Endocrine System

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Endocrine System

• Chapters 21, 22, 23, 24, 26

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Endocrine System

• Endocrine system regulates essential activities
  of the body
• Metabolism of nutrients
• Reproduction
• Growth and development
• Adapting to change in internal and external
  environments

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Major Elements of Endocrine System

• Hypothalamus
• Pituitary gland
• Thyroid gland
• Parathyroid glands
• Pancreas
• Adrenal glands
• Ovaries
• Testes

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Local Tissue Hormones

• Endocrine like cells in the
• Gastrointestinal mucosa hormones that aid in
  digestion
• Kidneys erythropoietin hormone that
  stimulates bone marrow to produce RBCs
• White blood cells cytokines inflammation
• Body tissues prostaglandins and leukotrienes

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Tumors

• Specific tumors produce hormones
• Lungs - ACTH
• Kidney parathyroid hormones
• Elevation of these hormones would aid in
  diagnosing the tumors

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Endocrine System and Nervous System

• Closely connected
• Work together to regulate body function
• Main connecting link is the hypothalamus
  responds to nervous system stimulation by
  producing hormones

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What is the Endocrine System?

• Endocrine system is in charge of the body
  processes that happen slowly, such as cell
  growth.
• The nervous system has to do with the faster
  processes, like breathing and body movement.

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Hormones

• The bodies chemical messengers
• Different hormones circulate throughout the blood
  stream, but only affects the cells they are
  genetically programmed to receive and respond to
  the message.

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Hormone Pharmacokinetics

• Water soluble hormones, protein-derived hormones
  have a short duration of action and are
  inactivated by enzymes in liver and kidneys
• Lipid soluble hormones and thyroid hormones have
  a longer duration because they are bound to
  plasma protein they are broken down in the
  liver and excreted in bile or urine

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Water Soluble Hormones

• Do not enter the target cells form weak bonds
  with receptor sites on the cell membrane
• Sometimes called the second messenger
• Examples glucagon, adrenalin and parathyroid
  hormones

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Glucagon

• Has a major role in maintaining normal
  concentrations of glucose in the blood.
• Glucagon increased blood glucose levels

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Adrenalin

• Adrenalin or epinephrine is a hormone that acts
  as a neurotransmitter.
• Most well known hormone secreted by the adrenal
  glands.

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Parathyroid Hormone

• Four parathyroid glands about he size of a grain
  of rice.
• Thyroid and parathyroid glands do not interact
  with each other.
• Parathyroid gland regulated calcium in the body.
• Electrical energy for nervous system
• Electrical energy for muscular system
• Strength of skeletal system through storage of
  calcium

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Parathyroid Gland
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Lipid Hormones

• Two know types of lipid soluble hormones are
  steroids and thyroid hormones. Both travel over
  long courses of time via the blood stream and
  directly effect DNA functions.

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Steroid Hormones

• Androgens male sex organs, sperm production,
  muscle mass and human aggression
• Estrogen and Progesterone female sex organs and
  characteristics
• Mineralocorticoids water balance / sodium /
  potassium
• Glucocorticoids carbohydrate metabolism / immune
  function

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Cellular Response

• Up-regulation receptors may be increased if
  there are low levels of hormone
• Down-regulation hormones may be decreased when
  there are excessive amounts

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Hormone Disorders

• Abnormal secretion and function of hormones can
  impair physical and mental health
• Hypersecretion (too much)
• Hyposecretion (too little)

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What Can Influence Hormone Levels?

