DRUGS ACTING ON THE ENDOCRINE SYSTEM

OVERVIEW:
The endocrine system
Basic structures and functions of endocrine system
glands that secrete different chemicals directly into blood.
These hormones travel throughout body to their target site to initiate their effect.
Structures of endocrine:
Pituitary
Thyroid
Parathyroid
Adrenals
Pancreas
ANTIDIABETIC AGENTS
Diabetes Mellitus
Absence / severe decrease in insulin secretion
Types :
Type 1 IDDM
Absence of insulin production
patient dependent on insulin to prevent ketoacidosis & maintain life
Type 2 NIDDM
Insulin deficiency by defects in production
patient not dependent on insulin adm for survival
Replacement Insulin
Stimulates synthesis of glycogen from glucose, fats from lipids, proteins from amino acids
Indications:
DM Type 1 diabetics who require replacement insulin
DM type II
not respond to diet, exercise & oral agents
when blood glucose is elevated during periods of emotional or physical stress
When OHA is contraindicated such as during pregnancy
Types of Insulin
Rapid acting
Intermediate acting
Long acting

Fast Acting : Clear insulin

Humulin Regular
15-30mins
Humalog (Lispro)
5-10mins
Novolog ( Aspart)
5-10mins
Last :2-3hrs
Onset : 5- 30 mins
Peak : 30-90 mins / 2 4
Duration : 6 8
Intermediate Acting: cloudy
NPH
Humulin N
Lente
Monotard
Onset : 1 - 2
Peak : 6 - 8
Duration : 18 - 24

Long Acting : Cloudy

PZI/ Humulin U
Ultralente Onset : 3 - 4
Peak : 16 - 20
Duration : 30 36
Insulin Glargine (Lantus)
No peak
24hr acting
Not mix with other meds

Check expiration date

Use appropriate insulin syringe for insulin strength
When mixing HR & other insulin , draw up HR 1st ( clear before cloudy)
Anticipate use of insulin coverage ( stress, infection, exercise,SX, meds,etc)
Only HR may be given via IV
Multidose vials good for 1 month
Date & label insulin vials when newly opened
Observe for side effects:
Localized :
Induration or Redness
Swelling
Lesion at the site
Lipodystrophy
Complications of insulin TX
Hypoglycemia
Recheck FSBS/ CBG in 15mins
Lipodystrophy (tissues atrophy & hypertrophy)
Somogyi effect
Physiologic reflexrebound hyperglycemia in am (6am) from unrecognized
hypoglycemia
Hypoglycemia occurs @ 12 am -3am
TX: decrease insulin; increased bedtime snack
Usually with type 1
Dawn phenomenon
Nighttime release of GH >=hyperglycemia 5am-6am
Tx : more insulin for overnight period
Eg. NPH @ 10PM
Cautions:
Pregnancy , lactation
Allergy to beef and pork products
Interactions:
MAOI, Betablockers, Salicylates, alcohol = low glucose level
Thiazide diuretic, glucocorticoids, estrogen = up glucose levels
Nursing Care
Assess patients
Ensure diagnosis
Laboratory exams FBS, glycosylated Hgb (Hba1c)
Capillary blood glucose
Ensure proper Storage of Insulin
Store in a cool place away from direct sun light
Monitor patients
During times of trauma or severe stress
Glucose levels AC or 2 hours pc
Signs of hypo or hyperglycemia
Do not administer intermediate or long acting insulin during hyperglycemic emergencies
Treat hypoglycemic reactions:
with an oral form of rapid acting glucose
or with Glucagon SC
or IV glucose (D50%)

Oral Hypoglycemic Agents (OHA)

