DRUGS AFFECTING GASTROINTESTINAL, ENDOCRINE AND RENAL

SYSTEMS

Learning Material Description

This learning material deals with different drugs affecting gastrointestinal, endocrine and
renal systems. This module introduces the different classifications of medicines affecting
gastrointestinal, endocrine and renal systems. Emphasis is given on proper drug
administration, assessing drug effects, accurate intervention to achieve its therapeutic effect
and providing health education about the drug regimen to ensure safety in nursing practice as
well as treatment of illness and the promotion, maintenance and restoration of wellness in
diverse individuals across the life span.

Course Learning Outcomes

Upon completion of this module, the learner is expected to demonstrate the following:

1. Explore and understand the mechanism of action, pharmacological actions and

interactions of drugs affecting the gastrointestinal, endocrine and renal systems.
2. Understand the importance of patient safety during medication administration of
drugs affecting the gastrointestinal, endocrine and renal systems.
3. Describe the actual and potential adverse and side effects of drugs affecting the
gastrointestinal, endocrine and renal systems.
4. Have an acceptable understanding of the following concepts provided in this module.

Pre-Test

MULTIPLE CHOICE

1. Which of the following statement from the patient taking Cholestyramine (Prevalite)
indicates further teaching?
a. “I will continue eating fibrous rich foods.”
b. “I will drink the cholestyramine faster for faster absorption.”
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c. “The medication will help lower my cholesterol level.”
d. “I will continue taking my supplement.”
2. Which condition/s can you safely administer Metoclopramide (Reglan)?
a. Patient with bowel tumor.
b. Patient with gastrointestinal trauma.
c. Patient undergoing radiation.
d. Patients with pheochromocytoma.
3. Which of the following is the therapeutic effect of Misoprostol (Cytotec)?
a. Prevent constipation
b. Stop diarrhea
c. Relief of gastric ulcer
d. Induce vomiting
4. Which of the following is the most common CNS side effect of cimetidine (Tagamet)?
a. Anxiety
b. Agitation
c. Stupor
d. Somnolence
5. When giving a bolus of cimetidine (Tagamet) which of the following parameters
should be closely monitored?
a. Blood pressure
b. Respiratory rate
c. AST and ALT
d. Temperature. Skin turgor.
6. Loperamide hydrochloride is indicated for the following conditions?
a. Dysentery
b. Bloody Diarrhea
c. Pheochromocytoma
d. Patient with ileostomy
7. Ondansetron (Zofran) is given to which of the following conditions?
a. Post-operative pain
b. Post-operative vomiting
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c. Prevention of infection
d. Prevention of lung collapse
8. When taking prednisolone which of the following food items should be avoided?
a. Canned foods
b. Peanuts
c. Bananas and oranges
d. Beef
9. When taking Glipizide (Glucotrol), which of the following should be avoided?
a. Alcohol
b. Coca cola
c. Milk
d. Juice
10. A nurse is teaching a patient on how to mix regular insulin and NPH insulin in the
same syringe. Which of the following actions, if performed by the patient, indicates
the need for further teaching?
a. Withdraws regular insulin first.
b. Withdraws NPH insulin first.
c. Injects an amount of air equivalent to the desired dose of insulin.
d. Injects air into the NPH insulin first.

Topic 1
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DRUGS AFFECTING GASTROINTESTINAL SYSTEM

ANTACIDS

Antacids are used to chemically react with and neutralize the acid in the stomach. They can
provide rapid relief from increased acid levels. They are known to cause GI alterations such
as diarrhea or constipation and can alter the absorption of many drugs.

Antacids: Generic and Brand Names

Classification Generic name Brand name

aluminum salts AlternaGEL

calcium salts Oystercal, Tums

Antacids magaldrate Losopan, Riopan

magnesium salts Milk of Magnesia, others

sodium bicarbonate Bell-ans

Antacids are a group of inorganic chemicals that neutralize stomach acid.

 Antacids are available OTC, and many patients use them to self-treat a variety of GI
symptoms.
 The choice of an antacid depends on adverse effects and absorption factors.

Therapeutic actions

 Neutralize stomach acid by direct chemical reaction.

 Symptomatic relief of an upset stomach associated with hyperacidity, as well as the
hyperacidity associated with peptic ulcer, gastritis, peptic esophagitis, gastric
hyperacidity, and hiatal hernia.
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Indication

 Symptomatic relief of GI hyperacidity, treatment of hyperphosphatemia, prevention

of formation of phosphate urinary stones.
 Treatment of calcium deficiency, prevention of hypocalcemia.
 Prophylaxis of stress ulcers, relief of constipation.