• Stress
• Infection
• Fluid balance
• Minerals in blood
• Structural changes in glands

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Glandular Hypofunction

• Congenital defect - infant
• Damaged or destroyed inflammation - tumor
• Atrophy of gland due to aging geriatric
  population
• Receptor defects in the gland
• Intracellular processes malfunction cellular
  level

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Hormonal Drugs

• Potent drugs that produce widespread therapeutic
  and adverse side effects
• Given when there is hypofunction of a gland

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Two Common Hormonal Drugs

• Pancreas dysfunction insulin needed to regular
  blood sugar levels
• Thyroid dysfunction
• hypothyroid conditions need replacement of
  hormone
• hyperthyroid may need to give medication that
  inhibits excess thyroid produced

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In a nut-shell

• With hormones the body needs a consistent amount
  to properly function too much or too little can
  be a problem

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Hypothalamic and Pituitary

• Chapter 22

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Pituitary Gland

• The pituitary gland is sometimes called the
  "master" gland of the endocrine system, because
  it controls the functions of the other endocrine
  glands. The pituitary gland is no larger than a
  pea, and is located at the base of the brain. The
  gland is attached to the hypothalamus (a part of
  the brain that affects the pituitary gland) by
  nerve fibers.

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Pituitary / Hypothalamic

• The pituitary gland is the Master gland of the
  body. The anterior and posterior pituitary
  secretes a battery of hormones that influence all
  cells and affect all physiological processes.

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Anterior Pituitary Gland

• Anterior pituitary gland
• Growth hormone
• Adrenal cortex ACTH glucocorticoids
• TSH thyroid stimulating hormone
• FSH follicle stimulating hormone ovary
  estrogen and progesterone
• LH - luteinizing hormone stimulates ovulation
• Prolactin breast tissue milk production
• Testosterone testes

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Medical Conditions

• Growth Hormone Therapy in pediatrics
• To stimulate secondary sexual characteristic in
  adolescents with delayed puberty
• Infertility
• Thyroid conditions

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Growth Hormone Deficiency

• In a child what do you think you might see?
• Height versus weight
• Growth curve
• What influences growth?
• How do you tell the drug is working?

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Posterior Pituitary Gland

• ADH antidiuretic hormone kidney regulates
  water balance
• Oxytocin uterus and breast labor and breast
  feeding

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Posterior Pituitary Dysfunction

• Desmopressin (DDAVP) or vasopressin synthetic
  ADH (antidiuretic hormone)
• Clinical Diagnosis diabetes insipidus
  characterized by high output of dilute urine
  can be idiopathic (do not know the cause) can
  occur after head trauma, with tumor of
  hypothalamus or posterior pituitary
• Importance of intake and output and specific
  gravity of urine (1.010 is normal)

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Intake and Output

• Why important?
• How besides urine output can a person lose fluid?
• Basic measures of intake and output mls or
  ccs

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Diabetes Insipidus
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Posterior Pituitary Hormone

• Oxytocin promotes uterine contractibility
• Clinical uses After delivery of infant and
  placenta in obstetrics.
• In small dosages to stimulate or induce labor in
  a pregnant woman
• When you will be doing your obstetrical rotation
  you will see oxytocin (Pitocin) given IV after
  delivery to help the uterus to contract.

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Ethical Consideration

• Abuse of Human Growth Hormone in athletes to
  improve performance older people in search of
  the fountain of youth
• Ovary stimulating drugs use to produce numerous
  ovaries to be artificially inseminated and
  implanted may lead to selective abortion of
  excess embryos after implantation

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Corticosteroids

• Chapter 23

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Corticosteroids

• Controlled by the hypothalamus
• Rate of secretion is kept within a very narrow
  range
• negative feedback mechanism when too much is
  released the mechanism for release shuts down
• Very important concept when we give steroid to a
  patient the higher plasma levels effectively
  shuts down the bodies production of the drug
  naturally this is a drug that cannot be
  abruptly stopped needs to be tapered

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Corticosteroids

• Produced by the adrenal cortex
• Involved in stress response, immune response and
  regulation of inflammation, carbohydrate
  metabolism, protein catabolism, blood electrolyte
  levels and behavior.

