Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Chapter 33 Adrenal Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Adrenal Gland Adrenal cortex Adrenal medulla Each portion has different functions and secretes different hormones Feedback process of hormone regulation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Adrenal Gland (cont’d) Adrenal medulla secretes catecholamines Epinephrine Norepinephrine Adrenal cortex secretes corticosteroids Glucocorticoids Mineralocorticoids (primarily aldosterone) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Adrenocortical Hormones Oversecretion leads to Cushing’s syndrome Undersecretion leads to Addison’s disease Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Adrenal Drugs Can be either synthetic or natural Many different drugs and forms Glucocorticoids Topical, systemic, inhaled, nasal Mineralocorticoid Systemic Adrenal steroid inhibitors Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Adrenal Drugs (cont’d) Glucocorticoids beclomethasone (several formulations) fluticasone propionate dexamethasone hydrocortisone (several formulations) cortisone methylprednisolone (Solu-Medrol) prednisone (Deltasone, Sterapred, Liquid Pred) prednisolone triamcinolone Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Adrenal Drugs (cont’d) Mineralocorticoid fludrocortisone (Florinef) Adrenal steroid inhibitor aminoglutethimide (Cytadren) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Mechanism of Action Most corticosteroids exert their effects by modifying enzyme activity Glucocorticoids differ in their potency, duration of action, and the extent to which they cause salt and fluid retention Glucocorticoids inhibit or help control inflammatory and immune responses Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Indications Wide variety of indications Adrenocortical deficiency Cerebral edema Collagen diseases Dermatologic diseases GI diseases Exacerbations of chronic respiratory illnesses, such as asthma and COPD Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Indications (cont’d) Wide variety of indications (cont’d) Organ transplant (decrease immune response) Palliative management of leukemias and lymphomas Spinal cord injury Many other indications Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Indications (cont’d) Glucocorticoids administration By inhalation for control of steroid-responsive bronchospastic states Nasally for rhinitis and to prevent the recurrence of polyps after surgical removal Topically for inflammations of the eye, ear, and skin Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question The nurse should teach a patient taking an oral corticosteroid to take the medication at what time? 8:00 am 12 noon 5:00 pm 8:00 pm Correct answer: A Rationale: Oral corticosteroids should be taken in the morning to minimize adrenal suppression. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Indications (cont’d) Antiadrenals (adrenal steroid inhibitors) aminoglutethimide (Cytadren) Used in the treatment of Cushing’s syndrome, metastatic breast cancer, and adrenal cancer Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Contraindications Drug allergies Serious infections, including septicemia, systemic fungal infections, and varicella However, in the presence of tuberculous meningitis, glucocorticoids may be used to prevent inflammatory CNS damage Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraindications (cont’d) Cautious use in patients with Gastritis, reflux disease, ulcer disease Diabetes Cardiac/renal/liver dysfunction Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Adverse Effects Potent effects on all body systems Cardiovascular Heart failure, cardiac edema, hypertension—all caused by electrolyte imbalances (hypokalemia, hypernatremia) CNS Convulsions, headache, vertigo, mood swings, nervousness, insomnia, “steroid psychosis,” others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient is receiving prednisone as part of treatment for severe arthritis. He is also receiving furosemide (a loop diuretic), levothyroxine (for hypothyroidism), and a proton pump inhibitor and antacid (for gastroesophageal reflux disease [GERD]). Which drug does the nurse identify as most likely to be a concern during the therapy with prednisone? Furosemide Levothyroxine Proton pump inhibitor Antacid Correct answer: A Rationale: Co-administration of a loop diuretic with a corticosteroid may result in hypokalemia because of the potassium loss caused by both drugs. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Adverse Effects (cont’d) Potent effects on all body systems Endocrine Growth suppression, Cushing’s syndrome, menstrual irregularities, carbohydrate intolerance, hyperglycemia, others GI Peptic ulcers with possible perforation, pancreatitis, abdominal distention, others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Adverse Effects (cont’d) Potent effects on all body systems Integumentary Fragile skin, petechiae, ecchymosis, facial erythema, poor wound healing, hirsutism, urticaria Musculoskeletal Muscle weakness, loss of muscle mass, osteoporosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Adverse Effects (cont’d) Potent effects on all body systems Ocular Increased intraocular pressure, glaucoma, others Other Weight gain Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question When administering aminoglutethimide (Cytadren) to a patient, it is most important for the nurse to monitor: serum electrolytes. cardiac enzymes. liver enzymes. arterial blood gases. Correct answer: C Rationale: Aminoglutethimide therapy may cause hepatotoxicity, so it is important to monitor liver enzymes. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Nursing Implications Perform a physical assessment to determine baseline weight, height, intake and output status, vital signs (especially BP), hydration status, immune status Obtain baseline laboratory studies Assess for edema and electrolyte imbalances Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Assess for contraindications to adrenal drugs, especially the presence of peptic ulcer disease Assess for drug allergies and potential drug interactions (prescription and over-the-counter) Be aware that these drugs may alter serum glucose and electrolyte levels Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Systemic forms may be given by oral, IM, IV, or rectal routes (not subcut) Prepare and administer according to manufacturer’s directions Oral forms should be given with food or milk to minimize GI upset Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) For topical applications, follow instructions about use and type of dressing, if any, to apply Clear nasal passages before giving a nasal corticosteroid Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) After using an orally inhaled corticosteroid, instruct patients to rinse their mouths to prevent possible oral fungal infections Teach patients on corticosteroids to avoid contact with people with infections and to report any fever, increased weakness, lethargy, or sore throat Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient is taking an inhaled corticosteroid for asthma. After the patient takes a dose of the inhaler, the nurse’s priority should be to: listen to the patient’s breath sounds. have the patient rinse his mouth with warm water. instruct the patient to cough and deep breathe. take the patient’s apical pulse for 1 minute. Correct answer: B Rationale: The patient should rinse his mouth with water immediately after taking an inhaled corticosteroid to avoid oral fungal infections and other oral irritations. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Patients should be taught to take all adrenal medications at the same time every day, usually in the morning, with meals or food Patients should not take with alcohol, aspirin, or NSAIDs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Sudden discontinuation of these drugs can precipitate an adrenal crisis caused by a sudden drop in serum levels of cortisone Doses are usually tapered before the drug is discontinued Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Monitor for therapeutic responses Monitor for adverse effects Copyright © 2014 by Mosby, an imprint of Elsevier Inc.