Module 4 Drugs That treat Hormonal imbalances

Thyroid Gland

Butterfly-shaped endocrine gland

Located in the midline anterior neck, anterior to the trachea

requires dietary iodine for hormone synthesis (T3, T$)

Thyroid hormone

• Tetraiodothyronine (T4)

  • Inactive; converted to T3

• Trilodothyronine

  • Active; more potent

Hormone regulation

• Controlled by TSH (thyroid-stimulating hormone) from the anterior pituitary

• Negative feedback loop with T3/T4 levels

Physiologic effects

• regulates metabolism

• increases heart rate and cardiac output

• affects body temperature

• supports growth and development

Clinical correlations

• Hypothyroidism: weight gain, fatigue, cold intolerance, bradycardia

• Hyperthyroidism: weight loss, heat intolerance, tachycardia

• Iodine deficiency→ goiter

Hypothyroidism

Prevalence:

• most common in women >50 and elderly

Pathophysiolgy

• low T3/T4 → slow metabolism

Clinical Manifestations

• fatigue, lethargy

• Bradycardia

• Weight gain

• Constipation

• Dry skin/ hair loss

• cold tolerancy

• high cholesterol

Complication

• myxedema coma (severe, life-threatening hypothyroidism)

Treatment

• Thyroid hormone replacement (levothyroxine)

Hyperthyroidism

Prevalence

• More common in women, typically ages 20–40

• Often caused by Graves Disease

Pathophysiology

• High T3/T4 → increased metabolic rate

Clinical Manifestations

• Nervousness, anxiety

• Tachycardia

• Weight loss

• Heat intolerance

• Diarrhea

• Warm, moist skin

• Hair thinning

• ↓ Cholesterol

Complication

• Thyroid storm (severe, life-threatening hyperthyroidism)

Treatment

• Antithyroid medications

• Radioactive iodine

• Surgery (if indicated)

Levothyroxine (Drug Classification: Thyroid Hormones)

Prototype: Levothyroxine

Indications: Replacement hormone therapy for patients with hypothyroidism

MOA: Acts as a synthetic form of thyroid hormones, increasing metabolism of all nutrients and promoting cell growth and protein synthesis

Side effects: When dose is too high, hyperthyroidism symptoms, including:

• Anxiety

• GI upset

• Sweating

• Weight Loss

• Heat intolerance

Nursing considerations: Monitor Thyroid hormones

Patient teaching: Take on an empty stomach before breakfast with a full glass of water. This is a lifelong treatment. Full effects may not be felt for weeks. Report chest pain, heart palpitations, dizziness, or excess weight loss

Methimazole/Propylthiouracil Drug claasification: Antithyroid agents

Prototypes:Methimazole/Propylthiouracil

Indications: treatment for hyperthyroidism often used to control hyperthyroidism in preparation for thyroidectomy or radioactive iodine therapy.

Mechanism of Action: Blocks the synthesis of thyroid hormones.

Side Effects: GI upset, rash. When dose is too high, the patient will have symptoms of hypothyroidism, including:

• Lethargy and depression

• Weight gain

• Cold intolerance

• Bradycardia

Adverse Effects: Hepatotoxicity, agranulocytosis (sore throat, fever, signs of infection), and methimazole is teratogenic and PTU would be used in early pregnancy.

Nursing Considerations: Monitor CBC and liver function tests. Assess for agranulocytosis. If patient has sore throat and fever, stop the medication and call the provider.

Patient Teaching: Monitor weight and notify health care provider of significant changes, report sore throat, fever, and laboratory tests will be done frequently. Report palpitations, nervousness, and insomnia (thyroid storm/thyrotoxicosis).

