Pharmacology Basics: Endocrine System Medication Part II
27
December

By Paul Henry / in , , /


This is part II to a lecture for endocrine
system medications. In this lecture we’re going to go over the pancreas, and
diabetes. So the pancreas is located in the abdominal cavity. It releases digestive
enzymes, and regulates blood sugar. It regulates blood sugar by the secretion
of insulin which brings the blood sugar down, and secretion of glucagon which
increases the blood glucose. Normally, blood glucose levels, they increase
slightly after you eat. When blood sugar rises, the cells in the pancreas release
insulin, causes the body to absorb glucose ,or in the blood, and lowers the
blood sugar back down to normal. So let me simply try to explain how the
body uses carbohydrate. So when you eat carbs, your body breaks them down
into simple sugars which are absorbed into the bloodstream. As the sugar levels
rise in your body the pancreas releases a hormone called insulin. Insulin is
needed to move sugar from the blood into the cells where the sugar can be used as
a source of energy. Hypoglycemia is caused by too little
glucose in the blood and can lead to death. If the patient has low blood
glucose, the cells don’t have enough energy to function to do.
You know, I think we’ve all gotten a little hypoglycemic at one time or
another when we haven’t eaten for a long time. Hypoglycemia can occur with prolonged fasting, missed meals, severe malnutrition,
or from strenuous exercise. You can be restless, shaky, and lethargic but if it’s
left untreated, hypoglycemia can cause seizures and coma. Hypoglycemia is
usually treated with a small dose of posts like hard candy, or orange juice with
sugar. Patients may carry an oral glucose preparation. You know, if they are
unconscious, they may be given injections of glucagon. So here’s the mnemonic;
cold and clammy need some candy. Diabetes mellitus is characterized by
hyperglycemia or high blood sugar. There’s type 1 and type 2. Type 1 is
insulin dependent diabetes. With type 1 there’s a substantial decrease or lack
of insulin. There’s also type 2 diabetes or non insulin-dependent diabetes. This
is when insulin is produced, but the glucose levels aren’t at the way they
need to be. You know, genetics, sedentary lifestyle, and obesity; these are major
contributing factors to non insulin-dependent diabetes mellitus. When sugar is high, the skin may be hot
and dry. Hot and dry, sugar’s high. Patients will also have increased
urination because the cells are excreting water to flush the glucose out
of the blood vessels into the kidneys. There’s also increased thirst because
the cells are dehydrated, and increased hunger may happen because of glucose in
the bloodstream and it’s not making it to the cells where it’s needed.
If hyperglycemia is not treated over time, body organs are affected. iI’s important
that our patients and we as allied health care professionals understand
this this. High blood sugar damages nerves, so vision will worsen and feet
can become numb. Wounds may not heal and kidney function can suffer.
Cardiovascular disease may also occur. Steady glucose levels can delay or
minimize these complications. If the blood sugar is extremely high, the
patient can develop ketoacidosis where there’s a burning of fat. This can
be a life-threatening condition. Insulin is required for type 1 diabetes.
They may also be given for individuals with type 2 if steady glucose levels
can’t be achieved with oral diabetic medications. There are many types of
insulin and it’s critical that the professional know the type of insulin
they are giving. You know the peak, onset, and duration of these types of insulin
can really vary and giving the wrong type or at the wrong time can be
detrimental to the patient. Rapid acting insulins or are your “logs” humalog
or novalog. Think of log, log, log, rolling down the hill. The generics are lispro,
and aspart. These insulin start working in about 15 minutes. Next there are short
acting insulin or regular insulin. These are usually prescribed on a sliding
scale and are administered before meals. A sliding scale means that the dosages
that’s given depends on the assessed blood sugar. Onset of regular insulin is
30 to 60 minutes peak is two to four hours and duration is five to seven
hours. Intermediate acting insulin or
intermediate- NPH , is usually mixed with other insulins to slow absorption by the
body. NPH is cloudy and appearance and this happens because the particles the
insulin are not fully dissolved. This insulin requires mixing which simply may mean rolling the insulin between your hands. This mixes the insulin without
creating a lot of bubbles. Long-acting insulin such as levemir or Lantus can
last up to a day or a day and a half. Glargine or Lantus should never be
mixed with another insulin. An insulin pump may be an option for patients with
a history of poor blood glucose control. These pumps are usually used with
short-acting insulin. A small needle is inserted subcutaneous, usually in the
abdomen, and the pump is hidden under the clothes. The pump delivers insulin 24
hours a day. Many times the pumps are adjusted to deliver different dosages
throughout the day and some of them have the option to give a bolus or an
additional dose to cover a meal or a snack. Knowledge of the handling of insulin is
important. It needs to be refrigerated until it’s opened. Refrigerating insulin
will extend the shelf life up to one or two years. Once insulin is opened, it has
to be kept at room temperature and discarded after it’s been open for a