Nursing Implementation with Rationale

 Adequate drug absorption. Administer the drug apart from any other oral medications
approximately 1 hour before or 2 hours after to ensure adequate absorption of the
other medications.
 Ensure therapeutic levels. Have the patient chew tablets thoroughly and follow with
water to ensure that therapeutic levels reach the stomach to decrease acidity.
 Perform diagnostic testing. Obtain specimens for periodic monitoring of
serum electrolytes to evaluate drug effects.
 Prevent imbalances. Assess the patient for any signs of acid-base or electrolyte
imbalance to ensure early detection and prompt interventions.
 Institute a bowel program. Monitor the patient for diarrhea or constipation to institute
a bowel program before severe effects occur.
 Ensure adequate nutritional status. Monitor the patient’s nutritional status if diarrhea
is severe or constipation leads to decreased food intake to ensure adequate fluid and
nutritional intake to promote healing and GI stability.
 Provide patient support. Offer support and encouragement to help the patient cope
with the disease and the drug regimen.
 Educate the patient. Provide thorough patient teaching, including the drug name and
prescribed dose, schedule for administration, signs and symptoms of adverse effects
and measures to prevent or minimize them, warning signs that may indicate possible
problems and the need to notify the health care provider immediately.

HISTAMINE-2 ANTAGONIST
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HISTAMINE-2 ANTAGONIST: GENERIC AND BRAND NAMES

Classification Generic name Brand name

cimetidine Tagamet

ranitidine Zantac
Histamine-2 antagonists
famotidine Pepcid

nizatidine Axid

Description

 Histamine-2 antagonists block the release of hydrochloric acid in response to gastrin.

 These drugs include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid),
and nizatidine (Axid).

Therapeutic actions

 Selectively block H2 receptors located on the parietal cells.

 Prevents the release of gastrin, a hormone that causes local release of histamine (due
to stimulation of histamine receptors), ultimately blocking the production of
hydrochloric acid.
 Decreases pepsin production by the chief cells.

Indication

 Short-term treatment of active duodenal ulcer or benign gastric ulcer.

 Treatment of pathological hypersecretory conditions such as Zollinger-Ellison
syndrome (blocking the overproduction of hydrochloric acid that is associated with
these conditions).
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 Prophylaxis of stress-induced ulcers and acute upper GI bleeding in critical patients
(blocking the production of acid protects the stomach lining, which is at risk because
of decreased mucus production associated with extreme stress).
 Treatment of erosive gastroesophageal reflux (decreasing the acid being regurgitated
into the esophagus will promote healing and decrease pain).
 Relief of symptoms of heartburn, acid indigestion, and sour stomach.

Nursing Implementation with Rationale

 Ensure therapeutic levels. Administer drug with or before meals and at bedtime (exact
timing varies with product) to ensure therapeutic levels when the drug is most needed.
 Prevent serious toxicity. Arrange for decreased dose in cases of hepatic or renal
dysfunction to prevent serious toxicity.
 Monitor IV doses carefully. Monitor the patient continually if giving IV doses to
allow early detection of potentially serious adverse effects, including cardiac
arrythmias
 Assess for potential drug-drug interactions. Assess the patient carefully for any
potential drug-drug interactions if given in combination with other drugs because of
the drug’s effects on liver enzyme systems.
 Provide patient’s comfort. Provide comfort, including analgesics, ready to access
bathroom facilities, and assistance with ambulation, to minimize possible adverse
effects.
 Reorient patient thoroughly. Periodically reorient the patient and institute safety
measures if CNS effects occur to ensure patient safety and improve and improve
patient tolerance of the drug and drug effects.
 Attend regular follow-ups. Arrange for regular follow-up to evaluate drug effects and
the underlying problems.
 Provide support. Offer support and encouragement to help patients cope with the
disease and the drug regimen.
 Educate the client. Provide patient teaching regarding drug name, dosage, and
schedule for administration; importance of spacing administration appropriately as
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ordered; need for readily available access to bathroom; signs and symptoms of
adverse effects and measures to minimize or prevent them.

PROTON PUMP INHIBITORS

Proton Pump Inhibitors: Generic and Brand Names

Classification Generic name Brand name

dexlansoprazole Kapidex

esomeprazole Nexium

Proton pump lansoprazole Prevacid

inhibitors omeprazole Prilosec

pantoprazole Protonix

rabeprazole Aciphex

PROTON PUMP INHIBITORS

 Proton pump inhibitors suppress the secretion of hydrochloric acid into the lumen of
the stomach.

Therapeutic actions

 The desired actions of antacids include the following:

 Blocks the final step of acid production, lowering the acid levels in the stomach.
 Inhibits the hydrogen-potassium adenosine triphosphate enzyme system on the
secretory surface of the gastric parietal cells.

Indication

 Treatment and maintenance of erosive esophagitis, treatment of heartburn associated

with GERD.
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 Treatment of GERD, severe erosive esophagitis, duodenal ulcers, and pathological
hypersecretory condition.
 Treatment of gastric ulcer.
 Maintenance therapy for healing duodenal ulcers and esophagitis.
 In combination therapy for eradicating Helicobacter pylori infection.
 Approved for use in children for treatment of GERD, peptic ulcer, and Zollinger-
Ellison syndrome.