Drug Classification: Strong Iodine Solution

Prototypes: strong iodine solution

Indications: Short term treatment for hyperthyroidism often used to control hyperthyroidism, thyrotoxicosis
(thyroid storm), and in preparation for thyroidectomy.
• Mechanism of Action: Blocks release of thyroid hormones. Decreases thyroid gland vascularity and size.
• Side Effects: GI upset, hypothyroidism (prolonged use), iodism. Hypersensitivity (rash and pruritic)
• Iodism (eye-oh-diz-um)
• Metallic taste, excessive salivation
• Stomatitis
• Severe GI upset
• Nursing Considerations: Short term use, monitor thyroid function tests, and assess for signs of iodism.
• Patient Teaching: Mix solution with juice or milk to improve bitter taste. Use a straw and rinse mouth. Report
signs of iodism

The role of the Pancreas in Glucose Regulation

Endocrine organ regulating blood glucose

Islets of Langerrhans

• β (Beta) cells → insulin → ↓ blood glucose

• α (alpha) cells → glucagon → ↑ blood glucose

Insulin released during a “fed” state

Glucagon released during a fasting state

Diabetes Mellitus

• Type 1: β-cell destruction → no insulin

• Type 2: insulin resistance + relative deficiency

Pharmacology Basics related to the Pancreas:

• Insulin meds replace pancreatic insulin

• Oral agents:
  • ↑ insulin secretion
  • ↑ insulin sensitivity
  • ↓ hepatic glucose production

Role of the Liver in Glucose Regulation

Primary glucose storage organ

• Stores glucose as glycogen

• Maintains normal blood glucose between meals

Key Liver Functions

• Glycogenesis: stores glucose as glycogen (after meals)

• Glycogenolysis: breaks down glycogen → releases glucose (fasting)

• Gluconeogenesis: produces glucose from non-carbohydrate sources

Hormonal Control

• insulin: promotes glycogen storage (↓ blood glucose)

• Glucagon: stimulates glucose release (↑ blood glucose)

• Epinephrine: rapid glucose release during stress

Clinical Relevance

• Liver is the main target of glucagon

• impaired liver function → poor glucose control

• Alcohol use increases risk of hypoglycemia
  • Memory: Liver = glucose bank

The Hormones: Insulin

Hormone produced by β cells of the pancreas

Lowers blood glucose by acting like a key — it triggers GLUT4 (insulin-dependent transport protein) to move to the cell membrane, allowing glucose to enter the cell by facilitated diffusion.

Promotes:

• Glucose uptake into cells

• Glycogen synthesis (liver, muscle)

• Fat and protein storage

Naturally released in patients with healthy glucose regulation in response to high blood glucose

Clinical Use

• Required for Type 1 diabetes

• Used in Type 2 diabetes when oral agents are insufficient

Nursing Focus

• Match insulin administration with meals

• Monitor for hypoglycemia

• Know onset, peak, duration

• Check blood glucose before administration
  • Think: Insulin = “puts glucose into cells”

The Hormones: Glucagon

Hormone produced by α cells of the pancreas

• Raises blood glucose by stimulating glycogen breakdown and glucose production in the liver.

Stimulates:

• Glycogen breakdown (glycogenolysis)

• Glucose production (gluconeogenesis)

Released during fasting or hypoglycemia

• Clinical Use

• Emergency treatment for severe hypoglycemia

• Used when patient is hypoglycemic unconscious or unable to swallow
  • Think: Glucagon = “emergency sugar release

The Hormones: Glycogen

Stored form of glucose
Found mainly in the liver and skeletal muscle
Allows rapid glucose availability

Key Functions

• Liver glycogen: maintains blood glucose between meals

• Muscle glycogen: used for local energy only (not released into blood)

Hormonal Control

• Insulin: promotes glycogen storage (glycogenesis)

• Glucagon: stimulates glycogen breakdown (glycogenolysis)

• Epinephrine: rapid glycogen breakdown during stress

Clinical Relevance

• Limited storage → depleted within ~24 hours of fasting

• Liver disease → impaired glucose regulation

• Essential for hypoglycemia prevention

Memory: Glycogen = stored glucose

Laboratory Findings for Glucose Imbalances

Hemoglobin A1C (HbA1c)
• Reflects average blood glucose over ~3 months
• Not affected by daily fluctuations
• Used to diagnose and monitor diabetes
• Reflects long-term control
A1C Values
• Normal: < 5.7%
• Prediabetes: 5.7–6.4%
• Diabetes: ≥ 6.5%
Blood Glucose Values
Fasting Blood Glucose
• Normal: 70–99 mg/dL
• Prediabetes: 100–125 mg/dL
• Diabetes: ≥ 126 mg/dL
Random Blood Glucose
• Normal: < 140 mg/dL
• Diabetes likely: ≥ 200 mg/dL with symptoms

