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Chapter 20
Endocrine System Disorders
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives
Describing hormones and their functions.
Explaining how hormones secreted by
anterior and posterior pituitary glands affect
diseases and their treatment.
Describing the role of the thyroid gland and
its replacements and antagonistic
medications.
Discussing forms of steroids and
corticosteroids and their role in treating
disorders.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives (cont’d.)
Describing the role of antidiabetic agents and
adjunctive agents in treating diabetes mellitus
(DM).
Describing role of glucose and glycogen in
maintaining homeostasis.
Providing patient education for compliance
with medications used to treat diseases and
conditions of the endocrine system.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Endocrine Disorders: Common
Symptoms
 Mental deviations
 Exceptional changes in energy levels
 Growth abnormalities
 Skin, hair, nail changes
 Weakness and atrophy of muscles
 Emotional disturbances, psychological disorders
 Edema
 Changes in blood pressure with heart irregularities
 Sexual irregularities
 Changes in urinary output
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
Endocrine Disorder Medications:
Common Side Effects
Increased appetite, swelling
Palpitations, tremors, nervousness
Tachycardia, increased blood pressure,
headache
Hypoglycemia, nausea, heartburn, diarrhea
Changes in diet
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
5
The Endocrine System
Endocrine system is a network of glands that
secretes hormones necessary for body
functions directly into bloodstream
Hormones are carried by circulatory or
lymphatic system to tissues and other glands.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Major Endocrine Glands
Figure 20-1 The major endocrine glands of the body. (From Applegate E: The
anatomy and physiology learning system, ed 4, Philadelphia, 2011, WB Saunders.)
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Hormone-Receptor Action of
Hormones
Figure 20-2 Hormone-receptor action of hormones in the body. ACTH, adrenocorticotropin; ADH, antidiuretic hormone; FSH, follicle-stimulating
hormone; GH, growth hormone; LH, luteinizing hormone; OXT, oxytocin; PRL, prolactin; TSH, thyroid-stimulating hormone. (From Applegate E: The
anatomy and physiology learning system, ed 4, Philadelphia, 2011, Saunders.)
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Steroid Hormones
Hormones produced by adrenal cortex
Messenger agents—regulate inner
environment of body with nervous system
Steroid hormones regulate:
 vital processes
 production of energy
 extracellular fluid
 adaptation of body to external environment
 growth and development
 reproduction, lactation
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Hormones: Major Therapeutic Uses
Replacement therapy—replace lost
hormones to assist body in maintaining
homeostasis.
Large hormone doses may provide beneficial
results in cases of inflammation or arthritis.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Pituitary Gland Hormones
Pituitary gland: master gland regulating
endocrine system
Location of the pituitary gland. From Mosby’s Medical, Nursing, & Allied Health
Dictionary (2002) (6th ed). St. Louis: Mosby.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
11
Anterior Pituitary Gland
Growth hormone (somatotropin)—stimulates
growth of tissues and organs
 decreased production = dwarfism
 increased production = acromegaly, gigantism
 regularly measure patients on somatotropin
therapy for height and weight
 indicated for children deficient in GH, not simply
short
 GH can elevate blood glucose levels in diabetic
children
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
12
Anterior Pituitary Gland
Adrenocorticotropic hormone (ACTH)
Diagnostic testing is primary use; rarely used
therapeutically
Basal vital signs important when using ACTH
Notify physician of infection when taking ACTH
Patient should not stop taking ACTH abruptly
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
13
Anterior Pituitary Gland
Thyrotropin - (TSH)
 stimulates thyroid gland function
• increases uptake of iodine
• increases synthesis and release of thyroid hormones
• promotes thyroid growth
 used diagnostically to differentiate primary
hypothyroidism from secondary hypothyroidism
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
14
Posterior Pituitary Gland
Oxytocin
 active on reproduction system
 functions during labor and delivery
Antidiuretic hormone (ADH)—vasopressin
 works on urinary system by promoting renal
conservation of water
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
15
Thyroid Gland Hormones
Largest gland
Located in anterior neck
Two lobes on either
side of larynx
From Thibodeau GA, Patton KT (2003):
Anatomy and physiology (5th ed).
