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Drugs for Thyroid Disorders Chapter 58 1 Thyroid Hormone Actions Stimulation of energy use Stimulation of the heart Promotion of growth & development 2 Thyroid 3 Figure 58-2 Steps in thyroid hormone synthesis. 4 Hypothalamus – Releasing Factors 5 Figure 58-3 Regulation of thyroid function. 6 Lab Tests • Thyroid Stimulating Hormone is the best test of thyroid function • Except in the case of… 7 Thyroid Problems Hypo • Cold skin • Dry skin & hair • Low HR • Lethargy • Weight gain • Cold intolerance Hyper • Increased body temp • Skin warm & moist • Elevated HR • Nervous, insomnia • Weight loss • Increased appetite 8 Hypothyroidism • Severe deficiency of thyroid hormone – Myxedema (adults) – Cretinism (infancy) • Top Causes – Autoimmune (Hashimoto’s thyroiditis) – Iodine deficiency 9 Hypothyroidism (cont’d) • Therapeutic strategy – Levothyroxine (T4) – Liothyronine (T3) 10 Thyroid Hormone Preparations • Levothyroxine (T4) [Synthroid] – Synthetic preparation of thyroxine (T4) – Conversion to T3 – Half-life is 7 days – Used for all forms of hypothyroidism – Adverse effects can you anticipate what these might be? 11 Hypothyroidism (cont’d) • • • • Therapeutic goal? When to dose? When to recheck TSH? What happens to dosing in pregnancy? 12 Hyperthyroidism • Two major forms of hyperthyroidism – Graves’ disease (most common) – Toxic nodular goiter (Plummer’s disease) 13 Hyperthyroidism (cont’d) • Cause of Grave’s disease – Thyroid-stimulating immunoglobulins (TSIs) • Treatment – Suppression of thyroid hormone synthesis – Surgical removal of thyroid tissue – Destruction of thyroid tissue 14 Propylthiouracil (PTU) • Inhibits thyroid hormone synthesis • Short half-life (about 75 minutes) • Therapeutic uses – Graves’ disease – Adjunct to radiation therapy – Preparation for thyroid gland surgery • Adverse effects – Agranulocytosis – Hypothyroidism Caution in Pregnancy and lactation 15 Methimazole • • • • First line drug Inhibits thyroid hormone synthesis Is safer and more convenient than PTU Is contraindicated during pregnancy and breastfeeding 16 Radioactive Iodine-131 (131I) • Radioactive isotope of stable iodine • Emits gamma and beta rays • Half-life is 8 days • Used in Graves’ disease • Action – Produces clinical remission with destruction of thyroid gland 17 Exophthalmos & Goiter Which is hypothyroid and which is hyperthyroid? 18 Case A 25-year-old, previously healthy woman presents with 1 month of anxiety, palpitations, loose stools, fine tremors, and hair loss. 20-pound weight loss over past 4 months, increased appetite. HR 115 to 130 BPM, T 37.5C. Exam notable for mild bilateral proptosis, thin hair, and moist skin. Goiter visible with audible bruit. Hyperreflexia and fine tremors. EKG – normal sinus tachycardia. 19 Question When caring for a client in thyroid crisis (storm), the nurse would question an order for… • IV Fluids • Propranolol • PTU • Hyperthermia (warming) blanket 20 Question A client is prescribed Synthroid daily. The most important instruction to give her is… • Taper dose & dc if mental and emotional statuses stabilize. • Take it at bedtime to avoid side effects of nausea and flatus. • Call the doctor immediately at the onset of palpitations or nervousness. • Decrease intake of juices and fruits with high potassium and calcium contents. 21 Drugs for Disorders of the Adrenal Cortex Chapters 60 & 72 22 Physiology of the Adrenocortical Hormones • Three classes of steroid hormones – Glucocorticoids- cortisol – Mineralocorticoids- aldosterone – Androgens- androstenedione 23 Glucocorticoids—Physiologic Effects • • • • • • • • Carbohydrate metabolism Protein metabolism Fat metabolism Cardiovascular system Skeletal muscle Central nervous system Stress Respiratory system in neonates 24 Figure 60-2 Negative feedback regulation of glucocorticoid synthesis and secretion. 