Ppt chapter 48-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 48

Drugs Affecting Corticosteroid Levels

Chapter 48

Drugs Affecting Corticosteroid Levels


QuestionQuestion

• Where are the adrenal glands located?

– A. Brain

– B. Pancreas

– C. Liver

– D. Kidneys


Answer Answer

• D. Kidneys

• Rationale: The adrenal glands are located on top of the kidneys.


Physiology Physiology

• The hormones of the endocrine system are important messengers in the communication between cells.

• Two adrenal glands are located one at the top of each kidney. Each gland is composed of two distinct parts—the medulla and the cortex.

• The medulla and cortex are crucial to metabolism and fluid and electrolyte balances.

• The adrenal medulla synthesizes and secretes catecholamines.

• The adrenal cortex is involved primarily in the synthesis and secretion of glucocorticoids and mineralocorticoids.


PathophysiologyPathophysiology

• There are two forms of adrenal insufficiency—primary and secondary.

• Primary adrenal insufficiency (Addison disease) results from the destruction of the adrenal cortex caused by infection or hemorrhage.

• In secondary adrenal insufficiency, the deficiency of cortisol secretion is secondary to insufficient secretion of ACTH by the anterior pituitary.

• Cushing syndrome is a rare disorder resulting from increased adrenocortical secretion of cortisol, resulting in chronic elevation in glucocorticoid and adrenal androgen hormones.


Glucocorticoids Glucocorticoids

• The primary endogenous glucocorticoids produced by the adrenal gland are cortisol (hydrocortisone) and cortisone.

• They have no role in any systemic anti-inflammatory therapeutic regimen because of their high mineralocorticoid activity relative to their anti-inflammatory activity.

• All natural and synthetic glucocorticoids act by binding to a specific cytoplasmic glucocorticoid receptor.


Glucocorticoids (cont.)Glucocorticoids (cont.)

• A common adverse effect of synthetic glucocorticoids administered in high doses for anti-inflammatory and immunosuppressant effects (combined or separately) is suppression of the HPA axis.

• Abrupt discontinuation of a glucocorticoid following prolonged administration may result in acute adrenal insufficiency.

• Prototype drug: prednisone (Deltasone, Prednicot)


Prednisone: Core Drug Knowledge Prednisone: Core Drug Knowledge

• Pharmacotherapeutics

– Anti-inflammatory and immunosuppressive effects

• Pharmacokinetics

– Absorbed from GI tract. Metabolized: liver. Excreted: urine.

• Pharmacodynamics

– Primarily glucocorticoid activity, although some mineralocorticoid activity is present and more apparent when the drug is administered in high doses


Prednisone: Core Drug Knowledge (cont.)Prednisone: Core Drug Knowledge (cont.)

• Contraindications and precautions

– Hypersensitivity and systemic fungal infections

• Adverse effects

– Anxiety, mood swings, insomnia, headache, GI complaints, menstrual irregularities, hyperglycemia

• Drug interactions

– Interactions with drugs and laboratory studies


Prednisone: Core Patient Variables Prednisone: Core Patient Variables

• Health status

– Review history and medication use

• Life span and gender

– Pregnancy Category C drug

• Lifestyle, diet, and habits

– Assess the patient’s diet.


Prednisone: Nursing Diagnoses and Outcomes Prednisone: Nursing Diagnoses and Outcomes

• Excess Fluid Volume related to sodium and water retention secondary to corticosteroid therapy

– Desired outcome: The patient will relate causative factors and methods of preventing edema and exhibit decreased peripheral and sacral edema.

• Risk for Infection or Risk for Injury related to anti-inflammatory, immunosuppressive, dermatologic, and metabolic effects of chronic corticosteroid therapy

– Desired outcome: The patient will demonstrate knowledge of risk factors associated with potential for infection or injury and will practice appropriate precautions for prevention.


Prednisone: Nursing Diagnoses and Outcomes (cont.)Prednisone: Nursing Diagnoses and Outcomes (cont.)• Imbalanced nutrition: More than Body Requirements

related to increased appetite secondary to corticosteroid medications

– Desired outcome: The patient will maintain a healthy weight, discuss current nutritional needs, and discuss the effects of exercise on weight control.

