ch.49: Pituitary, Thyroid, Parathyroid, and Adrenal Disorders

levothyroxine sodium drug class

thyroid hormone

levothyroxine sodium contraindications

Absolute contraindications: Thyrotoxicosis and myocardial infarction

Caution: Adrenal insufficiency; cardiovascular disease, including cardiac arrhythmias, hypertension, and angina pectoris; diabetes mellitus; osteoporosis; hypopituitarism; dysphagia

levothyroxine sodium drug interactions

Many drug-drug interactions exist and may alter the therapeutic effects of thyroid hormone replacement. Increased cardiac insufficiency occurs when levothyroxine is taken with sympathomimetics (e.g., epinephrine); levothyroxine increases the effects of anticoagulants, TCAs, vasopressors, decongestants, corticosteroids; decreases effects of antidiabetics (oral and insulin), digitalis products, beta blockers; decreased absorption of levothyroxine occurs with estrogens, antacids, cholestyramine, colestipol, sucralfate, and simethicone. Ketamines can worsen hypertension and tachycardia. Hepatic inducers (e.g., carbamazepine, barbiturates, hydantoins) increase the metabolism of thyroid hormones.

levothyroxine sodium food interactions

Drug should be taken on an empty stomach at least 30–60 min before breakfast and other medications. Tablets may be crushed and mixed in a small amount (5–10 mL) of water; use immediately after mixing. Do not mix with enteral or soy-based feedings. Certain food and beverages inhibit the absorption of thyroid hormones.

levothyroxine sodium lab interactions

Celery seed may reduce thyroid hormones.

levothyroxine sodium uses

To treat hypothyroidism, myxedema, goiter, and thyroid cancer

levothyroxine sodium action

Increases metabolic rate, oxygen consumption, utilization and mobilization of glycogen stores; promotes gluconeogenesis and body growth; stimulates protein synthesis

levothyroxine sodium side effects

Nausea, vomiting, anorexia, diarrhea, cramps, tremors, nervousness, irritability, insomnia, headache, weight loss, diaphoresis, and amenorrhea; usually due to undermedication or overmedication

levothyroxine sodium adverse effects

Tachycardia, hypertension, palpitations, osteoporosis, and seizures; usually due to overmedication. Other adverse reactions include urticaria, rash, and alopecia.

Life-threatening: Thyroid crisis, angina pectoris, cardiac dysrhythmias (atrial fibrillation), cardiovascular collapse

Thyroid Hormone assessment

• Determine baseline vital signs, including weight changes, for future comparisons. Report abnormal results.

• Report any abnormal results of serum triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) levels.

• Obtain a history of drugs and herbal products the patient is taking.

• Assess for signs and symptoms of thyroid crisis (thyroid storm), including tachycardia, cardiac dysrhythmias, fever, heart failure, flushed skin, apathy, confusion, behavioral changes, and, later, hypotension and vascular collapse. Thyroid crisis can result from a thyroidectomy (excess thyroid hormones released), abrupt withdrawal of antithyroid drug, excess ingestion of thyroid hormone, or failure to give antithyroid medication before thyroid surgery.

Thyroid Hormone analysis (patient problems)

• Altered functional ability related to imbalanced thyroid hormone

• Need for health teaching related to complex drug regimen

• General decreased tissue perfusion related to imbalanced thyroid hormone

Thyroid Hormone planning

• The patient will report an improved activity level within 1 to 4 weeks of thyroid treatments.

• The patient will report decreased signs and symptoms of hypothyroidism within 2 to 4 weeks with prescribed thyroid drug replacement, and the patient will not experience side effects.

• The patient will report decreased signs and symptoms of hyperthyroidism in 1 to 3 weeks with prescribed antithyroid drug.

Thyroid Hormone interventions

• Record vital signs. With hypothyroidism, temperature, heart rate, and blood pressure usually decrease. With hyperthyroidism, tachycardia and palpitations usually occur.