Blood Glucose Imbalance: Hypoglycemia

Blood glucose < 70 mg/dL
Cause: Too much insulin/meds, missed meals, exercise, alcohol

Clinical Manifestations:
• Shaky, sweaty
• Tachycardia
• Hunger
• Confusion
• Clammy skin
• Seizures / Decreased Level of Consciousness (LOC)
(severe)
Treatment
• Conscious → 15 g fast sugar
• Recheck in 15 min
• Unconscious → Glucagon IM/SQ or IV dextrose
Nursing Considerations
• Check blood glucose before administering insulin
• Give carbs first, protein later
• Memory: Cold and clammy need some candy!

Blood Glucose Imbalance: Hyperglycemia

High blood glucose, Usually > 180 mg/dL
Common in diabetes
Causes
• Too little insulin or meds
• Illness, infection, stress
• Excess carbohydrate intake
• Missed doses

Clinical Manifestations
• Polyuria, Polydipsia, Polyphagia
• Warm, dry skin
• Fatigue
• Blurred vision
• Severe form: Fruity breath (Linked to: Diabetic ketoacidosis [DKA])
Treatment
• Insulin
• IV fluids
• Monitor glucose & electrolytes

Nursing Pearls
• Check blood glucose before giving insulin
• Watch for diabetic emergencies: DKA or Hyperosmolar Hyperglycemic State (HHS)
• Treat early to prevent dehydration
• Hyper = hot and dry, may be high!

Type 1 Diabetes

• Autoimmune destruction of β cells
• No insulin production
• Usually, onset in childhood or adolescence
• Requires lifelong insulin
Key Features
• Prone to hypoglycemia
• High risk for DKA
• Weight loss, polyuria, polydipsia, polyphagia

Labs
• ↑ Blood glucose
• ↓ or absent insulin
• ↑ Ketones (with DKA)
Nursing Focus
• Never hold insulin
• Match insulin to meals, patient will often wear insulin pumps
and glucose monitoring devices
• Monitor for hypoglycemia
• Sick-day management is critical
• Teach management skills to prevent long-term complications
• Type 1 = makes no insulin naturally

Type 2 Diabetes

Insulin resistance + relative insulin deficiency
• Insulin present, but cells don’t respond effectively
• Usually onset in adulthood (increasing in youth)
• Strongly associated with obesity, inactivity, genetics
Key Features
•Gradual onset
•Hyperglycemia common
•Lower risk of DKA than Type 1
•High risk for HHS
Laboratory findings
•↑ Blood glucose
•Normal or ↑ insulin early, ↓ later
•Minimal or no ketones
• If not within long-term control, ↑ A1C
Treatment
• Lifestyle modification
• Oral antidiabetic agents
• Non-insulin injectables
• Insulin if needed
Nursing Focus
• Monitor blood glucose & A1C
• Assess for complications
• Encourage diet, exercise, weight loss
• Teach medication adherence to prevent long-term complications
Type 2 = insulin resistance

Medication Classification": Biguanides (Metformin)

Prototype: Metformin

Indications: Oral medication for the treatment of Type 2 Diabetes may be used with diet, insulin, or sulfonylurea oral hypoglycemic medications.

Mechanism of Action: Decrease glucose production in the liver, decrease intestinal
absorption of glucose, increase the insulin sensitivity of cell receptors.

Side Effects: GI Upset, metallic taste, lactic acidosis.
Adverse Effects: Lactic acidosis (nausea, vomiting, fatigue, muscle cramps, abdominal pain, tachypnea, and hypotension)

Nursing Considerations: Hold metformin before procedures that require contrast dye and for 48 hours after the procedure related to kidney damage. Monitor for signs of lactic acidosis. Not for patients with type 1 diabetes.

