroid hormones
– Produced by adrenal glands
• May be produced by:

– Adrenal gland tumor
– Prolonged administration of
corticosteroid drugs
– Enlargement of adrenal glands due to
pituitary tumor
Adrenal Gland
(hiperkortisolisme)
• Face appears round (“moon-faced”) and red
• Trunk becomes obese (buffalo humb)
• Limbs become wasted from muscle atrophy
• Acne
• Purple stretch marks on abdomen, thighs, and breasts
• Skin thins and bruises easily
• Weakened bones
– Increased risk for fracture
• Management
• Darah :
 hypokalemia,
 rasio Na/K >35,
 alkalosis,
 polisitemia,
 eosinopenia <50,
 gangguan toleransi glukosa pd hipertensi
• Manajemen Terapi:
 Adrenalektomi bilateral (operasi)  pasca op. bisa
timbul sindrom Nelson (pigmentasi krn tumor hipofise
local yg invasive)
 Iradiasi kelenjar hipofise/pituitary + metirapon
 Cyproheptadine selama 3 bulan atau lbh
 Untuk karsinoma adrenal yg metastatic  Mitotane
(adrenocorticolytic agent), DDD (adrenolytic agent)
 Untuk Ectopic ACTH Syndrome  operasi dgn
persiapan Metirapon sebelumnya
 Untuk sindrom Cushing Iatrogenik (krn OD
glukokortikoid)  dosis steroid diturunkan pelan dgn
menuju dosis terakhir pagi hari
Addison’s Disease
• Adrenal insufficiency
– Adrenal steroids are reduced
– Glucocorticoids
– Mineralocorticoids
– Androgens
– Common cause is atrophy of adrenal
tissue
• Less common causes: Hemorrhage,
infarctions, fungal infections, and
acquired immunodeficiency disease
• Sign and Symptoms
 Depresi  Hiponatremia
 Diare  Hiperkalemia
 Kelelahan  Nafsu makan rendah
 Sakit kepala  Periode mens yg
 Hiperpigmentasi pd terlewat
kulit  Mual dgn atau tanpa
 Hipoglikemia muntah
 Eosinofilia  Ingin mengonsumsi
 Hiperkalsemia garam
 Limfositosis  Penurunan BB
 Kelemahan
• Manajemen Terapi:
 Untuk mencapai keadaan fisiologis 
Hidrokortison atau sejenis dgn dosis : 3 x 20
mg sehari selama 2 hari
 Diteruskan dgn 20-30 mg/hari, dosis terbagi
pagi dan sore (bila keadaan membaik cukup
pagi saja
THANK YOU

Farmakoterapi Penyakit Gangguan Endokrin: Disampaikan Oleh: Dewi Oktavia Gunawan, M.Farm.,Apt Prodi Farmasi Unpak, 2019

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FARMAKOTERAPI

• How can you determine whether this is

• What thyroid emergencies could

• Which interventions will you consider?

• Hormone may affect

• All hormones operate within

• Usually pancreatic dysfunction

• Disorder of fat, carbohydrate, and protein

• Predisposes patient to several medical

• Secretion triggered by many physiological stimuli

• Antagonizes insulin by decreasing insulin actions on cell

• Most important is to increase blood glucose

• Effects on glucose metabolism

• Occurs any time after birth

• Lifelong treatment with insulin

• Often oral hypoglycemic medications, exercise, and

• Signs and symptoms

• Older patients with type 2 diabetes or

• Insulin or oral hypoglycemic use

• Alcohol or other drug consumption

• Thyroid storm is a life-threatening manifestation

• Leads to swollen neck

• Protruding eyes (exophthalmos)

• Anterior neck, just below

• Causes of thyroid gland disorders

• Signs and symptoms

• Results from thyroid hormone

• May be associated with:

• May be produced by:

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