adrenal cortex drug therapy

Which statement made by Ms. Sanders indicates a good understanding of the adverse effects of hydrocortisone and fludrocortisone therapy?

"I must have my blood checked regularly to assess for side effects of my medication."

A patient with Addison's disease is upset about weight gain and wants to stop taking hydrocortisone and fludrocortisone. Which response would the nurse make?

"If you stop taking the medications, you may have severe side effects."

A patient with type 1 diabetes has a new prescription for hydrocortisone. Which education should the nurse provide to this patient?

"The insulin drug dosage to manage your diabetes may need to be increased since hydrocortisone can raise your blood glucose levels."

Addisonian crisis

(acute adrenal crisis or adrenal insufficiency) is a life-threatening condition in which the body cannot make enough cortisol to meet demands. This crisis can occur gradually or suddenly, triggered by physiologic stress (surgery, trauma, infection) or by abruptly stopping corticosteroid drug therapy.

Replacement therapy: Adrenal insufficiency (acute adrenal crisis), Addison's disease, CAH.

*Note: There are many non-endocrine uses for hydrocortisone: allergic (hypersensitivity) response, immunosuppression (prevent rejection in organ transplants), cancer. Glucocorticoid drug dosage is significantly higher when treating non-endocrine disorders than that used as replacement therapy.

pharmacokinetics of Hydrocortisone

Absorption: well absorbed after administration Distribution: extensive protein binding; only unbound dose is active; widely distributed Metabolism: liver Excretion: by the kidneys via urine Crosses placenta

pharmacokinetics of Fludrocortisone

Absorption: well absorbed from gastrointestinal (GI) tract Distribution: 42% is protein bound; unbound is widely distributed Metabolism: liver and kidney Excretion: by the kidneys via urine

Which action describes how fludrocortisone raises the blood pressure in persons with Addison's disease?

Acts as a pressor on blood vessels Fludrocortisone acts directly as a pressor on the blood vessels and contributes to sodium retention, thus elevating the blood pressure.

Adverse Effects Related to Long-Term Therapy with hydrocortisone

Altered body image (redistribution of fat Cushing's syndrome) Muscle wasting Osteoporosis, fractures (hypocalcemia) Cataracts, glaucoma Infection due to immunosuppression Peptic ulcers, bleeding/ perforation (abdominal pain, black tarry stools) Heart failure

Which description of the therapeutic use of hydrocortisone in Addison's disease is accurate?

As replacement cortisol therapy Hydrocortisone is used in Addison's disease as replacement therapy for cortisol deficiency.

Before administering hydrocortisone, the nurse will:

Assess vital signs, especially blood pressure and pulse, and weigh the patient daily Notify the health care provider if patient is experiencing chest pain Screen for signs of infection (elevated white blood cell [WBC] count, sore throat, fatigue); fever not a good indicator of infection in a patient receiving corticosteroid therapy as it may be masked

Before administering fludrocortisone, the nurse will:

Assess: Vital signs, especially BP and pulse Weight Screen for infection Review laboratory test results: Serum sodium Serum potassium

Which phrase describes the action of metyrapone drug therapy in a patient with Cushing's disease?

Blocks process of cholesterol conversion to cortisol Metyrapone, a steroidogenesis inhibitor, blocks one or more steps in the conversion of cholesterol to cortisol. Through this process, cortisol levels are controlled in Cushing's disease on a temporary basis.

Congenital Adrenal Hyperplasia

CAH is a group of autosomal recessive disorders that affects production of adrenal cortex hormones.

evaluation for therapeutic response: fludrocortisone

Correction of adrenal insufficiency

Evaluation for therapeutic response: with hydrocortisone

Correction of cortisol insufficiency

Hydrocortisone is a synthetic steroid with a structure identical to which hormone?

Cortisol

An excessive level of cortisol manifests as

Cushing's disease and Cushing's syndrome. High levels of cortisol can be caused by both endogenous and exogenous factors. Cushing's disease usually has an endogenous cause, occurring when excessive ACTH stimulates adrenal production of cortisol. This excessive ACTH production is usually due to a pituitary tumor. In contrast, Cushing's syndrome typically has an exogenous cause, such as the use of drug therapy for non-endocrine health issues. For example, corticosteroid use in large does and/or long periods can lead to Cushing's syndrome.

