Endocrine Pharmacology:

Transcription

1 Endocrine Pharmacology: Part 1: Hypothalamus/Pituitary, Pineal, Thyroid/ Parathyroid, Adrenals, Ovaries/Testes Part 2: Diabetes mellitus types 1 & 2 PHRM 203 Allison Beale

2 Types of Diabetes D. mellitus Type I (Juvenile onset) Pancreas not producing enough insulin, must take insulin Type II (Non-insulin dependant diabetes mellitus, NIDDM) Usually insulin resistance, but may be not enough insulin Gestational Diabetes Placental hormones cause insulin resistance in mom Cystic fibrosis Diabetes Shared characteristics with Type I and II DM D. insipidus Problem with ADH (usually, pituitary or kidney issue) A Beale PHRM Endocrine 2

3 Pancreas is a combination of exocrine and endocrine glands Ducted (exocrine) gland Digestive enzymes secreted into small intestine Ductless (endocrine) gland Insulin Glucose out of blood Glucagon Glucose into blood A Beale PHRM Endocrine 3

4 Conditions that affect glycemic control Management of Hospitalized Patients with Type 2 diabetes Mellitus, SH Lilley and GI Levine, AAFP, 1 March 1998 Hyperglycemia ( [gl] blood ) Excessive food intake Physical activity Pancreatic disease Infection Ischemia/infarction Trauma Surgery Emotional stress Pregnancy (2 nd /3 rd T) Cirrhosis (liver disease) Hypoglycemia ( [gl] blood ) Dietary intake Physical activity Malabsorption Alcohol intake Adrenocortical insufficiency Renal insufficiency Hepatic failure Pregnancy (1 st T) Gastrectomy A Beale PHRM Endocrine 4

5 Drugs with diabetes interactions Drug Glucosamine Risperidone (Risperdal, an atypical antipsychotic) SSRIs Interaction May increase insulin resistance Linked to type 2 DM, pancreatitis Patients report hypoglycemia Low Blood Sugar Symptoms Headache, dizziness, hunger, confusion, trouble concentrating, weakness, nausea, blurred vision, drowsiness, rapid heart rate, sweating, tremors Severe Hypoglycemia Symptoms Confusion, stomach pain, trouble speaking, extreme weakness, blurred vision, sweating, tremors, seizures, coma Hyperglycemia Symptoms Thirst, loss of appetite, nausea, increased urination, vomiting, drowsiness, dry mouth, dry skin A Beale PHRM Endocrine 5

6 Drugs with diabetes interactions Drugs that blood glucose Cause HYPERGLYCEMIA Drugs that blood glucose Cause HYPOGLYCEMIA Glucagon Diuretics Insulin Sympathomimetics Ethanol (chronic) Oral antihyperglycemic agents Amphetamines Glucocorticosteroids Ethanol (acute use) β Blockers β Agonists Pentamidine (initially) Cyclosporins Growth hormone Pentamidine Diazoxide Niacin Salicylates (hi-dose) Management of Hospitalized Patients with Type 2 diabetes Mellitus, SH Lilley and GI Levine, AAFP, 1 March 1998 A Beale PHRM Endocrine 6

7 Drugs with possible diabetes interactions Drugs that may blood glucose Caffeine CCBs ACE - I Drugs that may blood glucose Clonidine Estrogen/progestins Anabolic steroids Isoniazid Nicotine Aspirin (high doses) Octreotide Phenothiazines Disopyramide (Norpace) Phenytoin Rifampin Ganciclovir, saquinavir Management of Hospitalized Patients with Type 2 diabetes Mellitus, SH Lilley and GI Levine, AAFP, 1 March 1998 Quinine (high doses) Sulfonamides Patients on SSRIs often report hypoglycemia A Beale PHRM Endocrine 7

8 Ketoacidosis If cells can t take up glucose (DMT1), or if glucose is unavailable, respiration shifts to fatty acid oxidation Fatty acids produce acidic lactones when burned Very high blood glucose treated with insulin VERY HIGH or VERY LOW blood sugar Thirst Fruity breath Vomiting Dehydration Deep, gasping breath Confusion Dry, flushed skin Coma and death A Beale PHRM Endocrine 8

