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Chapters 18, 19, & 21: Drugs for Osteoporosis and Hormonal Problems

Part 1: Women's Health & Osteoporosis

  • Copyright: 2022 by Elsevier Inc. All rights reserved.

Female Reproductive Functions

  • Female Sex Steroid Hormones:

    • Estrogens

    • Progesterone

  • Pituitary Gonadotropin Hormones:

    • Follicle-Stimulating Hormone (FSH)

    • Luteinizing Hormone (LH)

Estrogenic Drugs

  • Types of Estrogens:

    • Conjugated Estrogens: Premarin

    • Esterified Estrogens: Estratab

    • Transdermal Estradiol: Estraderm, Climara, Vivelle

    • Estradiol Cypionate:

    • Depo-Estradiol

    • DepoGen

    • Estradiol Valerate: Delestrogen

    • Ethinyl Estradiol: Estinyl

    • Estradiol Vaginal Dosage Forms: Vagifem, Estrace Vaginal Cream

    • Estrone: Estrone Aqueous

    • Estropipate: Ogen, Ortho-Est

Estrogens: Indications

  • Used for Treatment or Prevention of Disorders Caused by Estrogen Deficiency:

    • Atrophic Vaginitis

    • Hypogonadism

    • Oral Contraception (with Progestin)

    • Uterine Bleeding

    • Vasomotor Spasms of Menopause (e.g., hot flashes)

    • Osteoporosis (treatment and prophylaxis)

    • Palliative treatment for Breast or Prostate Cancer

    • Ovarian Failure or Castration (removal of ovaries)

Estrogens: Contraindications

  • When Not to Use Estrogens:

    • Drug Allergy

    • Any Estrogen-Dependent Cancer

    • Undiagnosed Abnormal Vaginal Bleeding

    • Pregnancy

    • Active Thromboembolic Disorder or History

Estrogens: Adverse Effects

  • Common and Serious Effects:

    • Thromboembolic Events: Most Serious

    • Nausea: Most Common

    • Hypertension, Thrombophlebitis, Edema

    • Vomiting, Diarrhea, Constipation, Abdominal Pain

    • Photosensitivity, Chloasma

    • Amenorrhea, Breakthrough Uterine Bleeding

    • Tender Breasts, Fluid Retention, Headaches

    • Other Effects

Estrogens: Interactions

  • Medications Affecting Estrogen Effectiveness:

    • Decrease activity of Oral Anticoagulants

    • Decrease effect of Rifampin

    • Drug Interactions: St. John’s Wort, Tricyclic Antidepressants, Smoking

Estrogens: Overview

  • General Info:

    • Indicated for clinical conditions due to estrogen deficiency

    • Use lowest effective dose for symptom relief or prevention

Progestins: Mechanisms of Action

  • Effects of Progestins:

    • Induction of secretory changes in endometrium

    • Increases Basal Body Temperature

    • Thickens Vaginal Mucosa

    • Relaxes Uterine Smooth Muscle

    • Stimulates Mammary Tissue Growth

    • Feedback Inhibition of Pituitary Gonadotropins

Progestins

  • Common Progestins:

    • Hydroxyprogesterone: Hylutin

    • Levonorgestrel: Plan B

    • Medroxyprogesterone: Provera, Depo-Provera

    • Megestrol: Megace

    • Norethindrone Acetate: Aygestin

    • Norgestrel: Ovrette, Ovral

    • Progesterone: Prometrium

    • Etonogestrel Implant: Implanon

Progestins: Indications

  • Conditions Treated with Progestins:

    • Functional Uterine Bleeding from:

    • Hormonal Imbalance

    • Fibroids

    • Uterine Cancer

    • Primary and Secondary Amenorrhea

    • Adjunctive/Palliative Treatment for Certain Cancers and Endometriosis

Progestins: Indications (Continued)

  • Additional Indications:

    • Prevent Conception (with Estrogens)

    • Prevent Threatened Miscarriage

    • Alleviation of Premenstrual Syndrome Symptoms

Progestins: Contraindications

  • Contraindications Similar to Estrogens

Progestins: Adverse Effects

  • Common and Serious Effects:

    • Liver Dysfunction: Cholestatic Jaundice

    • Thrombophlebitis, Thromboembolic Disorders (e.g., PE)

    • Nausea, Vomiting

    • Amenorrhea, Spotting

    • Edema, Weight Gain or Loss

    • Others

Medroxyprogesterone (Provera, Depo-Provera)

  • Mechanism of Action:

    • Inhibits secretion of Pituitary Gonadotropins

    • Prevents Follicular Maturation and Ovulation

    • Stimulates Mammary Tissue Growth

    • Shows Antineoplastic Action Against Endometrial Cancer

Contraceptive Drugs

  • Definition:

    • Medications that prevent pregnancy

    • Most contain combinations of Estrogens and Progestins

Other Contraceptive Forms

  • Forms Available:

    • Long-acting Injectable Medroxyprogesterone

    • Transdermal Contraceptive Patch

    • Intravaginal Contraceptive Ring

    • Implantable Rods

Contraceptive Drugs: Mechanism of Action

  • Prevent Ovulation:

    • Inhibits release of Gonadotropins

    • Increases Uterine Mucus Viscosity

    • Leads to:

    • Decreased Sperm Movement and Fertilization of Ovum

    • Possible Inhibition of Zygote Implantation

Contraceptive Drugs: Other Drug Effects

  • Positive Effects:

    • Improve Menstrual Regularity

    • Decrease Blood Loss During Menstruation

    • Decrease Incidence of Functional Ovarian Cysts and Ectopic Pregnancies

Contraceptive Drugs: Interactions

  • Drugs Affecting Effectiveness:

    • Decrease Effectiveness:

    • Antibiotics: especially Penicillins and Cephalosporins

    • Barbiturates

    • Isoniazid

    • Rifampin

    • Reduced Effectiveness of:

    • Beta-blockers, Warfarin, Tricyclic Antidepressants, etc.

Uterine Stimulants

  • Definition:

    • Medications that alter Uterine Contractions

    • Uses:

    • Promote Labor

    • Prevent or Stop Labor

    • Postpartum: Reduce Risk of Hemorrhage

Uterine Stimulants (Additional Details)

  • Also Known As: Oxytocics

  • Examples:

    • Oxytocin (Pitocin):

    • Used to induce labor at full-term

    • Control postpartum bleeding

    • Other uses: promote lactation

    • Ergot Alkaloids:

    • Increase force and frequency of contractions

    • Used to prevent postpartum atony and hemorrhage

Uterine Relaxants: Tocolytics

  • Definition:

    • Used to prevent premature labor

    • Generally used after 20 weeks of gestation

Uterine Relaxants

  • Common Types:

    • Indomethacin:

    • Nonsteroidal anti-inflammatory agent

    • Inhibits Prostaglandin Activity

    • Nifedipine:

    • Calcium Channel Blocker

    • Inhibits Myometrial Activity

Uterine Relaxants (Continued)

  • When Other Treatments Fail:

    • Corticosteroids: Betamethasone or Dexamethasone

    • Promote lung maturity in the fetus at 24-34 weeks of gestation

Osteoporosis

  • Definition:

    • Characterized by low bone mass and increased fracture risk

    • Affects women primarily; 40% of women over 50 will develop osteoporotic fractures; 20% of men will also be affected.

Osteoporosis: Risk Factors

  • Factors Increasing Risk:

    • Ethnicity: European or Asian descent

    • Body Build: Slender

    • Early Estrogen Deficiency

    • Lifestyle: Smoking, Alcohol Consumption, Sedentary Lifestyle, Low-Calcium Diet

    • Family History

Drug Therapy for Prevention of Osteoporosis

  • Recommendations:

    • Calcium Supplements and Vitamin D for high-risk women, especially over 60

Drug Therapy for Osteoporosis

  • Types of Medications:

    • Bisphosphonates:

    • Alendronate (Fosamax), Ibandronate (Boniva), Risedronate (Actonel), Zoledronic Acid (Reclast)

    • SERMs:

    • Raloxifene (Evista), Tamoxifen (Nolvadex)

    • Hormones:

    • Calcitonin (Calcimar)

    • Teriparatide (Forteo): Stimulates Bone Formation

    • Denosumab (Prolia): Prevents Bone Resorption

Drug Therapy for Osteoporosis (Continued)

  • Mechanisms:

    • Bisphosphonates: Inhibit Osteoclast-Mediated Bone Resorption, enhance bone mineral density

    • SERMs: Stimulate Estrogen Receptors on Bone and Increase Density

    • Calcitonin: Directly inhibits Osteoclastic Bone Resorption

    • Teriparatide: Only drug stimulating bone formation, similar to Parathyroid Hormone

    • Denosumab: Monoclonal Antibody blocking Osteoclast Activation, administered every 6 months with calcium and vitamin D

Drug Therapy for Osteoporosis: Indications

  • Specific Indications:

    • Dyphosphonates: Prevention and treatment of osteoporosis in men and postmenopausal women, glucocorticoid-induced osteoporosis, treatment of Paget's disease

    • Raloxifene: Prevention of postmenopausal osteoporosis

    • Teriparatide: High-risk patients

Drug Therapy for Osteoporosis: Contraindications

  • Contraindications:

    • Bisphosphonates: Drug Allergy, Hypocalcemia, Esophageal Dysfunction, Inability to remain upright for 30 minutes after dosing

    • SERMs: Known allergy, pregnancy, Venous Thromboembolic disorders

    • Calcitonin: Drug Allergy to Salmon

    • Teriparatide: Drug Allergy

    • Denosumab: Hypocalcemia, Renal Impairment or Failure, Infection

Drug Therapy for Osteoporosis: Adverse Effects

  • Common and Serious Effects:

    • SERMs: Hot Flashes, Leg Cramps, Increased Risk of Venous Thromboembolism, Teratogenic Effects, Leukopenia

    • Bisphosphonates: Headache, GI Upset, Joint Pain, Risk of Esophageal Burns, Osteonecrosis of the Jaw, Severe Bone Pain

    • Calcitonin: Flushing, Nausea, Diarrhea, Reduced Appetite

    • Teriparatide: Chest Pain, Dizziness, Hypercalcemia, Nausea, Arthralgia

    • Denosumab: Infections

Alendronate (Fosamax)

  • Description:

    • Oral Bisphosphonate, first non-estrogen non-hormonal option for preventing bone loss

    • Indications: Prevention and treatment of Osteoporosis in men and postmenopausal women, treatment of glucocorticoid-induced osteoporosis

Raloxifene (Evista)

  • Description:

    • SERM for prevention of postmenopausal osteoporosis

    • Adverse effect: Hot Flashes

Nursing Implications

  • Common Assessments:

    • Baseline Vital Signs, Weight, Blood Glucose Levels

    • Renal and Liver Function Studies

    • History of Smoking

    • Assess for contraindications including potential pregnancy

Further Nursing Implications

  • Uterine Stimulants:

    • Monitor Mother’s Vital Signs and Fetal Heart Rate

    • Use Uterine Relaxants for Premature Labor between 20-37 weeks

Additional Nursing Implications

  • Bisphosphonates:

    • Ensure no Esophageal Abnormalities

    • Patients should remain upright for 30 minutes after ingestion

Administration of Bisphosphonates

  • Instructions for Patients:

    • Take upon rising in the morning with full glass of water, 30 minutes before eating

    • Important to sit upright for at least 30 minutes

Administration of SERMs

  • Instructions for Patients:

    • Discontinue 72 hours before and during prolonged immobility

Part 2: Men's Health

  • Copyright: 2022 by Elsevier Inc. All rights reserved.

Androgens

  • Definition:

    • Male sex hormones primarily Testosterone

    • Functions:

    • Normal development of primary and secondary male sex characteristics

    • Development of Bone and Muscle Tissue

    • Inhibition of Protein Catabolism

    • Retention of Electrolytes

    • Stimulation of Blood Cell Production

Anabolic Steroids

  • Characteristics:

    • Promote tissue synthesis and increase formation

    • Controlled Schedule III drugs with potential for misuse by athletes

    • Examples: Oxymetholone (Anadrol-50), Oxandrolone (Oxandrin), Nandrolone (Deca-Durabolin)

Anabolic Steroids: Approved Indications

  • Uses:

    • Adjunctive therapy for weight gain post-surgery, trauma, chronic diseases, anemia, hereditary angioedema, metastatic breast cancer

Anabolic Steroids: Misuse Potential

  • Concerns:

    • Common in bodybuilding and weightlifting

    • Serious Consequences: Sterility, Cardiovascular Diseases, Liver Cancer

    • Potential for Psychological and Physical Dependence

Androgen Inhibitors

  • Mechanism:

    • Block effects of Endogenous Androgens

    • Examples:

    • 5-Alpha Reductase Inhibitors: Finasteride, Dutasteride

5-Alpha Reductase Inhibitors

  • Clinical Effects:

    • Immediate prostate shrinkage

    • May take up to 6 months for clinical effects

Alpha1-Adrenergic Blockers

  • Uses:

    • Symptomatic relief for BPH (Benign Prostatic Hyperplasia)

    • Examples: Doxazosin (Cardura), Tamsulosin (Flomax), Terazosin (Hytrin)

Drugs to Treat Erectile Dysfunction (ED)

  • Phosphodiesterase (PDE) Inhibitors

    • Used in ED treatment

    • First Oral Drug:

    • Sildenafil (Viagra): causes relaxation of smooth muscle and blood inflow

Other PDE Inhibitors

  • Examples:

    • Vardenafil (Levitra)

    • Tadalafil (Cialis)

    • Avanafil (Stendra)

Contraindications for Men's Health Drugs

  • General Contraindications:

    • Androgen-Responsive Tumors

    • PDE Inhibitors contraindicated with major cardiovascular disorders (especially with nitrates)