• Monitor the patient’s weight. Weight gain commonly occurs in patients with hypothyroidism.

• Obtain a pregnancy test, complete blood count (CBC), complete metabolic panel (CMP), liver function test (LFT), and electrocardiograph (ECG).

• Report periodic TSH, T3, and T4.

Thyroid Hormone general patient teaching

• Encourage patients to take drug at the same time each day in relation to meals. Levothyroxine is taken 30–60 minutes before any food or medications.

• Teach patients to check warnings on over-the-counter (OTC) drug labels. Avoid OTC drugs that caution against use by persons with heart or thyroid disease.

• Suggest that patients carry a MedicAlert identification card, tag, or bracelet that shows the health condition and the drug used to treat it.

• Instruct patients that certain foods can interfere with the absorption of thyroid hormones (e.g., soy products [estrogen], cruciferous vegetables [broccoli and cabbage], iodized salt, shellfish [iodine], and coffee).

• Instruct patients to take drugs as instructed; abrupt changes may lead to increased thyroid dysfunction.

• Recognize that family members may need guidance in understanding the disease processes of hypothyroidism or hyperthyroidism. Support patients and family members who may lack knowledge of prescribed drug therapy for management of thyroid conditions. Additional time in explanations and a written plan of care in the native language may be necessary for non-English-speaking persons.

Thyroid Hormone side effects teaching

• Direct patients to report symptoms of hyperthyroidism (tachycardia, chest pain, palpitations, excess sweating) caused by drug accumulation or overdosing.

• Demonstrate to patients how to take that pulse rate. Instruct patients to monitor pulse rate and to report increases or marked decreases in the rate.

• Teach patients the side effects of antithyroid drugs: skin rash, hives, nausea, alopecia, loss of hair pigment, petechiae or ecchymoses, and weakness.

• Advise patients to contact their health care provider if sore throat and fever occur while taking antithyroid drugs. A serious adverse reaction of antithyroid drugs is agranulocytosis (loss of white blood cells). CBC should be monitored for leukopenia.

Thyroid Hormone evaluation

• Evaluate both effectiveness of the treatment and drug compliance.

• Continue monitoring for side effects from drug accumulation or overdosing.

• Evaluate the patient’s knowledge of the medication regimen.

calcitriol drug class

vitmain D analogue

calcitriol contraindications

Absolute contraindications: Hypersensitivity, hypercalcemia, hypervitaminosis D

Caution: Cardiovascular disease, renal calculi, renal failure, hyperphosphatemia, dehydration, excess sunlight exposure, malabsorption syndrome, hypocalcemia

calcitriol drug interactions

Increased cardiac dysrhythmias with digoxin, verapamil; decreased calcitriol absorption with cholestyramine; decreased calcitriol effects with ketoconazole, barbiturates; enhanced calcitriol effects with thiazide diuretics

Calcitriol decreases the effects of estrogen.

calcitriol lab interactions

Increased serum calcium with thiazide diuretics, calcium supplements, calcium-rich foods; decreased serum calcium with low magnesium

calcitriol uses

To treat parathyroid disorders (hyperparathyroidism and hypoparathyroidism) and to manage hypocalcemia in chronic renal failure

calcitriol action

Calcitriol enhances calcium deposits into bones by the active form of vitamin D’s metabolite, calcitriol. Calcitriol reabsorbs calcium by the kidneys, enhances intestinal absorption of dietary calcium, and decreases serum phosphate, bone resorption, and parathyroid hormone levels.

calcitriol side effects

early signs of hypercalcemia: fatigue, weakness, somnolence, cephalgia, nausea, vomiting, diarrhea, cramps, drowsiness, dizziness, vertigo, metallic taste, lethargy, constipation, and xerostomia

calcitriol adverse effects

late signs of hypercalcemia: anorexia, photophobia, dehydration, cardiac arrhythmias, decreased libido, hypertension, sensory disturbances, hypercalciuria, hypercalcemia, and hyperphosphatemia

Parathyroid Hormone Insufficiencies assessment

• Note serum calcium level and report abnormal results.

