1. Chapter 27 Drugs Used to Treat Diabetes and Thyroid Disease

2. Endocrine system is made up of glands (fig. 27-1 p. 338)
endocrine glands secrete hormones that affect other organs and glands
pancreas and thyroid gland are part of the endocrine system
diabetes is MOST common endocrine disorder, it involves the pancreas
hyperthyroidism and hypothyroidism are thyroid disorders

3. pancreas secretes insulin
Box 27-1 p. 338
diabetes is a disorder in which the body cannot produce or use insulin properly
insulin is needed for glucose to move from the blood and into the cells, cells need glucose for energy
pancreas secretes insulin
without enough insulin, sugar builds up in the blood, blood glucose (sugar) is high, cells do not have enough sugar for energy and cannot function
3 types of diabetes:
Type I
Type II
gestational

4. Type I: Type II: occurs often in: children, teens, young adults
diabetes cont…
Type I:
occurs often in: children, teens, young adults
pancreas produces little or no insulin, rapid onset
risk factors: family history, whites have higher risk than non- whites
Type II:
occurs at any age, persons over 45 at higher risk
pancreas secretes insulin, however the body cannot use it well, slow onset
frequent infections, wounds heal slowly, gum disease is common
risk factors: overweight, lack of exercise, hypertension, African Americans, Native Americans, Hispanics

5. Signs and Symptoms of Diabetes:
diabetes cont…
Gestational:
develops during pregnancy
usually goes away after baby is born
mother is at risk for Type II diabetes later in life
Signs and Symptoms of Diabetes:
being very thirsty
urinating often
feeling hungry or tired
losing weight without trying
having sores that slowly heal
having dry, itchy skin
losing feeling or tingling in feet
having blurred vision

6. diabetes must be controlled to prevent complications
blood sugars must be monitored daily or 3-4 x/day
Type I: treated with insulin therapy, healthy eating and exercise
Type II: treated with healthy eating and exercise, oral drugs, some need insulin
hyperglycemia: high sugar in the blood
hypoglycemia: low sugar in the blood
see table 27-1 p. 339, for causes, signs/symptoms of hypo and hyper- glycemia

7. Thyroid diseases
the anterior pituitary gland secretes thyroid-stimulating hormone (TSH).
TSH stimulates the thyroid gland to release hormones
Tri-iodothyronine (T3)
Thyroxine (T4)
Thyroid hormones regulate metabolism
imbalances in thyroid hormone production may interfere with:
growth/development
carbohydrate, protein, fat metabolism
temperature regulation
cardiovascular function
lactation
reproduction
goal for therapy: return person to normal thyroid state
**BOX 27-2 discusses hyperthyroidism and hypothyroidism**

8. Drug Therapy for Diabetes:
insulin required to control type I diabetes
if diet and exercise don’t control, oral agents are used to treat type 2 diabetes
many people with type 2 diabetes need insulin:
if it is not controlled with other measures
during increased physical and psychological stress, surgery, infection, and pregnancy are examples
goals for treatment:
normal blood glucose levels
fewer long-term complications from poorly controlled diabetes

9. Insulin hormone produced by the pancreas
insulin is needed for glucose to enter skeletal muscles, heart muscle and fat, also needed for protein and lipid metabolism
pancreas secretes insulin at a steady rate
it is released in greater amounts when the blood glucose rises, such as after meals
insulin deficiency reduces rate of glucose transport into cells, this results in hyperglycemia

10. Delegation Guidelines
Drug Class: Insulin
Insulin is given parenterally- by subcutaneous or intravenous injection. Because you do NOT give parenteral dose forms, you do NOT give insulin. Should a nurse delegate the administration of such to you, you must:
-Refuse the delegation. Make sure to explain why. Do NOT just ignore the request. Make sure the nurse knows that you cannot give drug and why.
Some states allow MA-C’s to give insulin by the subcutaneous route or by inhalation. Exubera is an insulin inhalation powder. If you are allowed to give subcutaneous or inhaled insulin, make sure that:
you receive necessary education about the drug and dose form
you receive necessary education and training to perform skill correctly
a nurse is available to supervise you
a nurse is available to monitor how the drug affects the person

11. Promoting Safety and Comfort Drug Class: Insulin Safety: Insulin should not be allowed to freeze or be heated above 98°F, therefore its stored in refrigerator. Once opened, bottle is discarded in 30 days. After 30 days contents may not be sterile, microbes may grow in bottle. Pre-filled insulin syringes are stored vertically with the needle up. They are stored for up to 30 days. Having cold insulin injected is uncomfortable, therefore the agency may keep insulin at room temperature (68°-75°F). Insulin loses potency if kept above room temperature. For most refrigerated insulins, the bottle or syringe is gently rolled between the hands (not shaken) to warm and re-mix the insulin. Label directions must be followed

