DRUGS ACTING ON THE ENDOCRINE SYSTEM

DRUGS ACTING ON THE ENDOCRINE SYSTEMOVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEMcomposed of an interrelated complex of glands that secrete a variety of hormones directly into the bloodstream.major function, together with the nervous system, is to regulate body functionsHORMONE REGULATIONA. Hormones: chemical substances that act as messengers to specific cells and organs (target organs), stimulating and inhibiting various processes; two major categories:1. Local: hormones with specific effect in the area of secretion2. General: hormones transported in the blood to distant sites where they exert their effect

(pituitary, adrenals, thyroid, parathyroids, islet of Langerhans of the pancreas, ovaries and testes)2OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEMB. Negative feedback mechanisms:1. Decreased concentration of a circulating hormone triggers production of a stimulating hormone from the pituitary gland; this hormone in turn stimulates its target organ to produce hormones2. Increased concentration of a hormone inhibits production of the stimulating hormone, resulting in decreased secretion of the target organ hormone.

C. Some hormones are controlled by changing blood levels of specific substances (Ca, glucose)major means of regulating hormone levels3OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEMD. Certain hormones follow rhythmic patterns of secretion (female reproductive).

E. ANS and CNS control: hypothalamus controls release of the hormones of the APG through releasing and inhibiting factors that stimulate or inhibit hormone secretion(P-HA)4OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEMStructures and FunctionsPituitary Gland (Hypophysis)A. Located in sella turcica at the base of the brainB. Master gland; 3 lobes:1. Anterior lobe (adenohypophysis)a. secretes tropic hormones (hormones that stimulate target glands to produce their hormone):adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH)b. also secretes hormones that have direct effect on tissues: somatotropic or growth hormone, prolactinc. regulated by hypothalamic releasing and inhibitin factors and by negative feedback system

2. Posterior lobe (neurohypohysis): does not produce hormones; stores and releases antidiuretic hormones (ADH) and oxytocin, produces by the hypothalamus3. Intermediate lobe: secretes melanocyte-stimulating hormone (MSH)(P-HA)5OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEMAdrenal GlandsA. two small glands, one above each kidneyB. Consist of two sections:1. Adrenal cortex (outer portion): produces mineralocorticoids, glucocorticoids, sex hormones2. Adrenal medulla (inner portion): produces epinephrine, norepinephrineThyroid GlandA. Located in anterior portion of the neckB. Consists of two lobes connected by a narrow isthmusC. Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin6OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEMParathyroid GlandsA. Four small glands located in pairs behind the thyroid glandB. Produce parathormone (PTH)PancreasA. Located behind the stomachB. Has both endocrine and exocrine functionsC. Islets of Langerhans involved in endocrine functions1. Beta cells: produce insulin2. Alpha cells: produce glucagonGonadsA. Ovaries: located in the pelvic cavity, produce estrogen and progesteroneB. Testes: located in the scrotum, produce testosterone

7Laboratory/Diagnostic testsThyroid FunctionA. Serum studies: nonfasting blood studies (no prep)1. Serum T4 level: measures total serum level of throxine2. Serum T3 level: measures serum triiodothyronine level3. TSH: measurement differentiates primary from secondary hypothyroidism8Laboratory/Diagnostic testsPancreatic FunctionA. Fasting blood sugar: measures serum glucose levels; client fasts from midnight before the testB. Two-hour postprandial blood sugar: measurement of blood glucose 2 hours after a meal is ingested1. Fast from midnight before test2. Client eats a meal consisting of at least 75g CHO or ingests 100g glucose3. Blood drawn 2 hours after a meal9Laboratory/Diagnostic testsPancreatic FunctionC. Oral glucose tolerance test: most specific and sensitive test for diabetes mellitus1. Fast from midnight before test2. FBG and urine glucose obtained3. Client ingests 100g glucose; blood sugars are drawn at 30 and 60 minutes and then hourly 3-5 hours; urine specimens may also be collected4. Diet for 3 days prior to test should include 200g CHO and atleast 1500 kcal/day5. During test, assess the client for reactions such as dizziness, sweating and weakness

10Laboratory/Diagnostic testsPancreatic FunctionD. Glycosylated hemoglobin (hemoglobin A1c) reflects the average blood sugar level for the previous 100-120 days. Glucose attaches to a minor hemoglobin (A1c). this attachment is irreversible.1. Fasting is not necessary2. Excellent method to evaluate long term control of blood sugar