• Assess for symptoms of tetany in hypocalcemia: twitching of the mouth, tingling and numbness of fingers, carpopedal spasm, spasmodic contractions, and laryngeal spasm.

Parathyroid Hormone Insufficiencies analysis (patient problems)

• Hyper- or hypocalcemia related to hormonal imbalance and therapeutic regimen

• Need for health teaching related to complex drug regimen

• Disrupted fluid and electrolytes related to side effects of drug regimen

Parathyroid Hormone Insufficiencies planning

• The patient will maintain a serum calcium level within the normal range.

• The patient will report no or minimal side effects.

Parathyroid Hormone Insufficiencies interventions

• Monitor serum calcium level. The normal reference range is 8 to 10 mg/dL; serum calcium below 8 mg/dL indicates hypocalcemia. Total serum calcium greater than 10.5 mg/dL indicates hypercalcemia.

Parathyroid Hormone Insufficiencies general patient teaching

• Advise women to inform their health care provider about pregnancy status before taking calcitonin preparations.

• Encourage patients to check over-the-counter (OTC) drugs for possible calcium content, especially if the patient has an elevated serum calcium level. Some vitamins and antacids contain calcium. Tell patients to contact their health care provider before taking drugs with calcium.

Parathyroid Hormone Insufficiencies side effects teaching

• Direct patients to report symptoms of hypocalcemia (e.g., tetany).

• Teach patients to report signs and symptoms of hypercalcemia, which include bone pain, anorexia, nausea, vomiting, thirst, constipation, lethargy, bradycardia, and polyuria.

Parathyroid Hormone Insufficiencies evaluation

• Monitor effectiveness of drug therapy (e.g., serum calcium level, signs and symptoms of hypercalcemia or hypocalcemia).

• Continue monitoring for signs and symptoms of calcium imbalances.

• Evaluate the patient’s knowledge of medication regimen.

Prednisone drug class

Glucocorticoid/corticosteroid

Prednisone contraindications

Contraindication: Untreated serious infections, hypersensitivity, varicella

Caution: Psychosis, diabetes mellitus, renal disease, heart failure, myocardial infarction, hypertension, osteoporosis, cirrhosis, diverticulitis, hypothyroidism, myasthenia gravis, ulcerative colitis, seizures, visual disturbances, GI disorders, ocular herpes simplex

Prednisone drug interactions

Additive effects occur with other immunosuppressive drugs when taken concurrently with corticosteroids. Increased corticosteroid levels are seen with estrogens, diltiazem, ketoconazole; decreased levels are seen with barbiturates, phenytoin, and rifampin. Concurrent use of aspirin and NSAIDs increase GI toxicity; concurrent use of diuretics and amphotericin B increases potassium depletion; concurrent use with cardiac glycosides increases risk of dysrhythmias and digitalis toxicity; concurrent use with bupropion lowers seizure threshold

Prednisone herb interactions

Level is decreased with ephedra (Ma-huang).

Prednisone lab interactions

Hyperglycemia, false-positive TB test

Prednisone uses

Adrenocortical insufficiency, Addison disease

Prednisone action

Suppresses inflammation, immune responses (humoral), and adrenal function; has mild mineralocorticoid activity

Prednisone side effects

Fluid and sodium retention, nausea, diarrhea, abdominal distension, increased appetite, sweating, headache, depression, flushing, mood changes, cataracts, amenorrhea, anorexia, Cushing syndrome, psychosis, immunosuppression, HPA suppression, hypercholesterolemia, elevated hepatic transaminases

Prednisone adverse reactions

Angioedema, cardiac arrhythmia, avascular necrosis, osteoporosis, fractures, cardiac arrest, cardiomyopathy, GI ulceration, exfoliative dermatitis, GI bleeding and perforation, CHF, increased ICP, lupus-like symptoms, pancreatitis, pulmonary edema, ocular disease, CVA, tendon rupture, thromboembolism

Corticosteroids assessment

• Note baseline vital signs for future comparisons.