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Two Types

• Glucocorticoids anti-inflammatory
• Mineralocorticoids aldosterone controls
  electrolyte and water levels

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Uses of Corticosteroids

• Use to treat a number of different disorders
  especially inflammatory or immunologic disorders
• Arthritis
• Dermatitis
• Allergic reactions
• Asthma
• Hepatitis
• Lupus erythematosus
• Inflammatory bowel disease ulcerative colitis
  and Crohns disease
• Uveitis inflammation of eye

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Use in Orthopedics

• Cortisone can be injected directly into a joint
  to reduce inflammation
• Medrol dose pack is often prescribed for chronic
  back pain

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When not to use Corticosteroids

• Fungal infections thrush vaginal yeast
  infections
• Clients who are high risk for infection
• Diabetes
• Peptic ulcer
• Hypertension
• CHF
• Renal Failure

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How Administered

• Topical skin rashes - hydrocortisone
• Eye drops / ear drops cortisone ear drops or
  Prednisolone Ophthalmic suspension
• Nasal Nasonex
• Tablet or liquid form prednisone, Decadron
• IV methyl prednisone or Solu-medrol
• Inhaled - asthmatic or COPD

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Goals of Therapy

• To reduce symptoms to a tolerable level
• Total suppression of symptoms may require
  excessive dosages
• Avoid serious side effects

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Clinical Pearl

• Whenever possible the physician / nurse
  practitioner will prescribe a topical, nasal
  spray, eye drops or inhaled dosage before going
  to an oral route or intravenous route.
• Oral and intravenous routes are usually higher
  dosages and more likely to have side effects.

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Corticosteroids

• Pharmacology Classification corticosteroids
• Action suppress inflammation and the normal
  immune response.
• Adverse reaction and side effects depression,
  euphoria, hypertension, PEPTIC ULCER,
  THROMBOEMBOLISM, cushingoid appearance.

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Administration of PO Prednisone

• Take with meal or snack to decrease intestinal
  tract upset.
• Avoid consuming with grapefruit juice.
• If once a day dosing take in am before 9am.
• If more than once daily be sure to evenly space
  time medication is taken.
• In long term usage may need to take every other
  day in the morning so natural production is not
  totally suppressed.

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Inhaled Corticosteroids

• Used in asthma and COPD.
• Provided as an inhaled medication.
• Take daily in am.
• Rinse and spit after treatment to prevent thrush
  in mouth.
• Rinse mouth piece after use.

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Oral Thrush
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Side Effects

• Moon face, buffalo hump, obese trunk (love
  handles), acne, hirsutism, weight gain
• Impaired healing or bruising
• CNS nervousness, insomnia, depression,
  aggravation of pre-existing mental disorders
• Musculoskeletal long term use can cause
  osteoporosis, muscle weakness and atrophy
• GI peptic ulcer, increased appetite
• Cardiovascular fluid retention
• Ocular increased intraocular pressure, glaucoma,
  cataracts

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Moon Face
High-dose corticosteroid therapy produces a
characteristic moon face appearance.
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Before and After
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Thyroid Drugs

• Chapter 24

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Thyroid Gland
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Thyroid Gland

• Thyroid cells are the only cells in the body
  which can absorb iodine. These cells combine
  iodine and the amino acid tyrosine to make T3 and
  T4. T3 and T4 are then released into the blood
  stream and are transported throughout the body
  where they control metabolism (conversion of
  oxygen and calories to energy). Every cell in the
  body depends upon thyroid hormones for regulation
  of their metabolism.

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Hypothyroidism

• Primary infant born without a thyroid gland
• Secondary throiditis, tumor, destruction of
  thyroid tissue from radiation

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Hypothyroidism

• All newborns are tested at birth for thyroid
  function
• If untreated can lead to retardation due to
  effects on brain development

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Hypothyroidism - Adults

• Presenting clinical manifestations
• Weight gain
• Constipation
• Fatigue
• Irregular menstrual cycle in women
• Edema
• More common in females than males
• Common in Down Syndrome

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Hypothyroidism

• Laboratory value to look at
• TSH thyroid stimulating hormone will be
  increased - it is working hard to stimulate the
  production of T3 and T4
• T3 and T4 levels would be low

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levothyroxine

• Trade name drugs Synthroid, Eltroxin, Euthyrox,
  Levo-T, Levotabs, Levothroid
• Pharmacologic Classification hormone
• Action replaces the bodies natural thyroid
  hormone.
• Goals of treatment to keep TSH level between 0.3
  and 3.0 mIU/L.