11Specific Disorders of the Pituitary GlandHypopituitarismHypofunction of the APG resulting in deficiencies of both the hormones secreted by the APG and those secreted by the target glandsMay be caused by tumor, trauma, surgical removal; may be congenitalAssessment:1. Tumor, headache2. Retardation of growth3. Hormonal disturbances12Specific Disorders of the Pituitary GlandHypopituitarismMedical management: depends on cause1. Tumor: removal or irradiation2. Regardless of cause: treatment will include replacement of deficient hormones (cortico-steroids, thyroid hormones, sex hormones, gonadotropins -> to restore fertility)Nursing management:1. Provide care undergoing hypophysectomy or radiation therapy2. Provide client teaching and discharge planning:a. Hormone replacement therapyb. Importance of follow-up care13Specific Disorders of the Pituitary GlandHyperpituitarismHyperfunction of the APG resulting in oversecretion of one or more of the anterior pituitary hormones-> Overproduction of GH -> acromegaly (adults) or gigantism (children)Assessment:1. Tumor, headache2. Hormonal disturbances3. Acromegaly: enlargement of the bones, features becomes coarse and heavy, lips heavier, tongue enlargedMedical management: surgical removal or irradiation of the gland14Specific Disorders of the Pituitary GlandHyperpituitarismNursing interventions:1. Monitor for hyperglycemia and cardiovascular problems and modify care2. Provide psychological support and acceptance for alterations in body image3. Provide care undergoing hypophysectomy or radiation therapy15Specific Disorders of the Pituitary GlandDiabetes InsipidusHypofunction of the PPG resulting in deficiency of ADHExcessive thirst and urinationTumor, trauma, inflammation, surgeryAssessment1. Polydipsia and severe polyuria with low SG (less than 1.004)2. Fatigue, muscle weakness, irritability, weight loss, signs of DHN3. Tachycardia, eventual shock -> if fluids not replaced16Specific Disorders of the Pituitary GlandDiabetes InsipidusNursing interventions1. Maintain fluid and electrolyte balance (Keep accurate I&O; weigh daily, fluid replacement-IV/oral)2. Monitor vs and observe for DHN and hypovolemia3. Administer hormone replacement as ordereda. vasopressin (Pitressin)b. lypressin (Diapid): nasal spray4. Client teaching: Lifelong hormone replacement therapy; lypressin PRN to control polydipsia/uriaVasopressin man-made hormone adh(inject)17Specific Disorders of the Pituitary GlandSyndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)Hypersecretion of ADH from PPG even when the client has abnormal serum osmolality Assessment1. concentrated urine2. Fluid retention and sodium deficiencyMedical management1. Treat cause2. Diuretics and fluid restriction18Specific Disorders of the Pituitary GlandSyndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)Nursing interventions1. Administer diuretics (furosemide [Lasix]) as ordered2. Restrict fluids - to promote fluid loss and gradual increase in serum Na3. Monitor serum electrolytes4. Careful intake and output, daily weight5. Monitor neurologic status6. Increase Na in diet19Specific Disorders of the Pituitary GlandDISORDERS OF THE ADRENAL GLANDAddisons diseasePrimary adrenocortical insufficiency; hypofunction of the adrenal cortex causes decrease of the mineralocorticoids, glucocorticoids, and sex hormones

Rare disease caused by: idiopathic atrophy due to autoimmune process; destruction of the gland secondary to tuberculosis or infection20Specific Disorders of the Pituitary GlandAddisons diseaseAssessment:1. fatigue, muscle weakness2. anorexia, nausea, vomiting, abdominal pain, weight loss3. history of hypoglycemic reactions4. Hypotension, weak pulse5. Bronze-like pigmentation of the skin6. decreased capacity to deal with stress7. low cortisol levels, hyponatremia, hyperkaliemia, hypoglycemia

21Specific Disorders of the Pituitary GlandAddisons diseaseNursing interventions1. Administer hormone replacement therapy as ordereda. Glucocorticoids (cortisone, hydrocortisone): to stimulate diurnal rhythm of cortisol release, give 2/3 dose in early morning and 1/3 dose in the afternoonb. Mineralocorticoids: fludrocortisone acetate (Florinef)2. Monitor VS3. decrease stress in the environment4. prevent exposure to infection22Specific Disorders of the Adrenal GlandAddisons diseaseNursing interventions5. Provide rest periods; prevent fatigue6. Monitor I&O7. Weigh daily8. provide small, frequent feedings of diet high in CHO, Na and CHON to prevent hypoglycemia and hyponatremia and proper nutrition9. client teachings:a. disease process/signs and symptomsb. medications for lifelong replacement therapy; never omit medsc. avoid stress, trauma, infectionsd. diet modification-> high in protein, carbohydrates, sodium23Specific Disorders of the Adrenal GlandCushings SyndromeCondition resulting from excessive secretion of corticosteroids, particularly the glucocorticoid cortisol; Caused by adrenocortical tumors or hyperplasia; neoplasms secreting ACTH, causing increased glucocorticoids