Nursing Implementation with Rationale

 Proper administration. Administer drug before meals to ensure that the patient does
not open, chew, or crush capsules; they should be swallowed whole to ensure the
therapeutic effectiveness of the drug.
 Safety and comfort measures. Provide appropriate safety and comfort measures if
CNS effects occur to prevent patient injury.
 Institute a bowel program. Monitor the patient for diarrhea or constipation in order to
institute an appropriate bowel program as needed.
 Monitor nutritional status. Monitor the patient’s nutritional status; use of small
frequent meals may be helpful if GI upset is a problem.
 Ensure follow-up. Arrange for medical follow-up if symptoms are not resolved after 4
to 8 weeks of therapy because serious underlying conditions could be causing the
symptoms.
 Provide patient support. Offer support and encouragement to help the patient cope
with the disease and the drug regimen.
 Educate the patient and folks. Provide thorough patient teaching, including the drug
name and prescribed dosage; the importance of taking the drug whole without
opening, chewing, or crushing it; signs and symptoms of possible adverse effects and
measures to minimize or prevent them.
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DRUGS AFFECTING ENDOCRINE SYSTEM

ADRENOCORTICAL AGENTS
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 Adrenocortical agents are drugs used as short-term treatment to suppress immune
system in patients with inflammatory disorders.
 They are also used for replacement therapy to maintain hormone levels when adrenal
glands are not functioning adequately. These agents are classified into three:
glucocorticoids, mineralocorticoids, and androgens.

Glucocorticoids & Mineralocorticoids: Generic and Brand Names

Classification Generic Name Brand Name

beclomethasone Beclovent

betamethasone Celestone

budesonide Rhinocort, Entocort EC

Glucocorticoids dexamethasone Decadron

hydrocortisone Cortef

methylprednisolone Medrol

prednisolone Delta-Cortef

fludrocortisone Florinef
Mineralocorticoids
hydrocortisone Cortef

GLUCOCORTICOIDS

Glucocorticoids are agents that stimulate an increase in glucose levels for energy. They also
increase the rate of protein breakdown and decrease the rate of protein formation from amino
acids to preserve energy. They are also capable of lipogenesis, or the formation and storage
of fat in the body for energy source.

Therapeutic Action

 Bind to cytoplasmic receptors of target cells to form complex reactions needed to

reduce inflammation and to suppress immune system.
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 Other glucocorticoids like hydrocortisone, cortisone, and prednisone also have
mineralocorticoid activity so they can affect potassium, sodium, and water levels.
They can also limit the activity of lymphocytes to act within the immune system.
Furthermore, they inhibit the spread of phagocytes to the bloodstream and injured
tissues.
Indications

 Short-term treatment of inflammatory disorders by blocking the actions of

arachidonic acid leading to decrease in formation of prostaglandins and leukotrienes.
 Local agents are used to treat local inflammation.
 Systemic use is indicated for treatment of some cancers, hypercalcemia associated
with cancer, hematological disorders, and some neurological infections.
 When combined with mineralocorticoids, some of these drugs can be used in
replacement therapy for adrenal insufficiency.

Implementation with Rationale

 Administer drug daily at 8 to 9 AM to mimic normal peak diurnal concentration

levels and thereby minimize suppression of the hypothalamic-pituitary axis (HPA).
 Space multiple doses evenly throughout the day to try to achieve homeostasis.
 Taper doses when discontinuing to give the adrenal glands a chance to recover and
produce adrenocorticoids.
 Protect patient from unnecessary exposure to infection and invasive procedure
because the steroids suppress the immune system, and the patient is at increased risk
for infection.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

MINERALOCORTICOIDS
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Description

 Mineralocorticoids affect electrolyte levels directly and help maintain homeostasis.

 The classic mineralocorticoid is aldosterone.

Therapeutic Action

 Aldosterone increases sodium reabsorption in the renal tubules and increases

potassium and hydrogen excretion, leading to water and sodium retention.

Indications

 Mineralocorticoids are indicated for the following medical conditions:

 Partial replacement therapy in cortical insufficiency conditions, treatment of salt-
losing adrenogenital syndrome; off-label use: treatment of hypotension.

Implementation with Rationale

 Use only in conjunction with appropriate glucocorticoids to maintain control of

electrolyte balance.
 Increase dose in times of stress to prevent adrenal insufficiency and to meet increased
demands for corticosteroids under stress.
 Monitor for hypokalemia (weakness, serum electrolytes) to detect the loss early and
treat appropriately.
 Discontinue if signs of overdose (excessive weight gain, edema, hypertension) occur
to prevent the development of more severe toxicity.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

ANTIDIABETIC DRUGS
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Antidiabetic drugs are a group of drugs structurally unrelated to sulfonylureas and are
effective when used in combination with insulin or sulfonylureas. These drugs include alpha-
glucosidase inhibitors, biguanides, dipeptidyl peptidase-4 (DPP-4) inhibitors, human amylin,
incretin mimetics, meglitinides, and thiazolidinediones.