Use caution in persons with: hydrocortisone

Diabetes (r/t side effect of hyperglycemia) Cataracts, glaucoma (corticosteroids increase intraocular pressure) Gastric or peptic ulcer disease (corticosteroid use increases bleeding risk) Systemic infection (infection can worsen due to immunosuppressive effect of corticosteroids) Seizure history Cardiac, renal, and or liver dysfunction

Life span precautions: hydrocortisone

Do not give during pregnancy: corticosteroids cross the placenta; first trimester use is associated with increased incidence of cleft palate Distributed in breast milk; breastfeeding not recommended Do not give to older patients with delirium or at risk for delirium

Lifespan considerations before drug administration: with fludrocortisone

Do not give to children under 2 years of age. Use in pregnancy only if benefits outweigh weigh risks. Discontinue breastfeeding while on drug. Avoid in older adults with delirium or at high risk for delirium

Absolute Contraindication: hydrocortisone

Drug hypersensitivity

lab values with fludrocortisone

Drug increases sodium levels Drug decreases potassium levels False-negative: nitro blue tetrazolium test for bacterial infection

Monitor for complications during therapy: when taking hydrocortisone

Effectiveness and side effects Emotional lability; sleep disruption Delayed wound healing Decreasing urinary output, increased edema Indication of infection (sore throat, fever, increased WBC) Electrolyte imbalance (hypocalcemia: muscle twitching, cramps) Evidence of GI bleeding (abdominal pain, tarry stools) Evidence of hypokalemia (chest pain, weakness, irritability, electrocardiogram changes)

management of Addisonian crisis

Emergency drug replacement with hydrocortisone IV; fludrocortisone; manage dehydration with large volume fluid replacement and hypoglycemia with intravenous glucose.

Clinical manifestations of CAH

Females: Ambiguous genitals (due to high androgen); poor feeding, vomiting, dehydration, abnormal heart beat (due to low cortisol and aldosterone) Males: Appear unaffected at birth but may develop health problems within 2 to 3 weeks after birth

drug interactions with fludrocortisone

Fludrocortisone use decreases the effects of: Antidiabetic drugs; potentiates hyperglycemia (dosage adjustment may be needed) Oral anticoagulant drugs; decreased PT (dosage adjustment may be needed) Barbiturates, phenytoin, rifampin (increases metabolic clearance in liver)

fludrocortisone. Frequent side effects

Flushing, headache, sweating Hypertension Weight gain Note: These symptoms indicate fluid overload and potentially lead to complications of seizure and heart failure

Which foods would the nurse advise patients on long-term fludrocortisone for Addison's disease to include in their diet?

Foods rich in potassium

Administration of fludrocortisone

Give drug with food Use lowest dose possible (titrate) Scored tablets may be divided Give at a consistent time every day, usually in am Do not stop drug suddenly (can potentiate adrenal crisis)

When teaching a patient about the most common side effects of hydrocortisone, which information would the nurse include?

Heartburn or indigestion Insomnia and mood swings Delayed wound healing

A patient is admitted to the emergency department with acute adrenal crisis. Which drug would the nurse anticipate administering?

Hydrocortisone

lab values with hydrocortisone

Hydrocortisone causes increases in serum lipid, sodium, and glucose levels. Hydrocortisone causes decreases in serum calcium, potassium, thyroxine, and WBC levels.

drug interactions with hydrocortisone

Hydrocortisone effect can be increased with HIV medications (antiretroviral therapy [ART]): dose may need to be decreased. Hydrocortisone effects can be decreased with anticonvulsants, barbiturates, and hydantoins: dose may need to be increased. Hydrocortisone used in combination with thyroid and/or antifungal drugs can decrease renal clearance. Hydrocortisone use causes increases in blood glucose levels (antidiabetic drugs may need dosage adjustment). Hydrocortisone potentiates (increases):bleeding risk when used with aspirin, nonsteroidal antiinflammatory disease, acetaminophen hypokalemia when used with potassium wasting diuretics (e.g., furosemide)

Absolute contraindication: with fludrocortisone

Hypersensitivity to drug

Which changes in laboratory values can occur while taking fludrocortisone?