• Altered Body Image related to cushingoid characteristics or physical changes secondary to glucocorticoid therapy

– Desired outcome: The patient will verbalize and demonstrate acceptance of appearance, verbalize and demonstrate healthy adaptation and coping skills.


Prednisone: Planning and InterventionsPrednisone: Planning and Interventions

• Maximizing therapeutic effects

– The most opportune time for administration of daily doses or alternate-day doses of glucocorticoids is early in the morning.

• Minimizing adverse effects

– Monitor the patient, especially the surgical patient, carefully for signs of infection.

– Administration can lead to peptic ulcer disease.


Prednisone: Teaching, Assessment, and EvaluationsPrednisone: Teaching, Assessment, and Evaluations

• Patient and family education

– Discuss taking the drug exactly as prescribed.

– Discuss not stopping the drug abruptly.

– Emphasize the importance of patients’ notifying all health care providers about glucocorticoid therapy.

• Ongoing assessment and evaluation

– Monitor for therapeutic drug response, adverse drug reactions, and indications of drug toxicity.


QuestionQuestion

• Prednisone will increase the serum levels of K+ level.

– A. True

– B. False


Answer Answer

• B. False

• Rationale: Serum levels of K+ may be decreased with the use of prednisone.


Mineralocorticoids Mineralocorticoids

• Aldosterone, the naturally occurring mineralocorticoid, is expensive and requires parenteral administration.

• This adrenal corticosteroid has both high mineralocorticoid and glucocorticoid activity (its glucocorticoid potency is 15 times greater than that of hydrocortisone).

• However, when used as replacement therapy in adrenocortical deficiency, its therapeutic effect is the mineralocorticoid activity.

• Prototype drug: fludrocortisone (Florinef Acetate)


Fludrocortisone: Core Drug Knowledge Fludrocortisone: Core Drug Knowledge


– Partial replacement therapy for primary adrenocortical insufficiency


– Administered: oral. Peak: 1.7 hours. T½: 3.5 hours.


– Acts on the distal renal tubule to enhance the reabsorption of sodium and to increase the urinary excretion of both potassium and hydrogen ions


Fludrocortisone: Core Drug Knowledge (cont.)Fludrocortisone: Core Drug Knowledge (cont.)


– Hypersensitivity and systemic fungal infections

• Adverse effects

– Small doses: marked sodium retention and increased urinary potassium excretion.


– Fludrocortisone interacts with many of the same drugs as prednisone because of its high glucocorticoid activity.


Fludrocortisone: Core Patient Variables Fludrocortisone: Core Patient Variables

• Health status

– Review medical history.


– Pregnancy Category C drug


– Assess diet. The drug causes Na retention and K loss.

• Environment

– Assess the environment where the drug will be given.

• Culture and inherited traits

– Assess cultural and dietary practices.


Fludrocortisone: Nursing Diagnoses and Outcomes Fludrocortisone: Nursing Diagnoses and Outcomes

• Excess Fluid Volume related to mineralocorticoid-induced sodium and water retention

– Desired outcome: The patient will relate causative factors and methods of preventing fluid retention and exhibit decreased peripheral and sacral edema.

• Risk for Infection or Risk for Injury related to immunosuppressive effects of chronic corticosteroid therapy

– Desired outcome: The patient will demonstrate knowledge of risk factors associated with potential for infection and will practice appropriate precautions for prevention.


Fludrocortisone: Nursing Diagnoses and Outcomes (cont.)Fludrocortisone: Nursing Diagnoses and Outcomes (cont.)

• Risk for Injury related to adrenocortical insufficiency

– Desired outcome: The patient will demonstrate knowledge of risk factors associated with potential for injury and will practice appropriate precautions for prevention.


Fludrocortisone: Planning and InterventionsFludrocortisone: Planning and Interventions• Maximizing therapeutic effects

– Assess for drugs that may interact with and decrease its efficacy.

– Evaluate the need for an increased dose during times of injury, stress, infection, or surgery.


– Monitor blood pressure, fluid balance, and electrolyte status.