Patient teaching: Take with a meal. Do not consume alcohol. Follow prescribed diet and exercise. Report signs of lactic acidosis. Inform healthcare providers of medication before diagnostic procedures or surgery.

Medication Classification: Sulfonylureas (Glipizide/glyburide)

Prototype: Glipizide and Glyburide

Indications: Oral medication for the treatment of Type 2 Diabetes may be used with diet, insulin, or biguanide oral hypoglycemic medications.

Mechanism of Action: Lowers blood sugar by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites. May also decrease hepatic glucose production.

Contraindication: Use caution in patients with sulfa allergy (possible cross-sensitivity).

Side Effects: Photosensitivity, GI Upset.

Adverse Effects: Hypoglycemia

Nursing Considerations: Monitor glucose levels and A1C. Liver and renal studies. Not for patients with type 1 diabetes.

Patient teaching: Take 30 minutes before a meal. Do not consume alcohol. Follow prescribed diet and exercise. Report signs of hypoglycemia. Wear sunscreen

Medication Classification: Pancreatic Antihypoglycemic (glucagon)

Prototype: glucagon

Indications: Injectable medication for the acute management of severe hypoglycemia.

Mechanism of Action: Stimulates hepatic production of glucose from glycogen stores.

Side Effects: Increased heart rate and blood pressure, nausea, and vomiting.

Nursing Considerations: Hypoglycemia is most prevalent at the peak time of antidiabetic agents. Must monitor patient’s glucose after administration.

Patient teaching: Teach family members how to administer and if unconscious place patient in side-lying recovery position

Insulin Basics

Required for Type 1 diabetes mellitus , Used in Type 2 diabetes mellitus, if needed

Works in the same manner as naturally occurring insulin

Four categories of insulin that vary in onset, peak, and duration

Administration

• High-risk medication – two nurses complete independent check of dose, type, and timing

• Subcutaneous (most common)

• IV: Regular insulin only

• Use insulin syringes ONLY

• Do not substitute with TB syringes

• Injection Sites

• Abdomen (preferred, fastest absorption)

• Also, Upper arm, Thigh, Buttocks

• Rotate sites

  • Prevents lipohypertrophy (fatty lumps in tissue)

Storage

• Unopened insulin: refrigerate

• Opened insulin: can be at room temperature for up to 28 days (most manufacturers)

• Do not freeze

• Protect from heat and sunlight

• Check expiration date and appearance

  • Clear = should be clear

  • Cloudy = gently roll, do not shake

Major Risk

• Hypoglycemia

• Nursing Priorities

  • Check blood glucose before giving

  • Match insulin to meals

  • Know onset, peak, duration3

Insulin Categories and Information

Insulin Classifications (By Action)

• Rapid-acting: Lispro

• Short-acting: Regular

• intermediate-acting: NPH (Neutral Protamine Hagedorn)

• Long-acting: Glargine

Pre-mixed insulin is not covered in this course.
Key Concept

• All insulins have the same mechanism of action

• They differ by onset, peak, and duration

Insulin Timing Terms

• Onset: time until insulin begins lowering blood glucose

• Peak: time of maximum glucose-lowering effect

• Duration: total time insulin continues to work

Basal vs Bolus Insulin

• Basal insulin

  • Long-acting

  • Provides continuous background coverage

  • Controls glucose between meals and overnight

• Bolus insulin

  • Rapid- or short-acting

  • Given with meals

  • Controls postprandial glucose spikes

Medication Classification: Rapid Acting Insulin (Insulin Lispro)

Prototype: insulin lispro (liss-pro)

Indications: Given as a subcutaneous injection for the treatment of diabetes mellitus and work rapidly to lower blood sugar. Used as a corrective (bolus) insulin due to rapid onset.

• Onset: 5 – 15 minutes

• Peak: 1 – 2 hours

• Duration: 3 – 5 hours

Mechanism of Action: Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat.

Side Effects: Injection site redness and swelling, small bruise at injection site.

Adverse Effects: hypoglycemia, rebound hyperglycemia (Somogyi effect)

Nursing Considerations: Hypoglycemia is most prevalent at the peak time of antidiabetic agents. Check blood glucose before administration. Never give rapid acting insulin without food available or if patient cannot tolerate food (nausea and vomiting).