Hypokalemia

Review laboratory test results for: hydrocortisone

Hypokalemia Altered sodium Hyperglycemia Glucosuria Elevated cholesterol

Herb interactions with hydrocortisone

Hypokalemia can occur when corticosteroids are used in combination with cascara sagrada, yellow dock, and licorice potentiate

Which statement by the patient indicates an understanding of taking hydrocortisone as replacement therapy for Addison's disease?

I must take this medication on a daily basis as instructed." Replacement therapy is intended to be a long-term intervention for Addison's disease.

Hydrocortisone is prescribed to a patient newly diagnosed with Addison's disease. When reviewing current medications taken by the patient, the nurse is aware that hydrocortisone could increase the action of which drugs?

Ibuprofen, a nonsteroidal antiinflammatory drug, for pain Metformin, an antidiabetic drug Furosemide, a loop diuretic

herb interactions with fludrocortisone

Increased fludrocortisone effect with echinacea, St John's wort

food interactions with food

Increased fludrocortisone effect with high sodium foods.

frequent side effects with hydrocortisone

Insomnia, anxiety, mood swings Heartburn, diarrhea, constipation, abdominal pain Delayed wound healing

A female patient with Addison's disease has started taking fludrocortisone in addition to hydrocortisone. She calls the clinical nurse to report feet swelling and a headache. Which action should the nurse take?

Instruct the patient to come to the clinic for further evaluation.

This disorder manifests soon after birth with the infant exhibiting the following symptoms: of CAH

Lack of cortisol Lack of aldosterone Overstimulation from androgens (testosterone)

Fludrocortisone is sometimes used with hydrocortisone as therapy for Addison's disease. Which rationale for the addition of fludrocortisone is accurate?

Manage fluid and electrolyte balance Fludrocortisone, a mineralocorticoid, is used to maintain fluid and electrolyte balance and raise blood pressure primarily through retention of sodium.

Adverse effects: fludrocortisone

Masked signs of infection Hypokalemia acidosis Thrombophlebitis, embolism Anaphylaxis

A patient taking hydrocortisone therapy reports muscle twitching and cramps. Which intervention would the nurse take?

Obtain calcium level. Muscle twitching and cramps are symptoms of hypocalcemia, a side effect of long-term cortisone therapy. A calcium level should be obtained.

Drug: pasireotide Classification: somatostatin analogue Formulation: intramuscular injection Mechanism of action: neuroregulatory - reduces pituitary ACTH: considerations

Only orphan drug for Cushing's disease approved by the Food and Drug Administration Side effects: headache, nausea, vomiting, weakness, hyperglycemia

Addison's disease: drug dosage of fludrocortisone

Oral dosing: 0.05 to 0.1 mg/day (range from 0.1 mg 3 times a week to 0.2 mg daily)

Adrenogenital syndrome: drug dosage with fludrocortisone

Oral dosing: 0.1 to 0.2 mg /day *Typically given in conjunction with cortisone or hydrocortisone

Adverse Effects Related to Abrupt Withdrawal with hydrocortisone

Orthostatic hypotension, weakness, dizziness Fatigue, lethargy sudden joint pain Nausea, headache, fever Rebound inflammation

adult drug dosage with hydrocortisone

P0: 20 to 240 mg daily in divided dosesIM/IV: 100 to 300 mg every 2 to 6 hr*IV preferred for acute adrenal insufficiency

administration with hydrocortisone

PO: Give in am with food IM: Use large muscle and inject deeply (avoid deltoid) IV: Do not give acetate or suspension formulation intravenously Salts of hydrocortisone are not interchangeable Avoid aspirin use during therapy

Monitor lab values when taking hydrocortisone

Plasma cortisol - normal morning levels 138 to 655 mm.

Which concerns would the nurse address when teaching patients about long-term hydrocortisone therapy for Addison's disease?