St. Louis, Mosby.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
16
Thyroid Gland Hormones
T3—triiodothyronine
T4—thyroxine
calcitonin
 T3 and T4 controlled by TSH
 T3 and T4 stimulate protein synthesis, increase
blood sugar levels, decrease serum cholesterol
levels.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
17
Goiter
Palpation of the thyroid gland in goiter.
From Lemmi FO, Lemmi CAE (2000): Physical assessment findings CD-ROM. Philadelphia:
Saunders.
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18
Thyroid Gland Hormones
Thyroid Replacement Therapy
TSH and T4 levels routinely measured to
evaluate thyroid function
Thyroid hormones treat hypothyroidism, not
obesity
Therapy starts with small doses; incrementally
increased until adequate response is reached
Long-term thyroxine use associated with
osteoporosis
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
19
Antithyroid Medications
Hyperthyroidism
Hypersecretion of thyroid hormones due to
tumors or Graves disease in most cases
 Symptoms include increased cell metabolism,
weakness, anxiety, heat production
Treatment may include antithyroid
medications, irradiation of thyroid gland,
surgical removal of tissue
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
20
Antithyroid Medications
Interfere with synthesis of thyroid hormones
Drugs—iodine, radioactive iodine, thioamide
derivatives
 side effects—rashes, nausea and vomiting,
stomach pain, myalgia, fever
Agents cross placenta and stop fetal
development
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
21
Calcitonin
Secreted by thyroid gland, but works with
parathyroid hormone to ensure adequate
supply of calcium.
Calcitonin salmon administered in nasal
spray as replacement for human calcitonin.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
22
Corticosteroids/Steroids
Adrenal glands located directly over each
kidney
Composed of two parts:
 cortex—outer portion
 medulla—inner portion
Cross section of the adrenal gland.
From Herlihy B, Maebius NK
(2003): The human body in
health and illness (2nd ed).
Philadelphia: Saunders.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
23
Corticosteroids/Steroids
Activated by ACTH from pituitary gland
Essential for life functions
 regulate water and salt
 regulate carbohydrate metabolism
 produce antiinflammatory effects
“Adrenocorticosteroids,” “corticosteroids,”
and “steroids” all refer to same substance
Mineralocorticoids and glucocorticoids are
both secreted by adrenal cortex
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
24
Adrenal Cortex Hormones
Glucocorticoids
Regulate metabolism of proteins and
carbohydrates
Reduce inflammatory and immune system
responses in many conditions
 arthritis, allergic disorders, asthma, cancer,
suppress organ transplant rejection
Excessive doses, long-term therapy can lead
to cushingoid symptoms or Cushings disease
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
25
Cushingoid Symptoms
Fatigue
Weakness
Edema
Pot belly
Buffalo hump
Excessive hair growth
Mood and personality changes
Psychological dependence
Cushings syndrome.
From Zitelli BJ, Davis HW
(2002): Atlas of pediatric
physical diagnosis (4th ed).
St. Louis: Mosby.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
26
Mineralocorticoids
Regulate blood levels of sodium and
potassium
Most important mineralocorticoid is
aldosterone
 acts on kidney to promote retention of sodium and
water, excretion of potassium and hydrogen
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
27
Administration Techniques with
Steroid Therapy
Can be administered orally, parenterally,
topically, by inhalation, or by local injection.
Given two different ways:
 alternate-day therapy—given every other day in
AM
 declining dosage—therapeutic dose given, then
tapered off (Dose-Pak)
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28
Pancreatic Hormones
Pancreas.