12. Assisting With the Nursing Process
Insulin:
**To assist nurse you need to understand the onset, peak and duration for type of insulin used (27-2 p ). You assist with the planning and implementation steps.
Onset: time required for the insulin to have an initial effect or action
Peak: when the insulin will have the greatest effect
Duration: the length of time that the insulin is active in the body
ASSESSMENT: measure blood glucose, note person’s activity level, note when and what the person eats
EVALUATION: report and record:
-signs and symptoms of hypoglycemia (see table 27-1), more likely to occur when insulin reaches its peak
-signs/symptoms of hyperglycemia (see table 27-1)
-itching, swelling, redness at injection site: these signal allergic reaction, tell nurse at once

13. Biguanide Oral Anti-Diabetic Agents:
anti-diabetic agents prevent or relieve the symptoms of diabetes
ie: metformin (Glucophage)
metformin decreases the amount of glucose produced by the liver, also decreases the amount of glucose absorbed by the small intestine
by improving sensitivity more glucose enters skeletal muscle cells and fat cells
drug is used alone or with other oral anti-diabetic agents

14. Assisting With the Nursing Process metformin (Glucophage):
ASSESSMENT: measure blood glucose, note person’s activity level, note when and what the person eats
PLANNING: oral dose forms are:
500, 850, 1000mg tablets
500 and 750mg extended-release tablets
500mg/5mL oral solution
IMPLEMENTATION: adult dosages:
initial dose is 500mg 2x/day with morning and evening meal
dosage is increased by adding 500mg to the daily dose each week, up to or 2500mg daily
most persons need at least 1500mg daily for desired effects
at dosages of 2000mg and more, one of the following is ordered:
-drug is given 3x/day: 1000mg with breakfast, 500mg with lunch, 1000mg with dinner
-850mg is given 3x/day with breakfast, lunch and dinner
EVALUATION: report and record:
-nausea, vomiting, anorexia, abdominal cramps, flatulence: usually mild and tends to resolve, take drug with meals to reduce side effects
-malaise, muscle pains, respiratory distress, hypotension: signal a build-up of lactic acid in blood

15. Sulfonylurea Oral Hypo-Glycemic Agents:
hypo-glycemic agents are drugs that lower the blood glucose level
sulfonylureas lower blood glucose by stimulating the release of insulin from pancreas
they reduce amount of sugar produced and metabolized by the liver
drugs used when pancreas can still secrete insulin, hypoglycemia may result if too much insulin is produced

16. Assisting With the Nursing Process
sulfonylureas:
ASSESSMENT: measure blood glucose, note person’s activity level, note when and what the person eats
PLANNING: see table 27-3 pg. 343 for “oral dose forms”
IMPLEMENTATION: : see table 27-3 pg. 343 for “Initial Adult Dose”, “Adult Dose Range”, “Duration”
EVALUATION: report and record:
-nausea, vomiting, anorexia, abdominal cramps: usually mild and tends to resolve
-signs and symptoms of hypoglycemia (see table 27-1)
-anorexia, nausea, vomiting, jaundice: may signal liver toxicity
-sore throat, fever, jaundice, weakness: may signal changes in red blood cells and white blood cells
-rash, itching: may signal allergic reaction: tell nurse at once, do not give next dose until approved by nurse

17. Meglitinide Oral Hypo-Glycemic Agents:
stimulate pancreas to secrete insulin
drugs used when pancreas can still secrete insulin
may cause hypoglycemia if too much insulin is produced
drugs used alone or with metformin
have short duration of action, this reduces risk of hypoglycemia

18. Assisting With the Nursing Process
meglitinides:
ASSESSMENT: measure blood glucose, note person’s activity level, note when and what the person eats
PLANNING: see table 27-4 pg. 344 for “oral dose forms”
IMPLEMENTATION: : see table 27-4 pg. 344 for “Daily Adult Dose” and “Maximum Daily Dose”, dose is given 1 minute to 30 mins before meals, doses taken 2-4x/day in response to changing meal times, skip a dose if meal is skipped
EVALUATION: report and record:
-nausea, vomiting, anorexia, abdominal cramps: usually mild and tends to resolve
-signs and symptoms of hypoglycemia (see table 27-1)
-anorexia, nausea, vomiting, jaundice: may signal liver toxicity
-sore throat, fever, jaundice, weakness: may signal changes in red blood cells and white blood cells
-rash, itching: may signal allergic reaction: tell nurse at once, do not give next dose until approved by nurse