Antidiabetic Agents: Generic and Brand Names

Classifications Generic Name Brand Name

acarbose miglitol Precose, Glyset

Alpha-glucosidase inhibitors
miglitol Glyset

Biguanide metformin Glucophage

linagliptin Tradjenta

Dipeptidyl peptidase-4-inhibitors saxagliptin Onglyza

sitagliptin Januvia

Human amylin pramlintide acetate Symlin

exenatide Baraclude
Incretin mimetics
liraglutide Victoza

nateglinide Starlix
Meglitinides
repaglinide Prandin

pioglitazone Actos
Thiazolidinediones
rosiglitazone Avandia

Therapeutic Action

 Alpha-glucosidase inhibitors acarbose and miglitol inhibit alpha-glucosidase, an

enzyme that breaks down glucose for absorption. Therefore, they delay the absorption
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of glucose. They have only a mild effect on glucose levels and do not enhance insulin
secretion. They are associated with severe hepatic toxicity and GI distress.
 Biguanide metformin decrease the production and increases the uptake of glucose. It
is effective in lowering blood glucose and does not cause hypoglycemia as the
sulfonylureas do. It has been associated with development of lactic acidosis and GI
distress.
 Meglitinides nateglinide and repaglinide are newer agents that act like sulfonylureas
to increase insulin release.
 Synthetic human amylin pramlintide works to modulate gastric emptying after a
meal to cause a feeling of fullness or satiety. It also prevents the postmeal rise
in glucagon that usually elevates glucose levels. Human amylin is a hormone
produced by beta cells in the pancreas that is important in regulating postmeal
glucose levels. It should not be used when patient is unable to eat.
 Incretin mimetics exenatide and liraglutide mimic the effects of GLP-1:
enhancement of glucose-dependent insulin secretion by the beta cells in the
pancreas, depression of elevated glucagon secretion, and slowed gastric emptying to
help moderate and lower blood glucose levels.
 DPP-4 inhibitors lina-, saxa-, and sitagliptin slow the breakdown of GLP-1 to
prolong the effects of increased insulin secretion, decreased glucagon secretion, and
slowed GI emptying.
 Thiazolidinediones pioglitazone and rosiglitazone decrease insulin resistance.

Indications

 Biguanide metformin is approved for use in children 10 years of age and older. It is
also being used in the treatment of women with polycystic ovarian syndrome (PCOS).
 Meglitinides nateglinide and repaglinide are used to lower postprandial glucose
levels because they are rapid-acting and with a very short half-life. They are taken
just before meals.
 Thiazolidinediones pioglitazone and rosiglitazone are used in combination with
insulin, metformin, and sulfonylureas in patients with insulin resistance.
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 Bromocriptine, a dopamine agonist used to treat Parkinson’s disease was approved
in 2009 as a CNS approach to treat type 2 diabetes.

Nursing Considerations

 Nursing considerations are the same with sulfonylureas.

GLUCOSE-ELEVATING AGENTS

 Glucose-elevating agents raise blood level of glucose when severe hypoglycemia

occurs at <40 mg/dL. Two agents are used to elevate glucose: diazoxide and glucagon.

Glucose-Elevating Agents: Generic and Brand Names

Classification Generic Name Brand Name

Glucose-elevating diazoxide Proglycem, Hyperstat

agents glucagon GlucaGen

Therapeutic Action

 Increasing blood glucose by decreasing insulin release and accelerating the

breakdown of glycogen in the liver to release glucose.

Indications

 Diazoxide is an oral management of hypoglycemia, intravenous use for management

of severe hypertension.
 Glucagon is used to counteract severe hypoglycemic reactions.
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Nursing Implementation with Rationale

 Monitor blood glucose levels to evaluate the effectiveness of the drug.

 Have insulin on standby during emergency use to treat severe hyperglycemia if it
occurs as a result of overdose.
 Monitor nutritional status to provide nutritional consultation as needed.
 Monitor patients receiving diazoxide for potential cardiovascular effects, including
blood pressure, heart rhythm and output, and weight changes, to avert serious adverse
reactions.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

HYPOTHALAMIC AGENTS

 Hypothalamic agents can inhibit or stimulate the release of hormones from the
anterior pituitary using hormones or factors. However, not all of these hormones are
available for pharmacological use.
 Stimulating factors (agonists) include growth hormone-releasing hormone (GHRH),
thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone
(GnRH), corticotropin-releasing hormone (CRH), and prolactin-releasing hormone
(PRH).
 Factors that inhibit (antagonists) include somatostatin (growth hormone-inhibiting
factor) and prolactin-inhibiting factor.
 Other drugs acting on the endocrine system include the following: pituitary agents,
adrenocortical agents, thyroid and parathyroid agents, and agents to control blood
glucose levels.

