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Endocrine
Definitions:
Stress Feedback
Adrenal Suppression oral gluc. Stop the release of CRH and ACTH which inhibts
the release of glucocort by the adrenals. IF give gluc. Long term ant pit gets lazy so
must TAPER dose! Prepare to give extra gluc. During times of stress. Withdrawl
(stop giving gluc): hypotension, hypoglycemia, fatigue
Pharmacologic high doses- high anti inflammatory and imuno suppressive actions
(thrush). Have little mineralocorticoid activity, don’t worry about Na , K loss.
Pharm- cross placenta and enters breast milk BAD. DRUG inter: Watch out for
DIGOXIN, loop diuretics, NSAIDS, vaccine. Don’t give if have fungal infection.
CAN give it anyway.
Tests
1. Fasting plasma glucose- at least 8 hrs after meal normal less than 100, if
greater 126 have diabetes.
2. Casual plasma glucose test anytime less than 200 and display signs
(polyuria, polydyspia, ketonuria and rapid wt loss).
3. Oral glucose tolerance- used when first 2 test were not definitive, give
gluc of 75 g and measure 2 hrs later normal less 140, diab. Above 200.
Limits: Want premeal 90-130. POstmeal below 180. Hg A1C below 7 percent- tests
for the past 3 months!
Insulin made by beta cells in pancreas. Aplha cells inhibit release of insulin.
Insulin stores glucose! Anabolic. If don’t have insulin then sugar just floats around.
Types of Insulin
- give before or right after meals, clear solution, require prescription. Don’t
give IV! Give in belly change injection sites (15-30 min onset).
Slower acting/ short duration- Regular only insulin given IV. Available without
prescription.
Long Duration- Glargine- clear, colorless, once daily sometimes twice. Less risk of
hyper/hypoglycemia. Req prescription. Don’t MIX.
Random Info:
-only one can mix is NPH with short acting insulin’s (r, lispro, asp, gluli). Draw short
acting insulin into syringe first to avoid contamination of NPH vial. Good for 28 days
room temp, 1 month in fridge. Insulin should be given sub Q abdomen (fast) and
upper arm, thigh (slowest). Not by mouth! Rotate injection sites to reduce
lipohypertrophy fat patch.
ONLY regular insulin can be given IV! All patient with type 1 diabetes get insulin.
Oral Hypoglycemic for Type 2 (to treat hyperglycemia), all side effects
hypoglycemia
Biguanide (metformin)- dec. glucose production by the liver and increase tissue
response to insulin. DOES NOT promote insulin release. (can be used for type 1).
Can be given alone or with sulfonylureas. Exctreted unchanged in kidneys CHECK
Creatnine clearance. Side effect- weight loss and lactic acidosis, life threatening.
Nausia! (careful those with CHF)
Hypoglycemia- below 50. Get from unaccostmed exercise, alcohol, diarrhea, Take
fast acting sugar.
Hypoglycemia
Glucagon produced by alpha cells in pancrease. Inc plasma levels of cglucose and
relaxes smooth muscle in GI. Prevent insulin! Elevates blood glucose levels following
insulin overdose. Promotes breakdown of glycogen. Given Sub Q and IV.
INJECTIBLES
Delays gastric emptying and suppress glucagon secretions. Also acts to inc sense of
satiety and can thereby lower caloric intake. Can be used in type one and type 2.
Makes feel full. Adverse: hypoglycemia. Give po drugs one hour bf injection bc it
slows motility.
Makes feel full, also slows gastric empyting. Dont give to pts with renal ds. Drug
interactions oral contraceptives and antibiotics.
Clinical Features
Is a feedback mechanism. High tsh level, more hypothyroid bc means not getting
feedback to tell ant pituitary to stop making TSH
Less TSH , feedback is in action had too much so tell ant pit stop maing TSH.
Hyperthyroid.
Thyroid function test- use serum TSH test.
Cardiovascular
Hypertension
Goals: maintain systolic <140 and diastolic <90 in stage 1 and 2. For patients with
diabetes target BP 130/80.
Normal 120/80
DRUGS
Sites of Action for Hyp *if beta blocker is used as needed its not for BP
Antihypertensive Drugs
Loop Diuretics- Furosemide highest diuresis used for pts that need great diuresis
than thiazide and pts with low GFR (thiazide wont work if GFR too low) big prob:
hyperkalemia
Sympathilytics
Beta Blockers less effective in blacks than whites. Slow down Heart.
Adverse: can mask hypoglycemia. Bradycardia. Dec Av conduction.If not selective
will cause bronchochonstriction
Dihydropyradines- (Nifedipine)
Ang. 2 rec blockers- ( losartan, ibersartan) same as ace inhibitor EXCEPT cough.