• Assess laboratory test results, especially serum electrolytes and blood glucose. The serum potassium level usually decreases and blood glucose level increases when a corticosteroid, such as prednisone, is taken over an extended period.

• Obtain the patient’s weight and urine output for future comparisons. Corticosteroids can cause fluid retention and weight gain.

• Assess the patient’s medical and herbal history. Report if the patient has glaucoma, cataracts, peptic ulcer, psychiatric problems, or diabetes mellitus. Glucocorticoids can intensify these health problems.

Corticosteroids analysis (patient problems)

• Disrupted fluid and electrolyte balance related to treatment regimen

• Decreased immunity, risk for

• Decreased self-concept, risk for

Corticosteroids planning

• The patient will report decreased signs and symptoms of inflammation.

• The patient will report minimal side effects from glucocorticoid therapy.

• The patient will not develop new or worsening infection.

• The patient will have increased knowledge of the medication regimen.

Corticosteroids interventions

• Determine vital signs. Corticosteroids such as prednisone can increase blood pressure and sodium and water retention.

• Administer corticosteroids only as ordered. Routes of administration include oral, intramuscular (IM; not in deltoid muscle), intravenous (IV), aerosol, and topical. Apply topical corticosteroids in thin layers (see Chapter 45). Rashes, infection, and purpura should be noted and reported.

• Record weight. Report a weight gain of 5 lb in 2 days; this could indicate water retention due to sodium reabsorption from hyperaldosteronism.

• Monitor laboratory values, especially serum electrolytes and blood glucose. The serum potassium level could decrease to less than 3.5 mEq/L, and serum sodium and glucose could increase.

• Watch for signs and symptoms of hypokalemia: nausea, vomiting, muscular weakness, abdominal distension, paralytic ileus, and irregular heart rate.

• Assess for side effects from corticosteroid drugs when therapy has lasted more than 10 days and drug is taken in high dosages. Cortisone preparations should not be abruptly stopped because adrenal crisis can result.

• Monitor older adults for signs and symptoms of increased osteoporosis. Some corticosteroids promote calcium loss from bone.

Corticosteroids general patient teaching

• Advise patients to take drugs as prescribed, and caution patients not to abruptly stop drugs. When the drug is discontinued, the dose is tapered over 1 to 2 weeks.

• Direct patients not to take cortisone preparations (oral or topical) during pregnancy unless necessary and prescribed by the health care provider. Drugs may be harmful to the fetus.

• Inform patients that certain herbal laxatives and diuretics may interact with corticosteroid drug therapy and may increase the severity of hypokalemia.

• Teach patients to avoid large crowds and persons with respiratory infections, because corticosteroids can suppress the immune system.

• Teach patients receiving corticosteroids to inform other health care providers of all drugs taken.

• Encourage patients to carry a medical alert identification card, tag, or bracelet stating that corticosteroids are taken.

• Teach patients proper use of the drug.

• Counsel patients to take cortisone preparations at mealtime or with food to prevent irritation of gastric mucosa.

• Advise patients to eat foods rich in potassium, such as fresh and dried fruits, vegetables, meats, and nuts. Some corticosteroid preparations promote potassium loss.

• Explain to the family that the patient is not “dumb” or “uninterested” but has an adrenal problem. Explain that symptoms do not go away and may be progressive if prescribed therapy is not followed.

Corticosteroids side effects teaching

• Teach patients to report signs and symptoms of Cushing syndrome: moon face, puffy eyelids, edema in the feet, increased bruising, dizziness, bleeding, and menstrual irregularity.

Corticosteroids evaluation

• Evaluate effectiveness of corticosteroid therapy. If clinical manifestations have not improved, a change in drug therapy may be necessary.

• Continue monitoring for side effects, especially when a patient is receiving high doses of corticosteroids.

• Evaluate the patient’s knowledge of the therapy.