Potential infections Drug interactions Medication compliance

Management of Addison's disease

Replacement drug therapy with hydrocortisone; fludrocortisone, as needed

Management of CAH

Replacement drug therapy with hydrocortisone; fludrocortisone, if "salt losing"

Monitor for complications during therapy: with fludrocortisone

Report changes in weight greater than 5 lb weekly Monitor for hypertension; episodes of chest pain Assess for decreasing urine output accompanied by edema Assess for abnormal (delayed) growth rate in children Monitor for signs of infection (lethargy, malaise, fatigue, fever, WBC increase) Assess for rash, respiratory wheezing, increased respiratory rate, tachycardia, hypotension (symptoms of hypersensitivity reaction)

Pharmacodynamic Profile for fludrocortisone

Route: PO formulation only Onset of action: 10 to 20 minutes Peak: 1.7 hrs. Duration: unknown Half-life: 18 to 36 hours

Pharmacodynamic Profile Hydrocortisone

Route: oral (PO), intravenous (IV), intramuscular (IM); onset is typically rapid; IM onset of action is injection type and site blood supply specific Peak: 1 to 2 hours Duration: route and dose dependent Half-life: 8 to 12 hours

Monitor labs: with fludrocortisone

Sodium Potassium Chloride

Evaluation of therapeutic response and patient teaching are essential for safe care. Patient/Family Teaching: fludrocortisone

Stress rationale for therapy and need to follow-up with the health care provider. Advise to take drug at a consistent time every day (usually in a.m.) without stopping abruptly. Suggest wearing Medic Alert card of bracelet with health condition and therapy used. Instruct to schedule and keep appointments with the health care provider and to check serum electrolyte levels at scheduled intervals. Educate about dietary salt restrictions and the signs of salt and water retention (e.g., unusual weight gain, edema in the feet or lower legs). Advise to report signs and symptoms of Addison's disease or hypokalemia (e.g., muscle weakness, irregular heartbeat). Advise that drug causes a negative nitrogen balance; therefore a high-protein diet is usually recommended. Teach side effect and when to report adverse effects: behavioral changes, sore throat, muscle aches, sudden weight gain, swelling, visual disturbance, signs of infection (sore throat), and increased brushing. Report muscle aches, sudden weight gain, edema, and visual disturbance.

Teaching is the basis for effective self-care. Patient/family teaching with hydrocortisone

Stress the rationale for therapy and the importance of follow-up appointments with a health care provider to monitor response and side effects. Instruct about taking drug: follow prescribed dosing schedule, i.e., a.m. or in divided daily dose; take with food; have an emergency drug supply; do not abruptly discontinue drug; dosage may be adjusted during times of stress (e.g., infection, surgery, and trauma). Advise patients eat foods rich in potassium, such as fresh and dried fruits, vegetables, meats, and nuts. Encourage patients to wear identification (e.g., Medic Alert bracelet) to alert emergency medical personnel of their glucocorticoid requirements. Advise patients to avoid cortisone preparations during pregnancy due to possible fetal harm unless a health care provider finds it necessary. Avoid contact with infectious persons or children who have recently received live virus immunizations. Ask the health care provider about immunization during therapy due the reduced immune response. Teach to observe for side/adverse effects and report to the health care provider. Report signs and symptoms of drug overdose or Cushing's syndrome: moon face, puffy eyelids, swelling in the feet, increased bruising, dizziness, bleeding, and menstrual changes.

Newborn screening CAH

This mandated screening test will detect elevated levels of 17 OHP indicating CAH.

The nurse is administering pasiriotide to a patient with Cushing's disease secondary to a pituitary tumor. Which phrase describes the rationale for using this drug?