Hypothalamic Agents: Generic and Brand Names

Classification Generic Name Brand Name

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goserelin Zoladex

histrelin Vantas

Agonists leuprolide Lupron

nafarelin Synarel

tesamorelin Egrifta

degarelix
Antagonists
ganirelix Antagon

Therapeutic Action

 Not clearly identified as there are only minute quantities found.

 Not all of them are used as pharmacological agents. Some are used for diagnostic
purposes only and others are primarily used as antineoplastic agents.
 Tesamorelin is used to stimulate GH and its lipolytic effects, helping to decrease the
excess abdominal fat in HIV-infected patients with lipodystrophy.

Indications

 Hypothalamic hormones are not all available for pharmacological use; those that are
available are used mostly for diagnostic testing, for treating some forms of cancer, or
as adjuncts in fertility programs.
 Agonists like goserelin, histrelin, leuprolide, and nafarelin are analogues of GnRH.
They decrease production of sex hormones. They are used as treatment for precocious
puberty, endometriosis, and advanced prostate cancer.
 Antagonists of GnRH like degarelix and ganirelix are used as treatment for advanced
prostate cancer and inhibition of premature LH surge in women undergoing
controlled ovarian stimulation for fertility.

Nursing Considerations
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 The specific nursing care of patient who is receiving hypothalamic releasing factor is
related to the hormone(s) that the drug is affecting. This will be discussed further as
each drug affecting certain hormones will be covered in this study guide.

INSULIN

 Insulin is a drug that is used to control glucose in patients with diabetes mellitus. It is
the only parenteral antidiabetic agent available for exogenous replacement of low
levels of insulin.
 Insulin is the hormone produced by the pancreatic beta cells of the islets of
Langerhans. It is released into circulation when the levels of glucose around the cells
arise. Insulin circulates through the body and reacts with specific insulin receptor
sites to stimulate the transport of glucose into cells to be used for energy
(facilitated diffusion).
 Originally prepared from pork and beef pancreas, virtually all insulin is prepared by
recombinant DNA technology now. This is a purer form of insulin and is not
associated with sensitivity problems that many patients developed with the animal
products.

Therapeutic Action

 Insulin replaces endogenous insulin. It is the only parenteral antidiabetic agent

available for exogenous replacement of low levels of insulin. It reacts with the
receptors of the cells to facilitate transport of various metabolites and ions across cell
membranes and stimulates the synthesis of glycogen from glucose, of fats from lipids,
and of proteins from amino acids.

Indications
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 Treatment of type 1 diabetes

 Treatment of type 2 diabetes when other agents have failed
 Short-term treatment of type 2 diabetes during periods of stress
 Management of diabetic ketoacidosis, hyperkalemia, and marked insulin resistance

Nursing Implementation with Rationale

 Ensure that patient has dietary and exercise regimen and using good hygiene
practices to improve the effectiveness of the insulin and decrease adverse effects of
the disease.
 Monitor nutritional status to provide nutritional consultation as needed.
 Gently rotate the vial containing the agent and avoid vigorous shaking to ensure
uniform suspension of insulin.
 Rotate injection sites to avoid damage to muscles and to prevent subcutaneous
atrophy.
 Monitor response carefully to avoid adverse effects.
 Always verify the name of the insulin being given because each insulin has a different
peak and duration, and the names can be confused.
 Use caution when mixing types of insulin; administer mixtures of regular and NPH
insulins within 15 minutes after combining them to ensure appropriate suspension and
therapeutic effect.
 Store insulin in a cool place away from direct sunlight to ensure
effectiveness. Predrawn syringes are stable for 1 week if refrigerated.
 Monitor patient’s food intake and exercise and activities to ensure therapeutic effect
and avoid hypoglycemia.
 Monitor patient’s sensory losses to incorporate his or her needs into safety issues, as
well as potential problems in drawing up and administering insulin.
 Provide good skin care and foot care, to prevent the development of serious infections
and changes in therapeutic insulin doses.
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 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

PARATHYROID AGENTS

 Parathyroid agents are drugs used to treat disorders that affect serum calcium levels.
This can be either anti-hypocalcemic agent or anti-hypercalcemic agent (further
classified into bisphosphonates and calcitonins). The parathyroid glands are four very
small groups of glandular tissue located on the back of the thyroid gland. This
produce PTH and calcitonin to maintain body’s calcium balance. PTH is the most
important regulator of serum calcium levels in the body.

Table of Common Drugs and Generic Names

Classification Generic Name Brand Name

calcitriol Rocaltrol
Antihypocalcemic Agents
teriparatide Forteo

Antihypercalcemic Agents

Bisphosphonates alendronate Fosamax

ANTIHYPOCALCEMIC AGENTS

 Antihypocalcemic agents are drugs used to treat deficient levels of PTH.