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Synthroid

• Special considerations
• Take at the same time every day preferably in the
  morning.
• Take with a full (8oz) glass of water.
• Take on an empty stomach 30 to 60 minutes before
  eating.

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Synthroid

• Dietary considerations walnuts, dietary fiber,
  antacids, iron and calcium supplements may effect
  absorption.
• Drugs that may bind with Synthroid and reduce
  amount available
• antacids that contain aluminum
• Carafate (prescription ulcer medication)
• Questran (cholesterol lowering drug)
• ferrous sulfate (iron supplement)

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Hyperthyroidism

• Excessive secretion of thyroid hormone and
  usually involves an enlarged thyroid gland
• TSH levels would be low and the T3 and T4 high

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Over Activity of Thyroid Gland

• Body metabolism is increased
• Complaints of feeling hot
• Lose weight even though they are eating
• Fatigue at end of day but cant sleep
• Irritable and easily upset
• Trembling of hands
• Irregular heart beat (palpitations)

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Treatment of Hyperthyroidism

• Anti-thyroid Drugs goal is to prevent the
  thyroid from producing hormones.
• Two common drugs
• methimazole
• propylthiouracil (PTU)
• Both interfere with the thyroid glands ability
  to make its hormone.

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Treatment of Hyperthyroid

• Depends on the cause
• If thyroid is enlarged or tumor on thyroid
  surgery may be recommended

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Antidiabetic Hormone

• Chapter 26

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Insulin

• Protein hormone secreted by beta cells in the
  pancreas
• Average adult uses 40 to 60 units of insulin per
  day
• At the cellular level insulin binds with and
  activates receptors on the cell membrane of 80
  of body cells

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Pancreas

• The human pancreas is an amazing organ with two
  main functions 1 to produce pancreatic
  endocrine hormones (e.g., insulin glucagon)
  which help regulate many aspects of our
  metabolism and 2, to produce pancreatic
  digestive enzymes.

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What does the Pancreas Do?

• Pancreatic production of insulin, somatostatin,
  gastrin, and glucagon plays an important role in
  maintaining sugar and salt balance in our bodies
  and therefore any problem in the production or
  regulation of these hormones will manifest itself
  with problems with blood sugar and fluid / salt
  imbalances.

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Pancreatic Islets

• Pancreatic islets are scattered throughout the
  pancreas.  Like all endocrine glands, they
  secrete their hormones into the bloodstream.

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Insulin and Glucagon

• The human body wants blood glucose (blood sugar)
  maintained in a very narrow range.  Insulin and
  glucagon are the hormones which make this
  happen.  Both insulin and glucagon are secreted
  from the pancreas, and thus are referred to as
  pancreatic endocrine hormones.

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Blood Sugar Levels

• Normal range is from 80 to 100 mg / dL
• Levels between 100 and 126 mg / dL would be
  considered pre-diabetic type II
• Diabetes is typically diagnosed when fasting
  blood sugar is 126 mg / dL or higher

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A1C Laboratory Value

• Glycosylated Hemoglobin
• Normal less than 6.5
• Excellent 6.5 to 7.5
• Good 7.5 to 8.5
• Fair 8.5 to 9.5
• Poor greater than 9.5
• Video http//www.diabetesa1c.org/whatis_a1c.html

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A1C

• Studies have shown that overall good control of
  blood glucose in diabetes does correlate with
  decreased incidence of diabetic complications.

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Fasting Blood Glucose

• http//www.endocrineweb.com/diabetes/control.html
• Random testing done as a finger stick to
  determine blood glucose level.
• Fasting blood glucose done 3 hours after eating
  or after drinking a high calorie drink - often
  used to diagnose diabetes.