– Review the importance of following a diet high in potassium-rich foods.


Fludrocortisone: Teaching, Assessment, and EvaluationsFludrocortisone: Teaching, Assessment, and Evaluations


– Instruct patients to adhere to drug therapy as prescribed, stressing the importance of regular follow-up visits with the prescriber.

– Encourage patients to wear a medical identification bracelet stating their medical condition and their specific drug therapy.


– Monitor for edema, weight gain, hypertension, cardiac arrhythmias, or muscular weakness.


QuestionQuestion

• The patient is being discharged home on fludrocortisone. What would be important to teach the patient about diet?

– A. Limit salt and potassium intake

– B. Increase salt and potassium intake

– C. Limit salt intake and increase potassium intake

– D. Increase salt intake and limit potassium intake


AnswerAnswer

• C. Limit salt intake and increase potassium intake

• Rationale: Fludrocortisone causes sodium retention and potassium loss. Inform the patient of foods that are low in sodium or high in potassium.


Steroid Hormone Antagonists Steroid Hormone Antagonists

• Steroid hormone antagonists act to inhibit or suppress the adrenal cortex, thus controlling the symptoms of Cushing syndrome.

• Prototype drug: aminoglutethimide (Cytadren)


Aminoglutethimide: Core Drug Knowledge Aminoglutethimide: Core Drug Knowledge


– Used to treat hypercortisolism (Cushing syndrome)


– Administered: oral. T½: 5 to 9 hours.


– Inhibits enzymatic conversion of cholesterol to pregnenolone


Aminoglutethimide: Core Drug Knowledge (cont.)Aminoglutethimide: Core Drug Knowledge (cont.)


– Hypersensitivity

• Adverse effects

– Drowsiness, dizziness, skin rash, nausea, and anorexia


– Coumarin, warfarin, other oral anticoagulants, theophylline, digoxin, medroxyprogesterone, and dexamethasone


Aminoglutethimide: Core Patient Variables Aminoglutethimide: Core Patient Variables

• Health status

– Assess CBC and thyroid levels.


– Pregnancy Category D drug


– Assess daily activities.

• Environment

– Assess the environment where the drug will be given.


Aminoglutethimide: Nursing Diagnoses and Outcomes Aminoglutethimide: Nursing Diagnoses and Outcomes

• Risk for Injury related to CNS effects of hypotension and sedation, endocrine effects of hypothyroidism, or hematologic effects of agranulocytosis, leukopenia, and thrombocytopenia

– Desired outcome: The patient will remain injury-free during aminoglutethimide therapy.

• Imbalanced nutrition: Less than Body Requirements related to adverse effects of anorexia and nausea

– Desired outcome: There will be no change or an improved nutritional status.


Aminoglutethimide: Nursing Diagnoses and Outcomes (cont.)Aminoglutethimide: Nursing Diagnoses and Outcomes (cont.)

• Disturbed Body Image related to hirsutism and masculinization (in females)

– Desired outcome: The patient will identify and incorporate methods for camouflaging the adverse hormonal effects of aminoglutethimide therapy.


Aminoglutethimide: Planning and InterventionsAminoglutethimide: Planning and Interventions

• Maximizing therapeutic effects

– Advise the patient to carry medical identification and to inform health care professionals that this drug is being taken.


– Suppression of aldosterone production may cause orthostatic or persistent hypotension.


Aminoglutethimide: Teaching, Assessment, and EvaluationsAminoglutethimide: Teaching, Assessment, and Evaluations


– Discuss the adverse reactions of aminoglutethimide, including dizziness or drowsiness, nausea, anorexia, headache, orthostatic hypotension, and hirsutism.

– Caution patients about driving or performing other tasks that requires alertness, coordination, or physical dexterity until the effects of the drug are known.


– Continuously assess for adrenal insufficiency because adjustment of the aminoglutethimide dose may be necessary.


QuestionQuestion

• Aminoglutethimide is a Pregnancy Category ___ drug?

– A. A

– B. B

– C. C

– D. D

– E. X


AnswerAnswer

• D. D

• Rationale: Aminoglutethimide is a Pregnancy Category D drug.

Ppt chapter 48-1

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