Therapeutic Action
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 A vitamin D compound that regulates the absorption of calcium and phosphate from
the small intestine, mineral resorption in bone, and reabsorption of phosphate from
renal tubules, increasing the serum calcium level.
 Teriparatide stimulates new bone formation leading to increase in skeletal mass. It
increases serum calcium and decreases serum phosphorus.

Indications

 Management of hypocalcemia in patients on chronic renal dialysis

 Management of hypocalcemia associated with hypoparathyroidism and with sustained
systemic glucocorticoids therapy

Implementation with Rationale

 Monitor serum calcium concentration before and periodically during treatment to

allow for adjustment of dose to maintain calcium levels within normal limit.
 Provide supportive measures (e.g. analgesics, small and frequent meals, help with
activities of daily living) to help patient deal with CNS and GI effects of the drug.
 Arrange for nutritional consultation if GI effects are severe to ensure nutritional
balance.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

ANTIHYPERCALCEMIC AGENTS

 Antihypercalcemic agents are drugs used to treat PRH excess or hypercalcemia.

These agents include bisphosphonates and calcitonin salmon.
 These drugs act on the serum levels of calcium and do not suppress the parathyroid
gland or PTH.
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Therapeutic Action

 Bisphosphonates slow normal and abnormal bone resorption without inhibiting bone
formation and mineralization.
 Calcitonin inhibits bone resorption and lowers elevated serum calcium. It also
increases the excretion of filtered phosphate, calcium, and sodium by the kidney.

Indications

 Bisphosphonate is used to treat and prevent osteoporosis in postmenopausal women

and in men. It is also used to treat glucocorticoid-induced osteoporosis as well as to
treat Paget’s disease.
 Calcitonin is used for treatment of Paget’s disease, postmenopausal osteoporosis, and
emergency treatment of hypercalcemia.

Implementation with Rationale

 Ensure adequate hydration with any of these agents to reduce risk of renal
complications.
 Arrange for concomitant vitamin D, calcium supplements, and hormone replacement
therapy if used to treat postmenopausal osteoporosis.
 Rotate injection sites and monitor for inflammation if using calcitonins to prevent
tissue breakdown and irritation.
 Monitor serum calcium before and periodically during treatment to allow for dose
adjustment.
 Arrange for periodic blood tests of renal function if using gallium to monitor for renal
dysfunction.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.
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PITUITARY AGENTS

 Pituitary agents include drugs affecting anterior (further divided into growth hormone
agonists and growth hormone antagonists) and posterior pituitary hormones.
 Drugs that affect anterior pituitary hormones mimic or antagonize the effects of
specific pituitary hormones. They are used as replacement therapy, for diagnostic
purposes, and for blocking the effects of anterior pituitary hormones.
 The anterior pituitary hormone that is most commonly used pharmacologically
is growth hormone (GH).

Pituitary Agents: Generic and Brand Names

Classification Generic Name Brand Name

Anterior Pituitary Hormone Drugs

Nutropin, Saizen,
Growth Hormone Agonists somatropin
Humatrope

bromocriptine Parlodel

lantreolide Somatuline Depot

Growth Hormone Antagonists
octreotide Sandostatin

pegvisomant Somavert

chorionic gonadotropin Chorex

corticotropin Acthar
Other Drugs Affecting Anterior
cosyntropin Cortrosyn
Pituitary Hormones
menotropin Pergonal

thyrotropin alfa Thyrogen

Posterior Pituitary Hormone Drugs

Drugs Affecting Posterior conivaptan Vaprisol

Pituitary Hormones desmopressin DDAVP
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tolvaptan

GROWTH HORMONES AGONISTS

 Growth Hormone Agonists are responsible for linear skeletal growth, growth of
internal organs, protein synthesis, and stimulation of processes required for normal
growth.
 Hypopituitarism is often seen as GH deficiency before any other signs and symptoms
occur. It occurs as a result of the following: developmental abnormalities, congenital
defects of the pituitary, circulatory disturbances (e.g., hemorrhage), acute or chronic
inflammation of the pituitary, and pituitary tumors.
 Dwarfism is the GH deficiency in children which results to short stature.
 Somatotropin deficiency syndrome (SDS) is a condition in adults with
hypopituitarism caused by pituitary tumors or trauma or may have been treated for
GH deficiency as children, resulting in a shutdown of the pituitary production of
somatotropin.
 Therapeutic Action
 Replacing human GH and stimulate skeletal growth, growth of internal organs, and
protein synthesis.

Indications

 Long-term treatment of children with growth failure associated with various

deficiencies, girls with Turner’s syndrome, AIDS wasting and cachexia, GH
deficiency in adults, and treatment of growth failure in children of small gestational
age who do not achieve catch-up growth by 2 years of age.
 Somatropin (Nutropin, Saizen, Genotropin, Serostim) and somatropin rDNA origin
(Zorbtive) are used for GH replacement today.

