Endocrine Drugs

Week 8: Endocrine Drugs

• Quote from Varun Sharma: Connection between diabetes, hypertension, and kidney failure.

Etiquette

• Keep microphones muted unless speaking.

• Raise hand to speak.

Dosage Calculation Warm-Up

• Convert 2252 to standard time: 10:52PM

• Convert 08:41PM to military time: 2041

• Convert 3.7 grams to milligrams: 3700 milligrams

• Convert 0.12 micrograms to milligrams: $0.00012$ milligrams

• Convert 12 teaspoons to ounces: 2 ounces

  • 12 teaspoons * 5 ml/teaspoon = 60 ml

  • 60 ml / 30 ml/ounce = 2 ounces

• Convert 4.5 cups to ounces: 36 ounces

  • 4. 5 cups * 8 ounces/cup = 36 ounces

• Convert 44.7 pounds to kilograms: 20.3 kilograms $(\frac{44.7}{2.2} \approx 20.3)$ (rounded to the tenths place)

• Convert 7 pounds 3 ounces to kilograms: 3.3 kilograms

  • Ozs to lbs: $\frac{3}{16} = 0.1875$

  • Total lbs: $7.1875$

  • Lbs to kgs: $\frac{7.1875}{2.2} \approx 3.26 \approx 3.3$

Drug Label

• Brand name: Ryomet

• Generic name: Metformin

• Formulation: Oral solution

• Dosage: 500 mg/5 ml

• Total amount: 473 ml (16 ounces)

• Prescription only: Yes (Rx only)

Math Problem

• Order: Metformin 1500 mg PO q12 hours

  • What is available: $\frac{500mg}{5ml}$

  • Formula: Desired / Available * Quantity (D/H * Q)

  • $\frac{1500mg}{500mg} * 5 ml = 15$ ml

Med Rec Detective (Medication Reconciliation)

• Patient: 66-year-old man with CHF, asthma, and depression

Cyclobenzaprine

• Questionable due to patient's medical history.

• Drug class: Skeletal muscle relaxant.

• Indications: Muscle spasms, spasticity, chronic pain.

• Common side effect: Drowsiness.

Furosemide

• Agreed it makes sense the patient is on this drug.

• Drug class: Loop diuretic.

• Indication: Congestive heart failure, edema.

• Risk: Hypokalemia (f for falling potassium).

  • $K^+$ is decreased

Lisinopril

• Agreed it makes sense the patient is on this drug.

• Drug class: ACE inhibitor (ACE inhibitors end in pril).

• Indication: Congestive heart failure (decreases cardiac workload by blocking RAS).

• Risk: Hyperkalemia

  • $K^+$ increased.

Carvedilol

• Questionable due to asthma.

• Drug class: Nonselective beta blocker.

• Problem: Risk of bronchospasm in asthma patients (blocks beta-2 receptors).

• Should use a selective beta blocker.

• Indication: Heart failure (decreases cardiac workload by blocking sympathetic nervous system activity).

• Risks: Hypotension, bradycardia.

Albuterol

• Drug class: SABA (short-acting beta-2 agonist).

• Indication: Asthma (bronchodilator).

• Not an anti-inflammatory.

• Adverse effects: Tremors, tachycardia.

Salmeterol

• Drug class: LABA (long-acting beta-2 agonist).

• Problem: Black box warning: LABAs cannot be used without a steroid in asthma patients. Can increase risk of sudden death by masking symptoms.

• Adverse effects: Tremors, tachycardia.

Rivaroxaban

• Questionable; no clear indication in patient's history.

• Drug class: Anticoagulant (factor Xa inhibitor).

• Given for thrombotic issues.

• Adverse effect: Risk of bleeding.

Sertraline

• Makes sense based on history of depression.

• Drug class: Antidepressant (SSRI).

• Indication: Depression.

• Risk: Suicidal behavior in patients under 24. Serotonin syndrome.

Autonomic Nervous System Review

Sympathetic Nervous System

• Receptors: Adrenergic (alpha and beta).

• Drivers: Catecholamines (epinephrine and norepinephrine).

• Outcome: Fast and dry.

• Exception: Sweat glands activated.

Parasympathetic Nervous System

• Receptors: Cholinergic (muscarinic and nicotinic).

• Driver: Acetylcholine (ACH).

• Outcome: Slow and leaky; GI speeds up.

• Exception: Not diaphoretic.

Anticholinergic Drugs

• Cause sympathetic response.

• Block cholinergic receptors.

• Antimuscarinic.

• Memory trick: Can't see, can't pee, can't spit, can't poop - really fast and dry.