Sulfonylureas
1st generation
2nd generation
Non sulfonylureas
Alpha glucosidase inhibitor
Biguanide
Meglitinides
Thiazolidinediones
Sulfonylureas
Bind to K channels on pancreatic beta cells to up insulin secretion
Effective only in patients who have functioning beta cells
Give AC
Interactions:
Substances that acidifies urine (cranberry juice) = low drug excretion
Beta blockers = mask signs of hypoglycemia
First Generation:
Acetohexamide (Dymelor)
Chlorpropamide (Diabinase)
Tolazamide (Tolinase)
Tolbutamide (Orinase) Preferred for patients with renal problems
Second Generation:
safer to use on patients with renal disorders
do not interact with highly CHON bound drugs
Longer duration of action
Glimepiride (Amaryl)
Glipizide (Glucotrol)
Glyburide ( Micronase)

Nonsulfonylureas
Alpha glucosidase inhibitor
inhibits enzyme that breaks down glucose for absorption
Delays absorption of glucose, CHO
Mild effect on glucose level does not enhance insulin secretion
hepatotoxic
Acarbose( Precose)
Give @ start of meal
Miglitol (Glyset)
Biguanide
Decreases production, increases uptake of glucose
Effective in lowering blood glucose levels, does not cause hypoglycemia
Metformin (Glucophage) = GI s/s; with meals
SE: gas, diarrhea
Meglitinides
insulin release
Rapid onset/ short duration (4hrs)
Taken just before meals; give AC
Repaglinide( Prandin)
Nateglinide (Starlix)
Thiazolidinediones
Decreases insulin resistance; insulin agonist
Used in combination with sulfonylureas or metformin
Pioglitazone (Actos)
Rosiglitazone (Avandia)
Taken just before meals (AC)

New Med: OHA

Januvia (Sitagliptin)
Gliptins (DPP 4 inhibitors)
ninth class of antidiabetic meds
Concept of Action
dipeptidyl peptidase IV (DPP-IV) inhibitors (gliptins)
glucagon-like peptide (GLP) naturally occurring GI peptide
stimulates insulin secretion, suppresses glucagon levels, slows gastric emptying is rapidly
inactivated by DPP-IV.
(David M Nathan, N Engl J Med 2007 356: 437-440).

Adverse Effects
Hypoglycemia
GI distress : N/V, epigastric pain, discomfort, anorexia ,heartburn
Allergic skin reactions
Up risk of cardiovascular mortality
Particularly on first generation sulfonylureas
Metformin : metallic taste; diarrhea, gas
Acarbose : diarrhea, gas

Nursing Care
Assess patients blood glucose
Administer drug as prescribed in relation to meals
o Sulfonylureas give 30 mins before am meals
o Meglitinides immediately before meals
o Give metformin with meals
o Alpha-glucosidase inhibitors taken with the first bite of every meal
Monitor patients
Nutritional status
Blood Sugar
Compliance and therapeutic effect
Hypoglycemia
Liver enzymes q 2 months for the 1st year pioglitazone and rosiglitazone
During times of trauma or stress
Management of hypoglycemia
o Simple Sugars p.o.
5 mls. Pure honey / Karo syrup
3 4oz. regular soft drink
10 15 gms. CHO Hypoglycemia
3-4 oz. Fruit juice
o D50%W 20 50 mls / IV push
3-4 oz. skim milk
o Monitor BS
5 7 pcs. Lifesavers candies
o Patient teaching
3 pcs graham crackers
Causes
6 saltines
S & Sx
3 4 pcs. hard candies
Prevention
1 tbsp. Sugar
Management
Understand that the patient will need insulin during periods of increased stress
Teach the patient on how and when to monitor CBG
Glucose-Elevating Agents
o Diazoxide (Proglycem)- oral
Vascular effects : hypotension, headache, cerebral ishchemia, weakness, CHF and arrhythmias
Interactions: thiazide diuretics= up risk for toxicity
o Glucagon (Glucagen) SC
GI upset, N/V
Interactions: anticoagulants = up effect
o Pure Glucose, oral glucose tablets or gels ( Insta-Glucose)
o D50% IV
Monitor blood glucose
Have insulin on standby
Patient teachings
Thank You!
Developed by: Richmond M. Rivera
Prepared by: Mrs. Genecar Pe Benito, RN, MAN, CRRN
University of Santo Tomas-College of Nursing