Nursing Implementation with Rationale

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 Reconstitute the drug following manufacturer’s directions because individual
products vary; administer IM or SQ as ordered for appropriate drug delivery.
 Monitor response closely to determine need for dose adjustment.
 Monitor thyroid function, glucose tolerance, and GH levels periodically to monitor
endocrine changes and to institute treatment as needed.
 Provide comfort measures to help patient cope with the drug effects.
 Provide patient education (storage, preparation, administration techniques) about drug
effects and warning signs to report to enhance patient knowledge and to promote
compliance.

GROWTH HORMONE ANTAGONISTS

 Growth Hormone antagonists are used in treating GH hypersecretion

(hyperpituitarism) caused by pituitary tumors.

Therapeutic Action

 Acting directly on postsynaptic dopamine receptors in the brain to inhibit GH

secretion
 Octreotide and lanreotide are somatostatin analogues which are more potent in
inhibiting GH release with less of an inhibitory effect on insulin release. They are
used instead of somatostatin.

Indications

 Treatment of Parkinson’s disease, hyperprolactinemia associated with pituitary

adenomas, female infertility associated with hyperprolactinemia, and acromegaly;
short-term treatment of amenorrhea or galactorrhea.
 Bromocriptine is a semisynthetic ergot alkaloid and a dopamine agonist which is
frequently used to treat acromegaly. It may also be used as adjunct to irradiation.
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Implementation with Rationale

 Reconstitute the drug following manufacturer’s directions because individual

products vary; administer IM or SQ as ordered for appropriate drug delivery.
 Inject lanreotide deep into subcutaneous fat in the superior quadrant of the buttocks
and alternate from right to left to ensure proper drug delivery and prevent local
reactions.
 Monitor thyroid function, glucose tolerance, and GH levels periodically to monitor
endocrine changes and to institute treatment as needed.
 Arrange for baseline and periodic ultrasound evaluation of gallbladder if using
octreotide or lanreotide to detect any gallstone development and to arrange for
appropriate treatment.
 Provide comfort measures to help patient cope with the drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

DRUGS AFFECTING POSTERIOR PITUITARY HORMONES

 The posterior pituitary stores two hormones produced by

the hypothalamus (antidiuretic hormone or vasopressin [ADH] and oxytocin).
 ADH possesses antidiuretic, hemostatic, and vasopressor properties. It is the hormone
affected in diabetes insipidus, a condition characterized by production of a large
amount of dilute urine containing no glucose.

Therapeutic Action

 Pressor and antidiuretic effect by causing the cortical and medullary parts of the
collecting duct to become permeable to water, thereby increasing water reabsorption
and decreasing urine formation.
 Increasing levels of clotting factor VIII
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Indications

 Treatment of neurogenic diabetes insipidus and hemophilia A

Nursing Implementation with Rationale

 Monitor patient fluid volume to watch for signs of water intoxication and fluid excess
or excessive fluid loss.
 Monitor patient with vascular disease for any sign of exacerbation to provide for
immediate treatment.
 Monitor condition of nasal passages if given intranasally to observe for nasal
ulceration, which can occur and could affect drug absorption.
 Provide comfort measures to help patient cope with the drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

SULFONYLUREAS

 Sulfonylureas are another group of agents used to control blood glucose level. These
drugs are only effective in patients who have functioning beta cells. They are not
effective for all diabetics and may lose their effectiveness over time with others.
 Sulfonylureas are further classified as first-generation or second-generation
sulfonylureas.
 Use of first-generation sulfonylureas is declining as more effective drugs have
become available. Also, they are now thought to possibly cause an increase in
cardiovascular death.
 Use of second-generation sulfonylureas have several advantages over first-generation,
including safer for patients with renal dysfunction as they are excreted in urine and
bile, absence of interaction to many protein-bound drugs, and longer duration of
action.
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 All of sulfonylureas can cause hypoglycemia.

Sulfonylureas: Generic and Brand Names

Classification Generic Name Brand Name

chlorpropamide Diabinese

First-generation tolazamide Tolinase

tolbutamide Orinase

glimepiride Amaryl

Second-generation glipizide Glucotrol

glyburide DiaBeta, Micronase

Therapeutic Action

 Sulfonylureas stimulate insulin release from the beta cells in pancreas. They improve
insulin binding to insulin receptors and may actually increase the number of insulin
receptors.
 They are also known to increase the effect of antidiuretic hormone on renal cells.

Indications

 Sulfonylureas are used as adjunct to diet and exercise for the treatment of type
2 diabetes older than 10 years of age; extended-release form for patients older than 17
years of age; adjunct treatment with polycystic ovary syndrome.

Implementation with Rationale

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 Administer the drug as prescribed in the appropriate relationship to meals to ensure

therapeutic effectiveness.
 Ensure that patient has dietary and exercise regimen and using good hygiene practices
to improve the effectiveness of the insulin and decrease adverse effects of the disease.
 Monitor nutritional status to provide nutritional consultation as needed.
 Monitor response carefully; blood glucose monitoring is the most effective way to
evaluate dose. Obtain blood glucose levels as ordered to monitor drug effectiveness.
 Monitor patients during times of trauma, pregnancy, or severe stress, and arrange to
switch to insulin coverage as needed.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

THYROID AGENTS

 Thyroid agents either replace or remove hormones to prevent deficiency and excess.
Thyroid agents include thyroid hormones (T3, T4, TSH) and antithyroid drugs
(further classified as thioamides and iodine solution).