Iatrogenic: prolonged use of corticosteroidsusually females (30-60 y/o)24Specific Disorders of the Adrenal GlandCushings SyndromeAssessment:1. Muscle weakness, fatigue, obese trunk with thin arms and legs, muscle wasting2. Irritability, depression, frequent mood swings3. Moon face, buffalo hump, pendulous abdomen4. Purple striae on trunk, acne, thin skin5. Signs of masculinization in women, menstrual dysfunction, decrease libido6. Osteoporosis, decreased resistance to infection7. Hypertension, edema8. cortisol levels increased, slight hypernatremia, hyponatremia, hypokalemia, hyperglycemia25Specific Disorders of the Adrenal GlandCushings SyndromeNursing interventions1. Maintain muscle tone2. Prevent accidents or falls and provide adequate rest3. Protect client from exposure to infection4. Maintain skin integrity5. Minimize stress6. Monitor vs: hypertension, edema7. Monitor I&O and daily weights8. Provide diet low in calories and sodium and high in protein, potassium, calcium, vitamin D9. Monitor urine for glucose and acetone: administer insulin

26DISORDERS OF THE THYROID GLANDHypothyroidism (Myxedema)Slowing of metabolic processes caused by hypofunction of the thyroid glnd with decreased thyroid hormone secretion -> myxedema(adults); cretinism(children); Primary: atrophy; secondary: decreased stimulation from pituitary TSH; Iatrogenic: surgical removal of the gland or overtreatment of hyperthyroidism