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Diabetes Mellitus

• Type I chronic disorder of childhood results
  from autoimmune disorder that destroys pancreatic
  beta cells
• Type II characterized by hyperglycemia and
  insulin resistance insulin is present but is
  not able to be used impaired insulin action at
  the cellular level

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Diabetic Complication

• Related to blood vessel disease
• Small blood vessels
• Eyes (retinopathy), kidneys (nephropathy), nerves
  (microvascular)
• Large blood vessels
• Heart and blood vessels coronary artery disease,
  stokes, lower extremity pain and impaired healing
  due to lack of blood flow (claudication)

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Insulin

• Insulin is the only treatment for diabetes type I
  pancreas does not produce insulin
• Insulin cannot be given orally because it is
  destroyed by the enzymes in GI tract
• Different types of insulin long term and short
  term
• Daily insulin injections need to be given Sub Q
  or by a pump short term or regular insulin
• Daily monitoring of blood sugar levels

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Goals in Treating Diabetes

• Controlling elevated blood sugar levels without
  causing unusually low levels

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Control of Diabetes

• Type I Insulin, exercise, and a diabetic diet
• Type II weight reduction, diabetic diet,
  exercise and oral hypoglycemic drugs

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Insulin

• Used in the treatment of type 1 diabetes
• Used in type 2 only when blood glucose levels
  cannot be controlled by diet, weight , loss,
  exercise and oral medication.

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Insulin Administration

• Administration needs to mimic the natural pattern
  of insulin secretion by a healthy pancreas.
• Home glucose monitoring and multiple insulin
  injections throughout the day.

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Short-acting Insulin

• Regular Iletin, Humulin R, Novolin
• (clear appearance)

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Intermediate Acting Insulin

• NPH Ilente II, Humulin N, Novolin N

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Long Acting

• Humulin U, Ultralente (cloudy appearance)

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How Given?

• Sub-Q injection
• Regular can be given by pump
• Always written in units and delivered in a
  syringe marked in units.

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Why do I need to know about insulin onset, peaks
and duration?

• Although you will not be giving sub Q insulin you
  will need to know if your patient is receiving
  insulin.
• Snacks and meal trays will need to be delivered
  in a timely manner
• Blood glucose finger sticks need to be monitored.
• Always know what the clients last blood glucose
  level was

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Hypoglycemic Episodes

• Shakiness
• Dizziness
• Sweating
• Hunger
• Headache
• Pale skin
• Sudden moodiness or behavior changes
• Confusion or difficulty paying attention
• Tingling sensation around the mouth

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What do you do?

• Give a simple sugar, glucose tablet, hard candy,
  or ½ cup of juice.
• Check blood glucose level

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Diabetes Type II

• Diet and exercise are key elements
• Most often client is overweight and leads a
  sedentary life style.
• BMI 30 or greater
• Go to http//www.cdc.gov/nccdphp/dnpa/bmi/
• and calculate your BMI or google (cdc BMI)

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Insulin Resistance

• Insulin resistance occurs when the normal amount
  of insulin secreted by the pancreas is not able
  to unlock the door to cells.  To maintain a
  normal blood glucose, the pancreas secretes
  additional insulin.  In some cases (about 1/3 of
  the people with insulin resistance), when the
  body cells resist or does not respond to even
  high levels of insulin, glucose builds up in the
  blood resulting in high blood glucose or type 2
  diabetes.

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Oral Hypoglycemic Drugs

• Used in Diabetes type II along with dietary
  management and healthy life style choices
  including exercise.

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Hypoglycemia Drugs

• 5 oral drug classifications
• Sulfonylureas Amaryl, Glucotrol, DiaBeta
• Alpha-glucosidase inhibitors Precose, Glyset
• Biguanide Glucophage, Glucophage SR
• Glitazones Actos, Avandia
• Meglitinides Starlix, Prandin

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Sulfonylureas

• Oldest and largest group of agents lower blood
  glucose by increasing secretion of insulin.
• Increase peripheral use of glucose and decrease
  production of glucose, increase number of insulin
  receptors.
• Can be used only when functioning pancreatic beta
  cells are present.