month. You know, insulin is a protein dissolved
in water you can think of it like a soup broth like proteins, it can spoil. Keeping
it cold helps to keep it from spoiling. Bacteria growing in it, it will break
down the protein. This insulin will not poison you or make you sick but it won’t
work very well. You always want to label the container of insulin when you open
it with the time and the date. Also make sure you’re aware of the facility
guidelines for storage and expiration. If an injection is given with the insulin
at room temperature it will make injections less painful but my
experience is that insulin is usually kept refrigerated in most facilities.
When we administer insulin injections they are given subcutaneous always.
injection sites must be rotated scar tissue or abscesses can form and insulin
will not be absorbed if we don’t rotate sites. Rotation allows for even
absorption which in turn helps to maintain steady glucose levels. Sites
ideally should be used no more than one time a month and should be an inch away from
other sites. You know, insulin can be given IV and that’s usually your regular
insulin. Type two diabetes can be managed with
diet alone or with oral diabetic or anti hyperglycemic agents. These medications
work in different ways to control blood sugar. Some anti hyperglycemic drugs
encourage the pancreas to release insulin, while others encourage the liver
to tell the pancreas to release insulin. Other medications can cause
absorption from the intestine and lastly others can increase the sensitivity of
the muscle cells to insulin. You will see some medications listed as 1st or 2nd
generation. Whether a drug is 1st or 2nd generation is based on when they were
released. The second generation of anti- hyperglycemic medications tend to be
more potent and tend to be safer. We now have new incretin antagonist which we’ll
discuss in a moment. Incretin is a hormone that stimulates insulin after
you eat. So metformin is our most common oral
anti-diabetic medication. It’s in a class of its own called a biguanide. Metformin
whose brand name is glucophage, is our first line medication for the treatment
of type 2 diabetes. For side effects, I think of like the doctor’s like
metformin. So, like Like, L-I-K-E, first L is for liver. Metformin’s main site of action
is in the liver to reduce the excess of sugar where they seen a type 2 diabetic
patients. Also for L watch your patient for lactic acidosis. This is a buildup of
lactic acid in your blood which is very dangerous and usually fatal . The I is for
IV dye. This medication must be held if the patient is having an IV dye study
because it competes for the same receptor sites as metformin. K is for
kidneys. Metformin is eliminated by the kidneys and when a patient has poor
kidney function metformin can build and cause serious side effects like lactic
acidosis. Lastly E and that’s for E at. The main side
effect of metformin is diarrhea and stomach upset and cramping so it’s
important to take metformin with food to reduce stomach related side effects. There are some fairly new drugs that are
on the market now that are really exciting. These are called incretins.
So, what are those you might ask? Well, incretin again is a hormone released by
our gut. It stimulates the release of insulin after we eat and inhibits
glucagon secretion. Remember, glucagon brings sugar up. It also slows gastric
emptying and helps us feel full. Can you see the benefits of these medications
for diabetics? So GLP is an Incretn, which again is a
hormone that stimulates insulin release and inhibits glucagon after eating. These
medications and in “tide” T-I -D-E. Liraglutide or the brand-name Victoza is
a GLP agonist. Common side effects of these medications are nausea, vomiting,
and diarrhea. The patient must be assessed for pancreatitis. Signs for
pancreatitis are nausea, vomiting, and abdominal pain. This medication is a
daily injection. Patients should be taught proper administration and to not
mix this medication with insulin. Here’s another medication that works
with the incretins. Sitagliptin or Januvia. This is a DPP-4 inhibitor. DPP-4
is an enzyme that destroys the hormone incretin.
So again remember that the incretins encourage the release of insulin when
you eat. So if we keep the incretins around, there’ll be a decrease glucagon
concentrations and increased responsiveness of insulin released to
the glucose. The FDA though has issued a new warning about the possibility of
severe joint pain with these medications. It usually stops in about a month after
the medication is discontinued. Again we must assess our patients for
pancreatitis and also rash or Steven Johnson Syndrome. Cystic ffibrosis is a progressive genetic
disease that causes persistent lung infections and limits the ability to
breathe over time. In patients with cystic fibrosis, a defective gene causes
a thick buildup of mucus in the lungs, the pancreas and other organs. In the
lungs the mucus clogs the airways and traps bacteria leading to infections and
extensive lung damage and eventually respiratory failure. In the pancreas the mucus prevents the release of digestive enzymes that allow the body to
break down food and absorb vital nutrients. These individuals need to take replacement
enzymes such as Pancrelipase, which must be taken with food for a lifetime. Well this wraps up endocrine system
medications. If you have any questions make sure that you let me know,
write them down, bring them to class.


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