Cholinergics

• Cause parasympathetic effects.

• Pro-acetylcholine.

• Parasympathomimetics.

• Memory trick: Dumbbells - body gets really slow and leaky.

Sympathomimetics

• Cause sympathetic effects.

• Adrenergic agonists.

• Toxicity: Fast (hypertension, tachycardia, tachypnea, bronchodilation, pupils open).

• Cocaine is a sympathomimetic.

Sympatholytics

• Cause parasympathetic effects.

• Adrenergic antagonists.

• Central sympatholytics (e.g., clonidine).

• Toxicity: Slow (blood pressure drops, heart rate drops, respiratory rate drops, airways constrict).

Drugs for Low Blood Pressure

• Use sympathomimetics (e.g., norepinephrine).

Drugs for High Blood Pressure

• Use sympatholytics (e.g., beta blockers).

Drug Classes for Tonight

• Antidiabetic agents (hypoglycemics).

  • Injectable insulins.

  • Non-insulin injectables.

  • Oral hypoglycemic drugs.

• Hyperglycemics.

• Thyroid disease drugs.

• Synthetic hormones (growth hormone, antidiuretic hormone).
  *Corticosteroids are covered in week six so wont be repeated this week.

Insulin

Types of Insulin

• Rapid-acting (e.g., Lispro, glulisine, aspart).

• Short-acting (Regular human insulin).

• Intermediate-acting (NPH).

• Long-acting (Glargine, detemir).

Mechanism of Action

• Insulin produced by beta cells of pancreas.

• Normal job: Decreases blood sugar by pushing sugar into cells for energy.

• Anabolic: Promotes glycogenesis (creates glycogen from glucose).

• Insulin is like a key to unlock the cells.

• Bodybuilders use insulin for its anabolic effects.

• Basal insulin: Baseline level always circulating.

• Prandial spike: Increased insulin after a meal.

• Insulin controls blood sugar, it drops it.

Indications

• Diabetes mellitus (large discharge of sweet urine).

• Type 1 Diabetes:

  • Autoimmune destruction of beta cells.

  • Non preventable.

  • Etiology: Genetics + environment (viral illness).

  • Insulin key doesn't exist.

• Type 2 Diabetes:

  • Insulin resistance then reduced secretion from Beta cells malfunction.

  • Lifestyle driven.

  • Insulin key doesn't work.

• Complications: DKA (diabetic ketoacidosis), HHS (hyperosmolar hyperglycemic syndrome).

• Acute life threatening complications are those (DKA) HHS.

Contraindications/Cautions

• Hypoglycemia.

• Hypokalemia.

• Hepatic/renal dysfunction.

Interactions

• Increased insulin needs (antagonism):

  • Diuretics carry the greatest risk especially for prolonged amount of time, glucorticoids, levothyroxine, physiologic stress (increased counterregulatory hormone release).

• Decreased insulin needs (additive/synergistic):

  • Lifestyle modifications, oral hypoglycemic drugs, non-insulin injectables, and alcohol.

  • Alcohol: Decreases blood sugar by impairing glycogen release from the liver.

  • Glucagon directly antagonizes insulin.

• Beta blockers can mask the signs of hypoglycemia.

Administration and Assessment

• Physiologic insulin regimens (basal-bolus):

  • Mimics normal body function.

  • Longer-acting insulin as basal, quicker-acting as bolus (before meals).

  • We ideally do not want to give them sliding scale insulin.

• Non-physiologic regimens: Once or twice daily dosing.

• Fixed Dosing vs Non- Fixed Dosing (Sliding Scale):

  • Sliding scale dosing is bassed off pre meal blood sugar.

  • Sliding scale insulin is additional insulin you'd have to give on top of the fixed dosing to further correct any blood sugar problems

• Insulin is dosed in units.
  Example sliding scale for dosage on the quiz.

Rapid vs Short vs Intermediate vs Long Insulin Chart

• VERY testable information on this slide.

Chart

Notes on Table:

• Stars (*) indicate outliers.

Notes in Table:

• Mix Clear then Cloudy
  Agitate gently between palms resuspend the solution. (Rolling) Not shaking the vial. When drawing medication, inject air to inject cloudy NPH first.

Premixed or Combination Insulins:

Examples of pre-mixed and combination insulins.

Delivery Methods

• Vial and syringe: Inaccurate dosing.

• Insulin pens: Convenient.

• Jet injectors: Needle-free - not avail in us

• Insulin pump: Continuous infusion of insulin. It has a learning curve.

Storage

• Avoid freezing, direct sunlight, high temperatures (>86°F).