25 Adrenocortical Hormones • Mineralocorticoids – Circulatory balance – Retention of sodium (Na+) & water – Excretion of potassium (K+) 26 Physiology of the Adrenocortical Hormones • Two most familiar forms of adrenocortical dysfunction – Adrenal hormone excess • Cushing’s syndrome – Adrenal hormone deficiency • Addison’s disease 27 Cushing’s syndrome 28 Adrenal Hormone Excess • Cushing’s syndrome – Causes • Hypersecretion of adrenocorticotropic hormone (ACTH) • Hypersecretion of glucocorticoids • Administering glucocorticoids in large doses 29 Adrenal Hormone Excess (cont’d) • Cushing’s syndrome (cont’d) – Treatment • Surgical removal of the adrenal gland • Replacement therapy 30 Adrenal Hormone Insufficiency Addison’s disease Primary Adrenocortical Insufficiency – Causes - most often caused by autoimmune disease Acute adrenal insufficiency (adrenal crisis) • Causes – Adrenal failure – Pituitary failure – Inadequate doses of corticosteroids 31 Adrenal Hormone Insufficiency Addison’s disease Symptoms • Hypoglycemia • Malaise • Loss of appetite • Reduced capacity to respond to stress Treatment • Rapid replacement of fluid, salt, and glucocorticoids • Hydrocortisone is the drug of choice – Increase in time of physiologic stress – 3x3 rule 32 Hydrocortisone • Synthetic steroid • Therapeutic uses – Adrenal insufficiency – Allergic reactions to inflammation to cancer • Adverse effects – Adrenal suppression – Cushing’s syndrome 33 Glucocorticoids Drug Physiologic dose Nonendocrine dose Hydrocortisone 20-25 mg Up to 240 mg (up to 800 mg in MS!) Prednisone 5-10 mg Up to 60-80 mg Dexamethosone .25-.75 mg Up to 9 mg Relative GC efficacy Relative MC efficacy See Table 7.2 34 Fludrocortisone [Florinef] • Potent mineralocorticoid • Therapeutic uses – Addison’s disease – Primary hypoaldosteronism – Congenital adrenal hyperplasia 35 Fludrocortisone [Florinef] • Adverse effects – – – – Hypertension Edema Cardiac enlargement Hypokalemia 36 Glucocorticoids in Nonendocrine Diseases • Glucocorticoid physiology – Metabolic effects – Cardiovascular effects – Effects during stress – Effects on water and electrolytes – Respiratory system in neonates Physiologic vs. Pharmacologic doses What is the difference? 37 Pharmacology of the Glucocorticoids • Effects on metabolism and electrolytes • Anti-inflammatory and immunosuppressant effects • Therapeutic uses in nonendocrine disorders – Rheumatoid arthritis – Systemic lupus erythematosus – Inflammatory bowel disease – Miscellaneous inflammatory disorders 38 Pharmacology of the Glucocorticoids (cont’d) • Therapeutic uses in nonendocrine disorders (cont’d) – Allergic conditions – Asthma – Dermatologic disorders – Neoplasms – Suppression of allograft rejection – Prevention of respiratory distress syndrome 39 Pharmacology of the Glucocorticoids (cont’d) • Adverse effects – Adrenal insufficiency – Osteoporosis – Infection – Glucose intolerance – Myopathy – Fluid and electrolyte disturbance – Growth retardation – Psychologic disturbances 40 Pharmacology of the Glucocorticoids (cont’d) • Adverse effects (cont’d) – Cataracts and glaucoma – Peptic ulcer disease – Iatrogenic Cushing’s syndrome 41 Pharmacology of the Glucocorticoids (cont’d) • Development of adrenal suppression – Exogenous vs. endogenous • Adrenal suppression and physiologic stress • Glucocorticoid withdrawal – Taper the dosage over 7 days – Switch from multiple doses to single doses – Taper the dosage to 50% of physiologic values – Monitor for signs of insufficiency 42 Question A nurse knows the clinical manifestations of a client with Addison’s disease include… •Weight gain •Hypertension •Melanosis •Hypotension •Hyponatremia 43 Question A nurse knows the clinical manifestations of a client with Addison’s disease include… • Weight gain • Hypertension • Melanosis • Hypotension • Hyponatremia 44