Patient teaching: Sick days require close monitoring. Recognize signs and symptoms ofhyper and hypoglycemia and be aware of self-treatment. Long-term effects of poor glycemic control include neuropathy, nephropathy, retinopathy, stroke, and myocardial infarctions

Medication Classification: Short Acting Insulin (regular insulin)

Prototype: regular (reg-yu-ler) insulin

Indications: Given as a subcutaneous injection for the treatment of diabetes mellitus to lower blood sugar. Used as a corrective (bolus) insulin due to fast onset.

• Onset: 30 – 60 minutes

• Peak: 90 - 120 minutes

• Duration: 6 – 8 hours

Mechanism of Action: Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat.
Side Effects: Injection site redness and swelling, small bruise at injection site.
Adverse Effects: hypoglycemia, rebound hyperglycemia (Somogyi effect)
Nursing Considerations: This is the only insulin that can be administered intravenous (emergencies only). Hypoglycemia is most prevalent at the peak time of antidiabetic agents. Check blood glucose before administration.
Patient teaching: Sick days require close monitoring. Recognize signs and symptoms of hyper and hypoglycemia and be aware of self-treatment. Long-term effects of poor glycemic control include neuropathy, nephropathy, retinopathy, stroke, and myocardial infarctions

Medication Classification: Intermediate Acting Insulin (NPH)

Prototype: Neutral protamine Hagedorn [NPH] insulin

Indications: Given as a subcutaneous injection for the treatment of diabetes mellitus to lower blood sugar. Used to control glucose over time (basal insulin) and not corrective (bolus).

• Onset: 1 – 4 hours

• Peak: 4 – 8 hours

• Duration: 12 - 18 hours

Mechanism of Action: Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat.

Side Effects: Injection site redness and swelling, small bruise at injection site.

Adverse Effects: hypoglycemia, rebound hyperglycemia (Somogyi effect)

Nursing Considerations: Hypoglycemia is most prevalent at the peak time of antidiabetic agents. Check blood glucose before administration.

Patient teaching: Sick days require close monitoring. Recognize signs and symptoms of hyper and hypoglycemia and be aware of self-treatment. Long-term effects of poor glycemic control include neuropathy, nephropathy, retinopathy, stroke, and myocardial infarctions

Medication Classification: Long-Acting Insulin (glargine)

Prototype: Glargine

Indications: Given as a subcutaneous injection for the treatment of diabetes mellitus to lower blood sugar. Used to control glucose over time (basal insulin) and not corrective (bolus).

• Onset: 1 – 2 hours

• Peak: none

• Duration: ~24 hours

Mechanism of Action: Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat.

Side Effects: Injection site redness and swelling, small bruise at injection site.

Adverse Effects: hypoglycemia, rebound hyperglycemia (Somogyi effect)

Nursing Considerations: Hypoglycemia is most prevalent at the peak time of antidiabetic agents. Check blood glucose before administration. Cannot be mixed.

Patient teaching: Sick days require close monitoring. Recognize signs and symptoms of hyper and hypoglycemia and be aware of self-treatment. Long-term effects of poor glycemic control include neuropathy, nephropathy, retinopathy, stroke, and myocardial infarctions

Diabetes and Medication Interactions

Statins (HMG-CoA Reductase Inhibitors)r

• ↓ LDL, ↓ CV morbidity & mortality

• Slight ↑ blood glucose

• Benefit > risk in patients with diabetes

• ↓ MI and stroke risk

Corticosteroids - Endogenous (stress) or exogenous (medications)

• ↑ Hepatic glucose production

• ↑ Insulin resistance

• Can cause significant hyperglycemia

Thiazide Diuretics - Used for hypertension

• ↑ Blood glucose (dose-dependent)

• Common in patients with diabetes

Beta-Blockers

• May mask hypoglycemia symptoms (tachycardia, tremor)

• Non-selective beta blockers more than selective beta blockers

• Use with caution in insulin-treated patients

Nursing Consideration

• If blood glucose worsens → review non-diabetes medication list