often with women(30-60)In severe cases, myxedema coma may occur-> hypothyroidism, neurologic impairment-> coma27DISORDERS OF THE THYROID GLANDAssessment:1. Fatigue, lethargy, slowed mental processes, dull, slow clumsy movements2. Anorexia, weight gain, constipation3. Intolerance to cold, dry scaly skin, sparse hair, brittle nails4. Menstrual irregularities; generalized non-pitting edema5. Bradycardia, cardiac complications (CAD, angina pectoris, MI, CHF)6. Increased sensitivity to sedatives, narcotics, anesthetics7. Low T3 and T4 levels8. Exaggeration of these findings in myxedema coma: weakness, lethargy, syncope, bradycardia, hypotension, hypoventilation, subnormal temperature28DISORDERS OF THE THYROID GLANDMedical management1. Drug therapy: levothyroxine (Synthroid), thyroglobulin (Proloid), liothyronine (Cytomel)2. Myxedema coma is a medical emergencya. IV thyroid hormonesb. correction of hypothermiac. maintenance of vital functionsd. treatment of precipitating causes29DISORDERS OF THE THYROID GLANDInterventions:1. Monitor vs, I&O, daily weights, observe edema, signs of cardiovascular complications2. Administer thyroid hormone replacement as ordered and monitor effectsa. Observe for thyrotoxicosis (tachycardia, palpitations, nausea, vomiting, diarrhea, sweating, tremors, agitation, dyspnea) b. Increase dosage gradually3. Provide a comfortable warm environment4. Provide low-calorie diet30DISORDERS OF THE THYROID GLANDInterventions:5. Avoid the use of sedatives; reduce by half6. Institute measures to prevent skin breakdown7. Provide increased fluids and fiber to prevent constipation; stool softeners8. Observe for signs of myxedema coma9. Client teachings: take daily dose in the morning; protection for cold weather; prevent constipation(insomnia)31DISORDERS OF THE THYROID GLANDHyperthyroidism (Graves disease)Secretion of excessive amounts of thyroid hormone in the blood causes an increase in metabolic process; thyroid gland changes and overactivity may be present; unknown causeMost often seen in women (30-50) (insomnia)32DISORDERS OF THE THYROID GLANDAssessment1. Irritability, agitation, restlessness, hyperactivity, tremor, sweating, insomnia2. Increased appetite, hyperphagia, weight loss, diarrhea, intolerance to heat3. Exophthalmos, goiter4. Warm, smooth skin; fine, soft hair, pliable nails5. Tachycardia, increased systolic BP, palpitations6. Increased T3 and T4 levels(insomnia)33DISORDERS OF THE THYROID GLANDMedical managementa. Antithyroid drugs (propylthiouracil and methimazole [Tapozole]): block synthesis of thyroid hormoneb. Adrenergic blocking agents (propranolol [Inderal]): used to decrease sympathetic activity and alleviate symptoms(insomnia)34DISORDERS OF THE THYROID GLANDNursing interventions1. Monitor vs, daily weights2. Administer antithyroid medications as ordered3. Provide uninterrupted rest: (private room, meds)4. Provide cool environment5. Minimize stress6. Encourage quiet, relaxing diversional activities7. Diet: high in carbohydrates, protein, calories, vitamins, minerals8. Exophthalmos:( protect eyes; artificial tears); thyroid storm(insomnia)35DRUGS AFFECTING THE ENDOCRINE SYSTEMANTERIOR PITUITARY HORMONESUsed to antagonize the effects of specific pituitary hormonesMay be used as replacement therapy or diagnostic purposeGROWTH HORMONEResponsible for growth and CHON synthesisIndicated for growth failure (dwarfism)Somatotropin (Nutropin, Saizen, Humatrope)A: IV; D: wide; M: liver; E: urine and fecesContraindicated for allergy, closed epiphysis and obesitySerious adverse effect: DM(if prolonged used) CHECK BLOOD SUGARsomatostatin analogs - reduce growth hormone release.Radiation 5 to 10 yrs36DRUGS AFFECTING THE ENDOCRINE SYSTEMPOSTERIOR PITUITARY HORMONESADH (synthetic) antidiuretic, hemostatic, vasopressor propertiespromote water reabsorption from the renal tubulesreduction in urine outputvasopressin (Pitressin) parenteral/nasal; desmopressin (DDAVP)DI, hemophilia A, nocturnal enuresis, abdominal distentionD: wide; M: liver; E: urineCI: allergy, severe renal dysfunction; Caution: epilepsy, pregnancyAE: water intoxication, tremor, sweating, headachepromote water reabsorption from the renal tubules -> stops diuresisreduction in urine output -> measure for effectivenessDdavp-antidiuretic hormone37DRUGS AFFECTING THE ENDOCRINE SYSTEMDRUGS USED TO TREAT THYROID DISEASESGoal: To return the patient to a euthyroid state.Hypothyroidism: replacement of thyroid hormonesHyperthyroidism: thyroidectomy, radioactive iodine, antithyroid medicationsTwo general classes of drugs used to treat thyroid hormones:1. Replacement thyroid hormones levothyroxine (T4), liothyronine (T3), liothyronine, USP2. Antithyroid agents suppress synthesis of thyroid hormones (radioactive iodides, propylthiouracil, methimazole)Thyroid: TSHGOAL: normal thyroidTreated out-patient unless for surgery38DRUGS AFFECTING THE ENDOCRINE SYSTEMTHYROID REPLACEMENT HORMONESPrimary goal: normal thyroid state (euthyroid)Natural and synthetic sources(wt gain s/sy vs hyper)39DRUGS AFFECTING THE ENDOCRINE SYSTEMlevothyroxineSynthroid, LevoxylSyntheticT4Drug of choiceliothyronineCytomelSyntheticT3Rapid than levothyroxine; not indicated with CVDliotrixThyrolarSyntheticlevothyroxine+liothyronine4:1thyroid, USPFrom pig, beef, sheep; oldest; least expensive; lack purity, uniformity and stabilityNOTE: initial dosage depends on age of patient, severity of hypothyroidism and other medical conditions. -Hypothyroid patients are sensitive to replacement therapy -> monitor closely for adverse effects-PO: initiated in low dosages of levothyroxine (0.05 to 0.1 mg daily; ave: 0.1 mg to 0.2 mg) and gradually increased-same time of the day- taken on empty stomach (at least 45 minutes before ingestion of food; commonly after breakfast)40DRUGS AFFECTING THE ENDOCRINE SYSTEMADVERSE EFFECTS:Signs of hyperthyroidismTachycardia, anxiety, wt loss, abdominal cramping, diarrhea, palpitations, angina, heat intoleranceDose-related; may occur after 1-3wksReduction of dosage or discontinuation