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Sulfonylurea 2nd and 2rd Generation

• Glucotrol XL second generation take once a
  day
• Amaryl third generation take once a day
  different in that it does not bind with protein
  carriers in the blood so it is not effected by
  other medications that do.

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Laboratory Values

• Do not take if Creatinine levels elevated
• Elevated Creatinine levels reflect kidney
  dysfunction
• Normal Creatinine Levels
• 0.6 to 1.2 mg / dL
• Infants my be as low as 0.2 mg / dL
• Geriatric population may have lower levels
• Muscular males may have slightly higher levels

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Alpha Glucosidase Inhibitors (Precose)

• Works in GI tract to delay digestion of complex
  carbohydrates into glucose.
• Does not cause pancreas to produce more insulin.
• Recommended when blood sugar levels are slightly
  elevated especially after eating.

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Cautions and Side Effects

• Contraindicated in clients with DKA, hepatic
  cirrhosis, inflammatory or malabsorptive
  intestinal disorders and severe renal impairment.
• Side effects are mainly digestive symptoms,
  bloating, diarrhea, and flatulence (gas).
• May need to cut down consumption of starches and
  carbohydrates in diet.

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Biguanide (metformin Glucophage, Fortamet)

• Reduces glucogenesis is the liver and as a result
  lowers levels of glucose in the blood.
• Tends to make cells more willing to absorb
  glucose.
• Anti-hyperglycemic does not cause hypoglycemia
• Often used in combination with sulfonylurea drugs

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Metformin (Glucophage, Fortamet, Glucophage XR,
Riomet)

• Most widely used of the biguanides
• Indication Management of type II diabetes
• Action Decreases hepatic glucose production.
  Decreases intestinal glucose absorption.
  Increases sensitivity to insulin.
• Therapeutic effect maintenance of blood glucose

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Contraindications and Side Effects

• Contraindications hepatic or renal disorders,
  pregnancy, cardiac or respirator insufficiency
• Side effects diarrhea, abdominal bloating,
  lactic acidosis muscle stiffness
• Dosing 500 mg twice a day up to 2000 mg / day if
  needed
• Lab consideration monitor A1C and serum glucose
  levels

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glitazones (Actos Avandia)

• New class of drugs to treat Diabetes type II
• First two drugs taken off the market
• Helps body to use available amount of insulin
  more effectively
• Increase plasma blood volume and may cause fluid
  retention and heart failure
• Takes a few weeks to work
• Cost about 100 a month

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Actos

• Indication management of diabetes type II. May
  be used in combination with sulfonyluria,
  metformin or insulin if desired effect not
  achieve by other drugs.
• Action improves sensitivity to insulin by acting
  at receptor sites involved in insulin
  receptiveness and glucose production and
  utilization.
• Therapeutic effect glycemic control without
  hypoglycemia.

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Contraindications and Side Effects

• Side effects weight gain, edema, severe loss of
  appetite, nausea and vomiting, yellow
  discoloration of eyes and tea or dark colored
  urine
• Contraindications heart failure and active liver
  disease

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Meglitinides (Starlix Prandin)

• Lower blood sugar by stimulating pancreatic
  secretion of insulin
• Well absorbed in GI tract peak plasma in 1 hour
• Decreases workload of pancreas
• Acts more like normal insulin
• Should be taken 30 minutes before meal
• Good for people who do not eat full meals or have
  a sporadic eating schedule

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Contraindications and Side Effects

• Can be taken in patients with impaired kidney
  function and with sulfa allergies
• Contraindication liver disease and diabetes type
  I
• Side Effects nausea and vomiting, muscle aches,
  joint pain, headaches

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Goals of Therapy

• To maintain blood glucose at normal or
  near-normal levels
• Promote normal metabolism of carbohydrates, fat
  and protein
• Prevent acute and long-term complications
• Prevent hypoglycemic episodes

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Management to Prevent Complications

• Angiotension-converting enzymes - ACE inhibitors
  to protect kidneys.
• Use of statins to reduce risk of occlusive
  arterial disease (cholesterol lower drugs)
• Aspirin therapy
• Smoking cessation