1. The Endocrine System

2. Different hormones, different signals Anterior pituitary Thyroid gland TSH Thyroid hormones Negative feedback - + Hypo- thalamus Water absorption ADH osmolality Negative feedback - + Pancreas Liver, fat & muscle Insulin Glucose Negative feedback - + Para- thyroids Bone, GIT & Kidney PTH calcium Negative feedback - +

3. Growth Hormone Release of GH is stimulated by the release of GHRF secreted by the hypothalamus GH is inhibited by –Glucocorticoids –Obesity –Depression –Progesterone –Hypokalemia –Altered thyroid function

4. Hormones of pituitary gland

5. Deficit of GH

6. Overproduction of GH

10. Posterior pituitary hormones

11. Synthetic Human Growth Hormones somatrem (Protropin) somatropin (Humatrope) Drug List

12. Growth Hormone The younger the patient at time of treatment the greater the height that may be achieved Little response is seen after age 15-16 in boys and 14-15 in girls

13. Thyroid Gland Produces hormones (T 3 and T 4 ) that stimulate metabolic activity of body tissues Hypothalamus and pituitary glands work together to release TSH TSH stimulates T 3 and T 4 release

14. Thyroid Hormone Feedback Loop Thyroid hormones build up in the blood Signals are sent to the hypothalamic- pituitary axis that adequate levels have been met TSH levels decrease

15. Feedback Anterior pituitary Thyroid gland TSH Thyroid hormones Negative feedback - +

16. Hypothyroidism Production of thyroid hormones is below normal Cretinism occurs in children at birth due to inadequate maternal iodine intake –Can cause mental retardation, thick tongue, lethargy, lack of response, short stature – can be corrected if treated

17. Primary and secondary disorders Primary Thyroid disease Secondary Thyroid disease

19. Hypothyroidism Symptoms Apathy Constipation Decreased heart rate Depression Dry skin, nails, and scalp Easy fatiguing Enlarged thyroid Lowered voice pitch Myxedema Puffy face Reduced mental acuity Swelling of eyelids Tongue enlarged and thickened Weight gain

20. Struma (goiter) and hyperthyroidism Hypothyroidism Thyrotoxicosis Thyrotoxicosis

22. Congenital hypothyroidism (physical and mental retardation – nanism - pygmy, idiotism

23. Causes of Hypothyroidism Autoimmune destruction of the gland Radioactive iodine therapy Surgical removal of the gland

24. Agents for Hypothyroidism levothyroxine, T 4 (Levothroid, Levoxyl, Synthroid) liothyronine, T 3 (Cytomel) liotrix (Thyrolar) thyroid (Armour Thyroid) Drug List

25. levothyroxine, T 4 (Levothroid, Levoxyl, Synthroid) Used for chronic therapy Can be cardiotoxic Alters protein binding of other drugs Should not switch brands once stabilized

26. levothyroxine Dispensing Issues Can be cardiotoxic; report any of the following: –Chest pain, increased pulse, palpitations, heat intolerance, excessive sweating Warning!

27. levothyroxine Dispensing Issues Look-alike and Sound-alike Drugs: –levothyroxine (thyroid replacement) –levofloxacin (antibiotic) Warning!

29. Hyperthyroidism Excessive thyroid hormone Most common cause is Grave’s disease Other causes: –Excessive exogenous iodine –Thyroid nodules –Tumor in the pituitary causing overproduction of TSH

31. Symptoms of Hypterthyroidism Decreased menses Diarrhea Exophthalmos Flushing of the skin Heat intolerance Nervousness Perspiration Tachycardia Weight loss

32. Agents for Hyperthyroidism methimazole (Tapazole) propylthiouracil, PTU radioactive iodine, 131 I Drug List

34. Hypoglycemic Agents In the islets of Langerhans, in the pancreas, there are two primary specialized cells Alpha Cells –Produce glucagon and raise blood glucose levels Beta Cells

35. Hypoglycemic Agents In the islets of Langerhans, in the pancreas, there are two primary specialized cells Alpha Cells –Produce glucagon and raise blood glucose levels Beta Cells –Produce insulin and lower blood glucose levels

37. Insulin Helps cells burn glucose for energy Works with receptors for glucose uptake Enhances transport and incorporation of amino acids into protein Increases ion transport into tissues Inhibits fat breakdown

38. Insulin Administered subcutaneously due to degradation in the GI tract Different types of insulin have different onset of action times and duration of action times

40. Insulin Duration of Action TypeDuration of Action Humalog, Novolog 1 hr (works in 15 mins and gone in about an hour) Regular5-6 hours (onset – 30 mins) NPH10-16 hours Lente12-18 hours Lantus24 hours mixedQuick onset, longer duration

41. Insulin Dispensing Issues It is very easy to grab the wrong insulin in the refrigerator Always double-check yourself They look exactly alike Warning!

42. Insulin administration sites should be rotated

43. Hypoglycemia Blood glucose levels of <70 mg/dL Can be caused by –Skipping meals –Too much exercise –Poor medication regimen –Certain drugs

44. Signs & Symptoms of Hypoglycemia Confusion Double vision Headache Hunger Numbness and tingling in mouth and lips Nervousness Palpitations Sweating Thirst Visual disturbances Weakness

46. insulin glargine (Lantus) Synthetic long-acting insulin Absorbed slowly and works over a 24-hour time period Works similarly to physiologic insulin release

48. Human Insulins Mixtures insulin aspart w/ protamine-insulin aspart (NovoLog Mix 70/30) insulin lispro w/ protamine-insulin lispro (Humalog Mix 75/25) insulin with zinc (lente) (Humulin L) NPH-regular insulin (Humulin 70/30) Drug List

50. Oral Hypoglycemic Agents First- Generation Sulfonylureas chlorpropamide (Diabinese) tolbutamide Drug List

51. Oral Hypoglycemic Agents Second-Generation Sulfonylureas glimepiride (Amaryl) glipizide (Glucotrol, Glucotrol XL) glyburide (DiaBeta, Glynase, Micronase) Drug List

53. Oral Hypoglycemic Agents Enzyme inhibitors: acarbose (Precose) miglitol (Glyset) Biguanide: metformin (Glucophage, Riomet) Drug List

55. Oral Hypoglycemic Agents Combinations glipizide-metformin (Metaglip) glyburide-metformin (Glucovance) rosiglitazone-metformin (Avandamet) Drug List