Thyroid Agents: Generic and Brand Names

Classification Generic Name Brand Name

Thyroid Agents

levothyroxine Synthroid, Levoxyl

Thyroid Hormones
liothyronine Cytomel, Triostat
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liotrix Thyrolar

thyroid dessicated Amour Thyroid

Antithyroid Agents

methimazole Tapazole
Thioamides
propylthiouracil (PTU) –

sodium iodide I131 –

Iodine solutions strong iodine
Thyro-Block
solution, potassium iodide

THYROID HORMONES

 Thyroid hormones are made available to replace the low or absent levels of natural
thyroid hormone and suppress the overproduction of TSH by the pituitary.
 These can contain both natural and synthetic thyroid hormone.

Therapeutic Action

 This is replacement hormone for hypothyroid states like myxedema coma, goiters,
and thyroid cancer increases the metabolic rate of body tissues, increasing oxygen
consumption, respiration, heart rate, growth and maturation, and the metabolism of
fats, carbohydrates, and proteins.
 Levothyroxine, a synthetic salt of T4, is the most frequently used replacement
hormone because of its predictable bioavailability and reliability.

Indications

 Replacement hormone for hypothyroid states like myxedema coma, goiters, and
thyroid cancer
 Treatment for thyroid toxicity in conjunction with antithyroid drugs
 Treatment for thyroid overstimulation during pregnancy
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Implementation with Rationale

 Administer a single daily dose before breakfast each day to ensure consistent
therapeutic levels.
 Administer with a full glass of water to prevent difficulty of swallowing
and esophageal atresia.
 Monitor cardiac response to detect cardiac adverse effects.
 Arrange for periodic blood tests of thyroid function to monitor the effectiveness of
the therapy.
 Provide comfort measures (temperature control, rest as needed, safety precautions) to
help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

ANTITHYROID AGENTS

 Antithyroid agents are drugs used to block the production of thyroid hormone and
treat hyperthyroidism.
 This includes thioamides and iodide solutions. These groups of drugs are not
chemically related but they both block the formation of thyroid hormones within the
thyroid gland.
 Therapeutic Action
 Thioamides lower thyroid hormones by preventing the formation of thyroid hormone
in the thyroid cells. They also partially inhibit the conversion of T4 to T3 at cellular
level. Thioamides include propylthiouracil (PTU) and methimazole.
 Iodine solutions in high doses block thyroid function. They cause the cells to become
oversaturated with iodine and stop producing hormones.

Indications
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SYSTEMS
 Treatment of hyperthyroidism
 Thyroid blocking in a radiation emergency

Implementation with Rationale

 Administer PTU three times a day, around the clock to ensure consistent therapeutic
levels.
 Give iodine solution through a straw to decrease staining of teeth; tables can be
crushed.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
patient knowledge and to promote compliance.

Post-Test

1. When is the best time to take prednisone?

a. Early morning
b. Evening
c. Any time of the day
d. Lunch
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SYSTEMS
2. Which of the following manifestations would warrant you that to decrease the dose of
antidiuretic hormone for patients with diabetes insipidus?
a. Diarrhea
b. Constipation
c. Alertness
d. Drowsiness
3. Which of the following medications decreases their actions by thyroid hormone?
a. Vitamin K
b. Paracetamol
c. Zoloft
d. Metformin.
4. Which of the following is a side effect of intranasal Vasopressin (Pitressin).
a. Runny nose
b. Headache.
c. Flushing
d. Nausea.
5. Which of the following is intended for the drug propylthiouracil (PTU)?
a. Addison’s disease
b. Cushing’s syndrome
c. Grave’s disease.
d. Myxedema.
6. Which of the following should be immediately notified to the physician for clients
taking levothyroxine?
a. Tremors
b. Sweating
c. Cramps
d. Headache
7. Best time to take levothyroxine (Synthroid) is when?
a. Bedtime
b. Dinner
c. Taken with food
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d. Taken on an empty stomach.
8. What is the expected response of patient for patients receiving Desmopressin acetate
(DDAVP)?
9. Sucralfate is best taken when?
10. Expected effect of laxative?

Activity

Choose at least five drugs then explain their mechanism of actions to diseases.

Reference

Kee, J., Hayes, E., & McCuistion, L. (2014). Pharmacology: A Patient-Centered Nursing
Process Approach (8th ed.). Elsevier Health Sciences.

Reflection

Reflect on the learning outcomes you have achieved after completing this module. State what
aspects that need to improve to attain the learning outcomes of the course.