• Unopened insulin: Refrigerate until expiration date.

• Opened insulin: Room temperature, good for 28 days.

• Prefilled syringes:

  • One type of insulin: 28 days in refrigerator.

  • Two types of insulin: 7 days in refrigerator.

  • Store vertical, needle up.

  • Warm to room temperature before administration.

Giving Insulin

• Inspect drug label (concentration: U-100, U-200, U-300, U-500).

• Check blood glucose level.

• Use an insulin syringe (calibrated in units).

• Two nurse sign-off.
  *Rotate injection sites (abdomen, upper arms, thigh, buttocks) - to prevent lipodystrophy.

Therapeutic Effects

• Improved blood glucose control.

Adverse Effects

• Hypoglycemia.

  • Usually with 70. Hyopoglycemia kills you now. Hyper glycemia kills you later.
    Brain is affected.

• Hypokalemia. Low K.
  Insulin stimulate sodium potassium atpase pump, moving potassium into cells.

• Weight gain.

• Lipodystrophy. Damage to the tissue around site.
  Rotate Injection sites to prevent.

Somogyi Effect and Don phenomenon

*Rebound effect.
Remember s o (too much Insulin).
So you can check between two and four am so you can know.
Give bed time snack.
The treatment reduce knight shade insulin.

Down Insulin
They lack of Insulin. Lack of what is night time Insulin.

You may get or not hypthen.
Give or increase nick shade Insulin. Not bad times snacks.
This may happen just b

Patient Education Points

*Tell to the patient in a simple way.
*They don't care about medical lengo.

*Monitor blood glucose.
*Slinding scale.
*Carry snack.
*Diabetic ketocidoces.
*What is a red flag.
*Storage
*Keep fridge if unopened.
*Then room temp if has been opened.
*Dietary edition.
*signs and symptoms to what to be prepared if there are a signs and symptoms happening
*Excercise is necessary.

Non-Insulin Injectables

Examples

Amylin mimetics
Only pramlintide
Increateb mimetics.
Semaglutide that ozenpic.
Terzepatide mounjaro.

Mechanism of Action

Amylin Mimetics

Are synthetic Amylyn
Increase full full full
Satiety
The patient's lack of Emily secretion both type one and type two diabetes.

Incretin Mimetics:

Increase g o p 1 agonist.
They reduce and lower your blood sugar.
Incretin effect- incretin hormones released in response to food.

Contraindications/ Cautions

acute illness/procedures, gastroparesis, hepatic/renal dysfunction, pregnancy/breastfeeding

*Increased risk of thyroid cancer
Increasetin mimetics and thyroid cancer.
tumors in animals
Active pancreatitis
Increasen memecti

Interactions

Insulin
Oral hypoglycemia additive.
Beta blockers.
Increase the bleeding if that person is in anticoagulants. B/c It may interact. Increase. This
PO drug avoid a or or absorption problems avoid.

Metoclopramide
Metoclopramide for your to accelerate in the Gastric issue . Is

Administration and Assessment

Frequency schedule basis
reduce the side: they usually try to gradually to trade your dose, avoid fatty, state you all try today.

The rout SQ. Also, sametide and or

Adverse Side Effects

GI problems.
Injection said. To prevent the injection do rotating the injections.
Gallstones increase mimectics

Medication Math

A nurse is going to give .45% sodium chloride, 100 mill over 45 minutes. What's the Florida mill per hour? Round to the nearest whole number.
The order is for 100. Mls and 45 minutes.
. 75 hours.
Hundred divots in 75 + 1 33
. . . . Repeat.

A nurse is gonna give a pint with no % sodium chloride, 250 mm to infuse over 2 hours. The drop factor is 10. What comes to Florida and drug per million right in the nearest whole number
What two times 60 = 1 2
Then just do your 250 * 10/ What do you do = 20

Oral Hypoglycemics

Are prescribed.

Categories of Oral hypglycemics:

Biguanides: metformin
Sulfonylureas: glipizide and glimepiride
Maglitinides: repaglinide and nataglinide
Thiazolidinediones pioglitazone and rosiglitazone.
Alpha glucosidase inhibitors: acarbose and miglitol.
(DPP4) inhibitors sitagliptin linagliptin
(SGLT1) gliflozins - dapagliflozin and bexagliflozin

Mechanism of Action Orals:

Metformin increases insulin sentivity;
Reduces glucous production from your lever and increase of the glucose intestinal reabsortion;
Sulf increases insuln release from the pancreas;
Megl increases insulin from the pancrease;
The glita increase insulian sentivity;
Alpha decreases the absorcion of glucos in the intestine
SLGT 3 increased glucose in the excretion;
B decreases hepatic glucose production;
Decreass insulian from liver.
For the T2DM
Contraindicates to that

Contraindications and Cautions

Type 1
Inc. physiologic stress
inadequate caloric intake
hepatic/renal dysfunction
pregnancy/breastfeeding.
Metformin can't be administer if: 1) hepatic/renal dysfunction, 2) metabolic acidosis, 3) hospitalized, 4) getting procedures.