41DRUGS AFFECTING THE ENDOCRINE SYSTEMDRUG INTERACTIONS:Warfarin: requires increased dosage of anticoagulants; assess also for signs of bleeding; reduce after four weeksDigoxin: requires decrease dosage if with hypothyroidism, but with therapy, gradual increase may be necessaryEstrogen: may require increase dosage of thyroid hormoneHyperglycemia: monitor for development of hyperglycemia, specially early weeks-> assess; adjust dosage42DRUGS AFFECTING THE ENDOCRINE SYSTEMANTITHYROID MEDICATIONSPropylthiouracul (PTU, Propasil); methimazole (Tapazole)Antithyroid agents by blocking synthesis of T3 and T4 in the thyroid glandDo not destroy any T3 and T4 already producedUSES: long-term treatment of hyperthyroidism or short-term treatment before subtotal thyroidectomy

ADVERSE EFFECTS:Purpuric rash/puritus (most common), bone marrow suppression, hepatotoxicity, nephrotoxicity(for Graves/hyperfuction; s/sy-tachy, nervousness,heat int)Note: PTU, PO; 100-150 mg q 6-8 hrs daily(initial); 50 mg 2-3times daily;Methimazole, PO; 5-20 mg q 8 hrs daily (initial); 5-15 mg (maintenance)1-2 years 43DRUGS AFFECTING THE ENDOCRINE SYSTEMADRENOCORTICAL AGENTSGLUCOCORTICOIDS- enter target cells and bind to cytoplasmic receptors, initiating many complex reactions -> anti-inflammatory and immunosuppressive effectsACTIONS: suppresses hypersensitivity and immune responseUSES: short-term treatment of inflammatory disorders, to relieve discomfort, and give the body a chance to heal from inflammatory effects: replacement therapy for patients with adrenocortical insufficiency; immunosuppression; reduction of inflammation and its effects(allergy and anti-inflammatory reactions)44DRUGS AFFECTING THE ENDOCRINE SYSTEMBethametasoneCelestoneLong-acting steroid; parenteral or oral; inflammationCortisoneCortone AcetateOne of the first corticosteroids; orally and parenteral for adrenal insufficiency and acute inflammationDexamethasoneDecadron, etc.Dermatologic, ophthalmologic, parenteral, inhalation; can last 2-3 daysHydrocortisoneCortefPowerful; both M & G; replacement therapy in patients with adrenal insufficiencyMethylprednisoloneMedrolLittle mineralocorticoid; drug of choice for inflammatory and immune disorders; oral, parenteral, enemaprednisoloneDelta-CortefIntermediate corticosteroid; oral, topical, intralesional and intra-articular injections, oral, topicalPrednisoneDeltasone, etcOral; adrenal insufficiency; inflammation; TAPEREDCommon drugs45DRUGS AFFECTING THE ENDOCRINE SYSTEMPHARMACOKINETICS:

CONTRAINDICATIONS AND CAUTIONS:Allergy; lactation; diabetes; pregnancy; ulcers

ADVERSE EFFECTS:fluid retention, potential CHF, increased appetite and weight gain; fragile skin and loss of hair; muscle weakness and atrophy, Cushings syndromeABSORPTIONMany sitesDISTRIBUTIONWell-distributed; crosses placenta and BMMETABOLISMLiverEXCRETIONUrine(glucose-elevating effects)fluid overload and HPN46DRUGS AFFECTING THE ENDOCRINE SYSTEMNURSING RESPONSIBILITIES:Take drugs at meal time or with food.Eat foods high in potassium, low in sodium.Instruct client to avoid individuals with RTI.Instruct client not to stop medication abruptly, it should be tapered to prevent adrenal insufficiencyAvoid taking NSAID while taking steroids.Take inhaled bronchodilators first before taking inhaled steroids, and rinse mouth after using.Teach the client the signs and symptoms of excess use of glucocorticoids(glucose-elevating effects)fluid overload and HPN47ANTIDIABETIC AGENTS:1. Sulfonylureas - stimulate insulin secretions and increase tissue sensitivity to insulin. First Generation : chlorpropamide (Diabenese) - most frequently used - disulfiram precautions tolbutamide (Orinase) - more easily cleared from the body - congenital defect tolazamide Second Generation : glypizide, glimepiride (Glucotrol)-less expensiveNormal serum glucose = 70-110/80-120 mg/dlType 1 early inlife; Type2 later in lifeSecond Generation : safer to patients with renal dysfunction; do not interact with as many CHON-drugs; longer duration; same action as 1st gen48ANTIDIABETIC AGENTS:2. Biguanides - facilitates insulin action on the peripheral receptor site. Metformin and Glucophage (Glucovance) -acts by decreasing hepatic production of glucose from stored glycogen. As the result of this action, metformin:decreases the serum glucose levels following a meal inhibits glycogenolysis, reduces absorption of glucose, increases insulin sensitivity improving glucose uptake; decrease in FBG