19. Assisting With the Nursing Process
Thiazolidinedione Oral Anti-Diabetic Agents:
TZD oral agents make muscle and fat cells more sensitive to insulin, this lowers blood glucose levels
TZDs also may decrease the amount of glucose produced and released by liver
used when pancreas can still produce insulin
Assisting With the Nursing Process
TZDs:
ASSESSMENT: measure blood glucose, note person’s activity level, note when and what the person eats
PLANNING: see table 27-5 pg. 345 for “oral dose forms”
IMPLEMENTATION: : see table 27-5 pg. 345 for “Daily Adult Dose” and “Maximum Daily Dose
EVALUATION: report and record:
-nausea, vomiting, anorexia, abdominal cramps: usually mild and tends to resolve
-signs and symptoms of hypoglycemia (see table 27-1)
-anorexia, nausea, vomiting, jaundice: may signal liver toxicity
-weight gain: common to gain a few pounds, may be edema though

20. Alpha-Gluocosidase: Acarbose (Precose)
miglitol (Glyset)
Acarbose (Precose)
inhibits a pancreatic and GI enzymes used to digest sugars
this results in delayed glucose absorption and lowers hyperglycemia after eating
drug does NOT cause hypoglycemia
may be used with other oral anti-diabetic drugs

21. Assisting With the Nursing Process
acarbose (Precose):
ASSESSMENT: measure blood glucose, note person’s activity level, note when and what the person eats
PLANNING: oral dose forms: 25, 50, 100mg tablets
IMPLEMENTATION: : initial oral dose is 25mg 3x/day, given at start of each main meal, dosage is adjusted at 4-8 week intervals based on blood glucose levels. Maintenance dose is usually mg, 3x/day
EVALUATION: report and record:
-abdominal cramps, diarrhea, flatulence: usually mild and tends to resolve
-signs and symptoms of hypoglycemia (see table 27-1)
-anorexia, nausea, vomiting, jaundice: may signal liver toxicity

22. Assisting With the Nursing Process
Miglitol (Glycet):
ASSESSMENT: measure blood glucose, note person’s activity level, note when and what the person eats
PLANNING: oral dose forms: 25, 50, 100mg tablets
IMPLEMENTATION: : initial oral dose is 25mg 3x/day, given at start of each main meal, dosage is adjusted at 4-8 week intervals based on blood glucose levels. Maintenance dose is usually mg, 3x/day, maximum dosage is 100mg, 3x/day
EVALUATION: report and record:
-abdominal cramps, diarrhea, flatulence: usually mild and tends to resolve
-signs and symptoms of hypoglycemia (see table 27-1)

23. Drug Therapy for Thyroid Disease
2 classes of drugs are used to treat thyroid disease:
Thyroid replacement hormones: used for tx of hypothyroidism
Anti-thyroid agents: suppress the production of thyroid hormones

24. Delegation Guidelines Drug Therapy for Thyroid Disease Some drugs used to treat thyroid diseases are given parenterally. Because you do NOT give parenteral dose forms, you do NOT give insulin. Should a nurse delegate the administration of such to you, you must: -remember that parenteral dosages are often very different from dosages for other routes -Refuse the delegation. Make sure to explain why. Do NOT just ignore the request. Make sure the nurse knows that you cannot give drug and why.

25. Assisting With the Nursing Process Thyroid replacement hormones:
Hypothyroidism is treated by replacing the thyroid hormones T3, T4
Thyroxine (T4) is partially metabolized into T3
Therapy with T4 replaces both T3 and T4
Assisting With the Nursing Process
Thyroid replacement hormones:
ASSESSMENT: measure vitals, use apical site for heart rate, ask about bowel elimination, measure weight, observe for signs of hyperthyroidism (box 27-2)
PLANNING: see table 27-6 for “oral dose forms”
IMPLEMENTATION: see table 27-6 for “Adult Dosage Range”
EVALUATION: report and record:
- Signs and symptoms of hyperthyroidism (box 27-2)

26. Anti-Thyroid Drugs:
block formation of T3 and T4 in thyroid gland, they do not destroy any that already has been produced
once therapy is started it takes a few days to 3 weeks to notice improvement of symptoms
examples: propylthiouracil (PTU, Propacil)
methimazole (Tapazole)

27. Assisting With the Nursing Process
Anti-Thyroid Drugs:
ASSESSMENT: measure vitals, measure weight, observe for signs of hypothyroidism (box 27-2)
PLANNING: oral dose forms:
PTU: 50 and 100mg tablets
Tapazole: 5 and 10mg tablets
IMPLEMENTATION: PTU initial dose is mg every 6-8 hours, ranges up to 900mg/day, maintenance dose is usually 50mg 2-3x/day
Tapazole: initial dose is 5-20mg every 8 hours, maintenance dose is 5-15mg daily
EVALUATION: report and record:
rash, itching: often occur in first 2 weeks of therapy, usually resolve
headache, salivary gland and lymph node enlargement, loss of taste, usually mild and resolve
sore throat, fever, jaundice: may signal problems with blood cell production
anorexia, nausea, vomiting, jaundice: may signal liver toxicity
decreased urine output, bloody or smoky-colored urine: may signal kidney toxicity