Adverse Effects of Men's Health Drugs

  • Common and Severe Effects:

    • Androgens: Fluid Retention, Thromboembolic Disorders, Heart Attack

    • Anabolic Steroids: Liver Issues, Severe Toxicities

Priapism

  • Definition:

    • Uncommon, prolonged penile erection

    • A medical emergency requiring urgent attention

Additional Adverse Effects of Men's Health Drugs

  • PDE Inhibitors:

    • Can cause unexplained visual loss

    • Finasteride:

    • Loss of libido, erectile dysfunction, hypersensitivity reactions

Drug Interactions for Men's Health Drugs

  • General Interactions:

    • Increase variations in anticoagulant activity

    • Risk of hypotension when combined with nitrates

Nursing Implications for Men's Health Drugs

  • Administration Instructions:

    • Follow exact instructions for all forms, including sublingual and oral

    • Transdermal patches have specific application instructions

Pregnancy Considerations

  • Safety:

    • Pregnant women should avoid handling crushed or broken hormone drugs

Part 3: Endocrine Drugs

  • Copyright: 2022 by Elsevier Inc. All rights reserved.

Endocrine System Overview

  • Main Goal: Physiologic stability

  • Influence: Every cell and organ affected by the endocrine system

Hormones

  • Definition: Chemical messengers in the bloodstream

    • Secreted into Bloodstream

    • Travel to specific sites of action

Neuroendocrine System: Pituitary Hormones

  • Components:

    • Hypothalamus: Part of CNS

    • Pituitary Gland: Anterior and Posterior sections

    • Govern all bodily functions with hormones and feedback loops

Negative Feedback Loop

  • Regulation:

    • Endocrine system monitored and regulated based on body’s needs

    • Hormone secretion commonly controlled by negative feedback loops

Anterior Pituitary Hormones

  • Hydrocortisone (Cortef): Definition and Effects

    • Drug form of Cortisol, anti-inflammatory effects

    • Promotes sodium retention, leading to edema, hypertension

  • Cosyntropin (Cortrosyn):

    • Stimulates cortisol release from adrenal cortex

    • Used in diagnosis of adrenocortical insufficiency

  • Somatropin and Somatrem:

    • Recombinant Growth Hormones

    • Stimulate skeletal growth in GH deficient patients

Posterior Pituitary Gland: Hormones

  • Vasopressin and Desmopressin:

    • Mimic Antidiuretic Hormone effect, increase water resorption in nephrons

    • Used to Treat Diabetes Insipidus

  • Vasopressin:

    • Potent vasoconstrictor for hypotensive emergencies

  • Desmopressin:

    • Increases Plasma Levels of Factor VIII, used in controlling nocturnal enuresis

Nursing Implications for Endocrine Drugs

  • General Instructions:

    • Monitor for therapeutic responses

    • Ensure patient safety and proper administration techniques

    • Report any severe or unusual symptoms immediately

Thyroid Disorders

  • Thyroid Gland Functions:

    • Secretes T4, T3, and Calcitonin for metabolism regulation

Hypothyroidism

  • Definition:

    • Deficiency in thyroid hormones classified by type (Primary, Secondary, Tertiary)

  • Common Symptoms:

    • Thickened Skin, Hair Loss, Constipation, Lethargy, Anorexia

Hyperthyroidism

  • Causes:

    • Diseases causing excessive thyroid hormones (e.g., Graves’ disease)

  • General Symptoms:

    • Increased Metabolism: Weight Loss, Increased Appetite, Muscle Weakness

Treatment of Hyperthyroidism

  • Methods:

    • Radioactive Iodine Therapy

    • Surgery for thyroid gland removal

    • Antithyroid Drugs (e.g., Methimazole, Propylthiouracil)

Thyroid Replacement Drugs

  • Common Drugs:

    • Levothyroxine (Synthroid), Liothyronine (Cytomel), Liotrix (Thyrolar)

Adverse Effects of Thyroid Replacement Drugs

  • Common Effects:

    • Cardiac Dysrhythmias, Insomnia, Weight Loss

Antithyroid Drugs: Nursing Implications

  • Cautious Use:

    • Assess for allergies, contraindications, monitor vital signs and weight

Thyroid Crisis (Thyroid Storm)

  • Definition:

    • Severe exacerbation of hyperthyroidism, life-threatening

    • Requires immediate assessment and intervention

Summary of Nursing Implications

  • Educate on medication adherence, importance of not stopping medications suddenly, and monitoring for adverse events.

Conclusion

  • Comprehensive understanding of drugs for osteoporosis, hormonal problems, and endocrine treatments is crucial for effective patient care. Regular monitoring and patient education are key components of care management.