HTN first line drug: Thiazide, beta blockers, Ace inhibitors, CCB.
Stage 2: thiazide combines with beta Blocker, ace inhibitor CCB or ARB.
**if you give a vasodialtor give with beta blocker to prevent reflex tachycardia.
Special considerations: Renal dz. THiazide may not work in severe renal ds bc
low GFR so use loop dieretic. Targer BP 130/80
DIURETICS see page 445 all can cause Hypotension (higher up go more diuresis and
loss of K+)
K+ SPARING (at very end of kidney) mild diuresis advrs Hyperkalemia esp with
ACE
Nitrates- drug of choice for angina. Promotes vasodialtation. Can give most routes.
Dec angina pain. ADvrs: headache, hypotension, tachycardia. Let 8 hours pass of
drug free pd. ..transdermal patch.
Sublingual works fastest so if feel an attack take sublingual Nitrate. Sublingual only
good for a year, if opened only good for 3 months. Can take up to 3 doses 5 min
apart. Patch not for ongoing attack. RIGHT NOW- buccal, sublingual, spray.
Isosorbide mononitrate and dinitrate- same as NTG. Give PO. Amyl Nitrate- give for
acute episodes of angina pectoris.
Cardiovascular 2
CHF= a condition in which the heart can no longer pump enough blood to
the rest of the body.
*doesn’t allows have s/s of pulmonary or systemic congestion.
Stage B- no s/s but has structural heart dz, prob already had a heart attack. (LV)
TRT: same as stage A plus an ACE inh or ARB and a Beta Blocker is added for pts
with reduced ejection fraction, hx of MI or both.
Stage C: s/s and structural heart ds. Trt: diuretic, Ace in or ARB, BB, add digoxin if
Sx cant be controlled. If good renal function use thiazide if probs use loop. (can add
aldosterone anag only if good kindye function and normal K+. Avoid:
antidysrythmic, CCB’s, NSAIDS.
Remodling- change in size, shape or function of the heart after injury of the
ventricles.
Starling effect- more blood comes into the heart more blood is ejected from the
heart in systole. Heart will inc in size to pump harder.
The kidneys will sense that there is less blood flow, urine is dec and h20 is retained
not excreted. HF activates RAAS and ang 2 is released to constrict vessels have inc
venous and arterial pressure. If still low blood eventually lead to pulmonary and
peripheral edema and death.
Thiazide- hydrochlorothiazide- used for long term tx of HF, edema not bad.
Not as effective if GFR is low and cant be used if CO is low. AE: Hypokalemia, which
inc risk of digoxin induce dysrhythmias.
Drugs that inhibit RAAS help stop remodling., ACE inh, ARBS and Aldosterone
Antagonist
ARBS- same thing without the cough bc don’t increase kinin. First try ACE if get
cough switch.
BB- (carevidol, bisoprolol, metoprolol)- they improve left vent ejection and
PROLONG LIFE. Start does low so don’t reduce contractility too much.
Toxicity: stop digoxin and K+ wasting diuretics. MOniter serum K+. Give activated
charcoal or cholestyramine binds to digoxin and prevent absorption. S/S
dystrythmia, blurred vision, halos.
AE: NARROW THERAPEUTIC DRUG keep within .5-.8. Hypokalemia may need to
give K+ supplements or spirinolactone.
Drug interactions: diuretics bc cause K+ loss. ACE inh and ARBS inc K+ levels.
Sympathomimetic drugs (inc heart rate), quinidine, verapamil inc plasma levels.
DRUGS:
Class 1: Na+ channel Blockers: blocks Na channels slow impulse early on.(Quinidine,
procainamide, disopyramide,(strong anticholinergic) lidocaine (IV ONLY),
mexiletine, phenytoin), Flecainide, propafenone) adverse: thrombi
Class 2: Beta Blockers- reduce Ca+ entry, cardiac effects same as CCB’s. drugs:
propranolol, acebutolol, - both non selective beta 1 and 2 esmolol, sotalol, selec. Beta
1, Sotalol also blocks K+ channels. Used for life threatening.
Class 3: K+ channel blockers amiodarone (only for life threatening vent dys, don’t
take with grapefruit juice.), bretyllium , dofetilide, ibutilide, sotalol.
Class IV: CCBs: Verapamil and DIlitiazem ONLY DRUGS WORK DIRECTLY ON
HEART! Elevate digoxin levels, BB bc of inc bradycardia.
Other drugs: Digoxin, Adenosine (DOC for terminating paroxysmal SVT)
Coagulation- damaged vessel= platelets come, contact with collagen and platelets
are activated and form bridges, thromboxan A2, thrombim collagen PAF and adp
bind to fibrinogen.