- adjunct to diet to lower blood glucose (Type 2 DM)- does not cause hypoglycemia and weight gain, decreases cholesterol - side effect is lactic acidosis49ANTIDIABETIC AGENTS:3. Alpha-glucosidase inhibitors- antihyperglycemic agent; enzyme inhibitor (alpha-amylase, alpha-glucoside hydrolase)- This agent is prescribed for clients who cannot control blood sugar by diet because: - delay carbohydrate absorption in the intestinal system/ it inhibits the digestive enzyme for carbohydrates in the small intestinedoes not cause hypoglycemia Acarbose (Precose) side effect is diarrhea- adjunct to Type 2 DM which exercise and diet cannot control50ANTIDIABETIC AGENTS:4. Thiazolinidine (TZD) - increase tissue sensitivity of insulin. -> allowing more glucose to enter the cells in the presence of insulin for metabolismdo not stimulate the release of insulin, rather, insulin must be present to be effective Rosiglitazone (Avandia)- effective in Type 2 DM-can be used alone or in combination51ANTIDIABETIC AGENTS:5. Meglitinides - stimulate insulin release in pancreatic B-cells.- effective in type 2 DM not controlled by diet or exercise (pancreas still has capacity to secrete insulin); not effective in type 1DM

Repaglinide (Prandin)- can be used with metformin-short duration of action lesser risk for having hypoglycemic effects52ANTIDIABETIC AGENTS:Nursing considerations : - Effective only for type II DM. - Contraindicated to pregnant & breastfeeding. - Given before meals. - Monitor for signs of hypoglycemia.53ANTIDIABETIC AGENTS:INSULIN hormone produced in the beta cells of the pancreasrequired for the entry of glucose into skeletal and heart muscle and fatif insulin is deficient, the transport of glucose into the cells is reducedhyperlipidemia, ketosis, acidosis-> key regulator of metabolism-> hyperglycemia54ANTIDIABETIC AGENTS:InsulinOnsetPeakDurationImmediate-acting (lispro)0.15h (ave: 5 mins)0.51h5 hShort-acting(regular-IV, semilente, human)0.5-1 h2-4 h5-7hIntermediate-acting (NPH, lente)1-3 h8-12 h18-24 hLong-acting (ultralente, Lantus no peak)4-6h10-30 h24-36 hMixed Humulin (regular 30%, NPH 70%)0.5 h4-8 h25 h55ANTIDIABETIC AGENTS:Nursing considerations :- The insulin that has fewer antigenic, allergic, and insulin resistance effects is: human insulin (Humulin) - Usually given before meals. - Roll the bottle in palm of hands, dont shake.- insulin syringe (100-unit insulin syringe) - Inject amount of air that is equal to each dose into the bottle short acting last (clear).- The client is to receive regular and NPH insulins. In preparing the syringe(s), the nurse or client would use: one injection: draw up regular insulin first - Aspirate short acting first, then long or intermediate (cloudy).56ANTIDIABETIC AGENTS:- Alcohol is recommended for cleansing bottle but not with skin. - Pinch skin, avoid I.M, dont aspirate (SC). - Rotate the injection site an inch a part. - Prefilled syringes are stored vertically, needle-up. - May increase dose during illnesses. - Used bottles stored in room temperature, unused bottle stored in refrigerator.Combination insulins that are commercially premixed, such as Humulin 70/30, are primarily for clients:who can use the prepared amount of regular and NPH units- insulin pump: regular insulin -> maintain glucose level-in case of infection/s: increase dosage

57ANTIDIABETIC AGENTS:- assesses signs and symptoms of hypoglycemic reaction (insulin shock):nervousness and tremors - Monitor for acute hypoglycemia : a. 3-4 commercially prepared glucose tablet b. 4-6 ounce of fruit juice or regular soda c. 2-3 teaspoon or honey d. Glucagon 1 gm SQ or IM e. D50-50 IV.- give glucagon as first aid on collapsed person58