Interactions

Othe hypoglycemics with other adittives
Grape juice
The sulfo may bring other side effects.
Alcohol increases the risk of lactic acidosis.

Administration and Assessment

Do not crush or chew it if its the extended release.
Take medication after meal
If weird taste comes you my try with ment or drink more water
To discontinue when hospitalized
Tharpeutic side effects better control

Adverse effects

cancer a b c d can take side effects
lactic acidosis is a potential life threatening. Lactic acid means like any product and anaerobic repiratation, can increase because metformin, decreases the hapatic metabolism that is why the kideys needs to be working properly.
Liver and kidney is where it comes from the metabolism
Vitamin B12 deficiency
GI problems also you be careful with grapefruit juice and the p side effects
Always. Educate the patient
That a side. Note for
Those oral.

*Proper educate and rotate if there are adverse side effects and rotate if it is a injections.

The Hyperglycemics DRUGS: Glucagon

Where its produce and function

It is produced by the pancreas alpha
Is to increase blood sugar
It is catabolic which it opposes the
Counterulatory effect which it opposed the what is supposed to happen which that the increase of blood Sugar the insulin.
To be treat
It is used for episode of severe hypoglycemia cause it increase your blood sugar.
Increase your blood sugar by the liver.

Contraindicates and CAUTIONS:

hyper sensitivity if there are an alergic

Administration and Assessment:

May cause you to not have the basic A BC D.
IV or sub q if can be given at the hospital.
EMERGENCY KITS can given at home if there are an emergency.

The provider can may give it a time 2x every minute or one at one time and if after redose or time can give a secondary dose if there is still no
Effect on the patient.
The patient needs to be position in one side or lateral side to prevent them if may vomit. To be aspirate for them.
Give the patient a carbs so there will be no re bounds.
Meds to work for more. And the goal is to better the glucose. If not than will not a good good good sign

Thyroid Replacement Drugs: Levothyroxine

Mech. of Action TH drug replace TH hormone from the Thyroid

Synthtetic T4
T4 vs T3 TH differences:
T=Tyrosine. TH combine iodinge to this specific amino acid

Production of the t4 majority of 80%.
Is an inactive of the TH. Then to go periphally converted in T3.

The T3 20% is the active form of the TH
Which helps to deliver the target Cells/function properly.
Because is catabolic this helps with the thyroid process that helps in the weight process if this process does not happen then the individual start to gain the weight.

How this is used indications to the patient:

Hypothyroidism this is way of the most thing used. Or come that may show as
If it's not managed. Myxedema. The life threathenting condition. And they Will may required life time
For this medicine

Contraindications and Cuations:

TH may cause a.sympathetic drive which to a high heart rate
and a highthen of a.heart may cause some problems or risks if the patient's already heart conditions going on before. Osteperosis a weaking process
Adrinail insufficiency means an insufficient of cortisol. It help the body to be manage as the person's demands may be higher then expected,
TH may make the. Sugar hi which May lead it to the bad diabetic TH levels is the key to
Hebrew.
And may be cause high the body so needs to stay balanced and be watched on on TH . Is always best to not take meds as always .
Olest is because people use ir to loss weight.

Interations to DRUGS:

In a side note TH interact with so many drugs.
From these side notes we get that they all have a similar side effect:
That they affect the distribution. Which is is the protein bind. The.high the.more drug to have the effect.
It is important to the acidity is how it breaks and it absorbs.
Food this may also affect the absorption because of the things it has like:
fiber,Caffein or milk products

Administration and Assessment

In short when giving this drug the assessment need too still worry may have the ABCD.
given orally but hospital is iv as an exception to give the med right away and given schedule base at the empty tummy. to take TH at the night!

Goal Therapeutic side effects:

They improve the hipthorminism levels . The TH to work properly.
Because that this drugs can affect all those parts so is important to teach the side and symptoms such has
have the hypoglycemia what happened in the body.

The adverse effects:

May causethem the cancer.
The ABCD
As mentioned from the notes is the same side if is what is wanted then to make sure to know the basic
Side effects to it

Synthetic Hormones

• Somatrophin and Anti Diuretic Hormones.

The growth hormone analog: called