To block production of adrenocorticotropic hormone (ACTH)

Drug: metyrapone Classification: steroidogenesis inhibitors Formulation: oral dosing Mechanism of action: Blocks one or more steps in conversion of cholesterol to cortisol and aldosterone: considerations

Typically used before surgery and for no longer than 3 months

Use caution in persons with: with fludrocortisone

Untreated systemic infection Cataracts, glaucoma (increases ocular pressure) Seizures disorder Thyroid disease Diabetes Cardiovascular disease, following acute myocardial infarction Mental health issues (psychosis, mood swings, euphoria, interrupted sleep)

Drug: ketoconazole Classification: azole anti-antifungal Formulation: oral dosing Mechanism of action: inhibits cortisol production: considerations

Use considered off label and reserved for cases when other therapy not successful Side effects: hepatotoxicity, dysrhythmias Multiple drug interactions exist; care must be taken when performing medication reconciliation

Drug: mitotane Classification: antineoplastic and steroidogenesis inhibitor Formulation: oral dosing Mechanism of action: inhibits steroid production: considerations

Used alone or with metyrapone for treatment of Cushing's syndrome, adrenal cancer, palliative therapy, adjunctive therapy after surgery

Clinical manifestations of Addisonian crisis

Weakness, fatigue Severe vomiting and diarrhea Sudden pain in lower back, abdomen, and legs Hypotension, tachycardia, and tachypnea May lead to seizures, shock, loss of consciousness, or coma

Fludrocortisone is used for

adrenal insufficiency, Addison's disease, CAH when salt-losing is a symptom. In most cases, fludrocortisone is given in combination with a glucocorticoid (e.g., hydrocortisone).

Hydrocortisone is the drug of choice for managing

adrenocortical deficiency. The goal of drug therapy with hydrocortisone is to promote homeostasis through hormone replacement.

Cortisol and aldosterone are produced

almost exclusively in the adrenal cortex. Deficiency in these steroid hormones can cause serious health problems and even death.

Addison's disease, or primary adrenocortical insufficiency (PAI), typically occurs through an

autoimmune destruction of all layers of the adrenal gland. Because of this process, the adrenal glands are unable to produce enough hormones. Low levels of cortisol affect the body's ability to produce and use glucose, contributing to hypoglycemia. Aldosterone deficiency with sodium and water loss leads to orthostatic hypotension.

Clinical manifestations: of Addison's disease

can be mild to life threatening; directly related to low cortisol and aldosterone levels: Weakness and fatigue Anorexia, nausea, vomiting, diarrhea, abdominal pain Hyperpigmentation of skin and mucous membranes (due to excessive ACTH with increased melanin level) Decreased androgens in women cause hair loss

Fludrocortisone, a mineralocorticoid, is given along with

hydrocortisone for adrenocortical replacement therapy.

Excessive levels of cortisol or aldosterone manifest in two health alterations:

hyperaldosteronism, in which fluid and electrolyte balance is affected, and Cushing's disease and syndrome, with overabundance of cortisol.

Patients taking hydrocortisone should not receive

immunizations because of lowered resistance and poor immune response. Patients taking hydrocortisone should not be around others who have the following viral illnesses or who have recently received live vaccine for the following viral illnesses: measles, mumps, influenza, poliovirus, rotavirus, and rubella.

Glucocorticoids are produced in the

middle and upper portions of the adrenal gland under the influence of pituitary adrenocorticotropic hormone (ACTH). The predominate glucocorticoid is cortisol, called the "stress hormone"; cortisol increases blood glucose levels. The mineralocorticoid aldosterone, synthesized in the outermost part of the adrenal cortex, promotes fluid and electrolyte balance.

Management of elevated cortisol levels depends on the

reasons for this elevation. For example, if Cushing's syndrome is caused by prescriptive therapy for specific health problems, then titration of the dosage should be done when possible.

In persons with Cushing's disease, a different approach would be necessary. If a tumor is contributing to elevated cortisol levels, then

surgery or radiation therapy would be appropriate. Currently there are four drugs prescribed individually or in combination to control excessive production of cortisol. These are used for persons awaiting, or perhaps not candidates for, surgery or radiation.

Fludrocortisone is a very potent

synthetic mineralocorticoid that has high glucocorticoid activity. This drug mimics aldosterone and acts on the distal tubules of the kidney to retain sodium and increase urinary excretion of potassium and hydrogen ions. It also causes a rise in blood pressure due to electrolyte exchanges and pressor action on the blood vessels.

Hydrocortisone is a

synthetic steroid that is structurally identical to cortisol produced by the adrenal cortex. In addition, it demonstrates mineralocorticoid action.