From Damjanov I, Linder J (1996): Anderson’s Pathology (10th ed.). St. Louis, Mosby.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
29
Drugs Used as Antidiabetic Agents
Insulin
Aids in utilizing glucose as energy
Stores excess glucose as glycogen in liver
Converts glucose to fat
Decreases blood glucose levels
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
30
Diabetes Mellitus
Disorder of carbohydrate metabolism
 insulin deficiency
 insulin resistance
Classic signs—polydipsia, polyphagia,
polyuria
Sixth leading cause of death in United States
Affects about 16 million Americans
90%–95% of cases are adult onset
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Diabetes Mellitus
Type I insulin-dependent diabetes mellitus
(T1DM) (formerly IDDM)
 Patients have little or no endogenous insulin;
require exogenous insulin to survive
 likely due to genetic abnormality
Type II: non-insulin dependent diabetes
mellitus (T2DM) (formerly NIDDM)
 usually mature onset, with patient having some
insulin function with low production or insufficient
secretions of beta cells
 can be result of aging, poor diet, or genetic factors
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
32
Diabetes Mellitus
Treatment
Dietary adjustment to limit carbohydrates
Consistent exercise
Drug control
Insulin
Oral hypoglycemics
Drugs affecting glucose absorption or
production
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
33
Hyperglycemia versus
Hypoglycemia
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34
Administration of Insulin in Type 1
Diabetes Mellitus
Requires SC injection.
Gastric juices destroy insulin.
Previously only pork and beef
insulin were available.
Today, insulin synthesized by
recombinant DNA
technology.
Insulin preparations vary in
time of onset of action, time
to peak action, duration.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
35
Insulin Peak Times
Figure 20-6 Peak times of various types of insulin.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
36
Administration of Insulin in Type 1
Diabetes Mellitus
Regular insulin is always clear.
Other insulins are cloudy because of added
precipitates.
Return precipitates to solution by rolling vials
or pens between hands.
Never shake or agitate insulin.
Store prefilled syringes vertically to prevent
clogging of needle with precipitate.
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
37
Insulin Delivery Systems
Traditional syringe and needle
Pens
Jet injectors—spray insulin through skin
without needle
Portable pumps—administer boluses or
concentrated medication amounts
Implantable pumps
Inhalation – nasal and pulmonary
Transdermal patch
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
38
Insulin and Other Drugs
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
39
Drugs Used as Oral Antidiabetic
Agents
Families of oral hypoglycemic agents:
 Sulfonylureas
 Glucose absorption inhibitors
 Biguanides
 Thiazolidinediones
 Metglitinides
 DPP-4 inhibitors
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
40
Drugs Used as Oral Antidiabetic
Agents
Sulfonylureas
first oral hypoglycemic agents
severe hypoglycemia often pronounced
unless strict diet is observed
become less effective after
10 years of use
believed to increase risk
of death from cardiovascular
disease
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
41
Drugs Used as Oral Antidiabetic
Agents
Glucose Absorption Inhibitors
Delay absorption of carbohydrates by slowing
absorption of glucose in small intestines
Use alone or in combination with insulin
Adverse effects—flatulence, abdominal
distention, diarrhea
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
42
Drugs Used as Oral Antidiabetic
Agents
Biguanides
Lower cellular resistance to insulin
Do not cause hypoglycemia
Side effects—anorexia,
nausea
Not recommended for elderly
Glucophage decreases liver production of
glucose but does not release insulin from
pancreas
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
43
Drugs Used as Oral Antidiabetic
Agents
Thiazolidinediones
Indicated in insulin-resistant patients
Avandia improves function of beta cells and
delays progression of diabetes
Side effects—headaches, edema, weight gain
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
44
Drugs Used as Oral Antidiabetic
Agents
Meglitinides
Stimulate the beta cells to release insulin
Short-acting medications
Can be used with injection insulin therapy
Repaglinide (Prandin) and nateglinide (Starlix)
typical medications
Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
45
Drugs Used as Oral Antidiabetic
Agents
DPP-4 Inhibitors
May be used alone or with metformin or the
thiazolidinediones
Less weight gain
Less hypoglycemia
Fixed doses
Typical medication – sitagliptin (Januvia)
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46
Other Injectables for Type 2 and
Type 1 Diabetes Mellitus
Incretin mimetics
 used to treat T2DM
 given subcutaneously twice a day
 typical medication – exenatide (Byetta)
 seems to cause weight loss
Synthetic human amylin
 given subcutaneously before meals and snacks
 cannot be given with other injectable
hypoglycemic preparations
 typical medication – pramlintide (Symlin)
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47
Hyperglycemic Agents
Elevate blood sugar level
Antagonists to insulin
Used to treat hypoglycemic reactions
Hypersecretion of insulin from pancreas in
pancreatic cancer
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48