1. The Endocrine System
Consists of glands and other structures that produce hormones which are released into the circulatory system

2. The Endocrine System
Consists of glands and other structures that produce hormones which are released into the circulatory system
Regulation is established through hormones affecting target tissue

3. Regulation Homeostatsis is achieved through feedback mechanisms
Negative feedback – negates change to bring levels back to normal

4. Pituitary Gland
Regulates other endocrine glands as well as other body activities

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

7. Growth Hormone
Non-endocrine related disorders can also cause growth delay:
Intrauterine growth retardation, chromosomal defects, abnormal growth of cartilage or bone, poor nutrition, variety of systemic diseases

8. Growth Hormone
Deficiency of endogenous growth hormone causes growth retardation
Growth delay may be caused by
Family growth patterns, genetic disorders, malnutrition, systemic or chronic illness, psychosocial stress, or a combination of these
Endocrine deficiency, or problems with thyroxine, cortisol, insulin, or GH

9. 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

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

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

12. Thyroid Gland
Produces hormones (T3 and T4) that stimulate metabolic activity of body tissues
Hypothalamus and pituitary glands work together to release TSH
TSH stimulates T3 and T4 release

13. 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

14. Feedback - + Anterior pituitary Thyroid gland TSH hormones Negative

15. 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

16. Primary and secondary disorders
Thyroid
disease
Secondary

18. 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

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

20. Treatment for Hypothyroidism
Thyroid replacement therapy
Should not be used to treat obesity

21. Agents for Hypothyroidism
Drug List
Agents for Hypothyroidism
levothyroxine, T4 (Levothroid, Levoxyl, Synthroid)
liothyronine, T3 (Cytomel)
liotrix (Thyrolar)
thyroid (Armour Thyroid)

22. levothyroxine, T4 (Levothroid, Levoxyl, Synthroid)
Used for chronic therapy
Can be cardiotoxic
Alters protein binding of other drugs
Should not switch brands once stabilized

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

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

26. 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

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

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

31. Discussion
What are the treatment options for hyperthyroidism?

32. Discussion What are the treatment options for hyperthyroidism?
Answer: in children: surgery and hormone replacement; adults: surgery or medications

33. Diabetes/Hypoglycemic Agents
In the islets of Langerhans, in the pancreas, there are two primary specialized cells
Alpha Cells
Beta Cells

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. Diabetes Caused by inadequate secretion or utilization of insulin
Leads to excessive blood glucose levels
Normal: 100 mg/dL

39. Type I Diabetes Occurs most commonly in children and young adults
Average age of diagnosis is 11 or 12
Patients are insulin dependent and have no ability to produce insulin on their own
May be due to an autoimmune response
Type I accounts for 5-10% of diabetic population

40. Type II Diabetes Affect 80-90% of diabetics
Most patients are over 40 and more women than men are affected
Could be caused by insulin deficiency or insulin receptor resistance
Many of these patients are overweight and can treat their diabetes with weight loss

41. Gestational Diabetes Occurs during pregnancy
Increases risk of fetal morbidity and death
Onset is during the 2nd and 3rd trimesters
Can be treated with diet, exercise, and insulin
30-40% of women with gestational diabetes will develop type II in 5-10 years

42. Secondary Diabetes Caused by medications
Oral contraceptives
Beta blockers
Diuretics
Calcium channel blockers
Glucocorticoids
phenytoin
May return to normal when drug is stopped

43. Symptoms of Diabetes Frequent infections Glycosuria Hunger
Increased urination and nocturia
Numbness and tingling
Slow wound healing
Thirst
Visual changes
Vomiting
Weight loss, easy fatigability, irritability, ketoacidosis

44. Complications of Diabetes
Retinopathy leading to blindness
Neuropathy
Vascular problems can lead to inadequate healing which could lead to amputation
Dermatologic involvement
Nephropathy is the primary cause of end-stage renal disease

45. Lack of Insulin Activity
Diabetics cannot use glucose therefore their bodies metabolize fat
Gluconeogenesis is the formation of glucose from protein and fatty acids
Fatty acid is oxidized into ketones

46. Ketones Strong acids Cause the body pH to drop
Excreted in the urine or eliminated through respiration
Causes a fruity acetone smell on the breath that can be mistaken for alcohol

47. Treating Diabetes
Treatment consists of diet, exercise, and medications
Blood glucose monitoring must be done regularly throughout the day
Type II diabetics may be able to control the disease through diet and exercise alone

48. Treatment for Type II Lifestyle changes Oral monotherapy
Combination oral therapy
Oral drug plus insulin
Insulin only

49. General Treatment Guidelines
Attention to diet
Blood pressure control
Compliance with medications
Control of hyperlipidemia
Daily foot inspections
Increased physical activity
Recognizing hypoglycemia
Blood glucose testing
Monitoring in the Dr’s office
Patient education
Prompt treatment of infections
Setting goals

50. Drug for Lower Extremity Diabetic Ulcers
Drug List
Drug for Lower Extremity Diabetic Ulcers
becaplermin gel (Regranex)

51. 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

53. Insulin Duration of Action
Type
Duration of Action
Humalog, Novolog
1 hr (works in 15 mins and gone in about an hour)
Regular
5-6 hours (onset – 30 mins)
NPH
10-16 hours
Lente
12-18 hours
Lantus
24 hours
mixed
Quick onset, longer duration

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

55. Insulin administration sites should be rotated

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

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

58. Drug List Human Insulins NPH isophane insulin (Humulin N)
insulin aspart (NovoLog)
insulin glargine (Lantus)
insulin lispro (Humalog)
regular insulin (Humulin R)

59. insulin lispro (Humalog)
Rapid-onset insulin
Can be injected immediately before or after meals
May be used with a pump

60. insulin aspart (NovoLog)
Rapid-acting insulin analog
Each dose should be administered before meals
May be used with a pump

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

64. Human Insulins Mixtures
Drug List
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)

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

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

69. glipizide (Glucotrol, Glucotrol XL)
Taken with breakfast
Promotes insulin release from beta cells
Increases insulin sensitivity

70. glipizide Dispensing Issues
Warning!
Look-Alike and Sound-Alike Drugs
Glucotrol
Glucotrol XL

71. glipizide Dispensing Issues
Warning!
Look-Alike and Sound-Alike Drugs
glipizide (Glucotrol, Glucotrol XL)
glyburide (DiaBeta, Glynase, Micronase)

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

73. metformin (Glucophage, Riomet)
Decreases intestinal absorption of glucose and improves insulin sensitivity
Has an effect on serum lipid levels
Best candidates are overweight diabetics with high lipid profile

74. Oral Hypoglycemic Agents Glitazones/Thiazolidinediones
Drug List
Oral Hypoglycemic Agents Glitazones/Thiazolidinediones
pioglitazone (Actos)
rosiglitazone (Avandia)

75. pioglitazone (Actos) Depends on the presence of insulin
Liver enzymes should be carefully monitored
May be taken without regard to food

76. rosiglitazone (Avandia)
Increases insulin sensitivity in muscle and adipose tissue
Can be taken without regard to food

77. Oral Hypoglycemic Agents Meglitinides
Drug List
Oral Hypoglycemic Agents Meglitinides
nateglinide (Starlix)
repaglinide (Prandin)

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

80. Discussion
What does a diabetic have to be concerned with in relation to diet?

81. Discussion
What does a diabetic have to be concerned with in relation to diet?
Answer: Eating at the same time everyday; to limit sugar intake by reading package labels