9 Parenteral Antihyperglycemic Drug Insulin (human Humulin R or Novolin R)! Indication Diabetes mellitus (all types), treatment of severe ketoacidosis, hyperkalemia, gestational diabetes. Expect nighttime hypoglycemia, especially in DMT2 patients when using insulin and/or insulin analogs. SC, IV, IM Short acting, used if eating minutes after injection R = Regular Which means, Human Top 4 drugs associated with medication errors: 1. Insulin 2. Morphine 3. Fentanyl 4. Tie: Metoprolol, Albuterol & Potassium chloride A Beale PHRM Endocrine 9

10 What about other routes? Insulin is a protein Subject to extensive and rapid metabolism Afrezza (human insulin of rdna origin) Previously called Afresa Nasal inhalation powder Approved 2014 Image: Huffington Post A Beale PHRM Endocrine 10

11 Types of insulin Aspart Detemir Glargine Glulisine Lispro Isophane (NPH) intermediate form produced by chemically combining insulin with protamine and zinc Regular - recombinant Zinc intermediate form. Zinc polymerizes the insulin making it last longer. Analogs produced by making slight changes to amino acid sequence. Some like Glargine are also complexed with zinc. These changes alter the kinetics. Analog, Beef or Pork analog = recombinant, beef/ pork isolated at slaughter (rarely used now) Human - recombinant Analog or Pork Novolog Levemir Lantus Apidra Humalog Humulin N Novolin N Relion Novolin N Iletin NPH Insulin Purified NPH Pork Humulin R Novolin R Iletin II Regular (Ultralente) Iletin Lente Iletin Lente Pork Lente Iletin II Novolin L A Beale PHRM Endocrine 11

12 Onset of action for Insulin types Rapid-Acting - for meals eaten at time of injection, typically used with longer-acting form Drug Onset (minutes) Peak (hours) Duration (hours) Lispro (Humalog)! Novolog or Aspart Short-Acting - for meals eaten within minutes of injection 3-5 Regular (R ) (Humulin R)! Intermediate-Acting - for overnight, or about 1/2 the day. Usually combined with above forms. Neutral Protamine Hagedorn - NPH (N)! (Humulin N) 1-2 hours 4-12 Lente (Humulin L)! hours Long-Acting - covers insulin needs for an entire day. May be combined with rapid/short form. Glargine (Lantus)! 1-3 hours A Beale PHRM Endocrine 12

13 1 st Generation Sulfonylureas Oral sulfonylureas stimulate the pancreas to secrete insulin Secretagogues Drug Chlorpropamide (Diabinese)! Tolazamide Tolbutamide Indication Adjunct to diet and exercise for type 2 DM If taking a sulfonylurea, patient must have a functional pancreas and be able to recognize and respond to symptoms of hypoglycemia Table adapted from: Focus on Nursing Pharmacology, 4th Ed., by AM Karch. Lippincott, Williams & Wilkins A Beale PHRM Endocrine 13

14 2 nd Generation Sulfonylureas Oral sulfonylureas can cause severe hypoglycemia & risk of CV death Drug Glimepiride Glipizide Glyburide (Micronase)! Indication Adjunct to diet and exercise for type 2 DM 1 st generation sulfonylureas are water soluble and less potent than 2 nd generation sulfonylureas which are lipid soluble. Table adapted from: Focus on Nursing Pharmacology, 4th Ed., by AM Karch. Lippincott, Williams & Wilkins A Beale PHRM Endocrine 14

15 Sulfonylureas ADRs SIADH G6PD Risk of CV death Hypoglycemia risk Blood dyscrasias Disulfiram-like rxns GI upset Dizziness, headache Drugs that hypoglycemic risk w/sulfonylureas NSAIDs & other highly PPB drugs Salicylates Sulfonamides Chloramphenicol Probenecid Coumarins MAOIs β blockers Other antidiabetes drugs Including the Sodium-Glucose Co-transporter 2 (SGLT2) inhibitors Canaglifozin (Invokana) Empagliflozin (Jardiance) A Beale PHRM Endocrine 15

16 Nonsulfonylureas Drug Metformin (Glucophage)! Pioglitazone (Actos)! Indication Biguanide Adjunct to diet & exercise for DMT2, also treats polycystic ovary syndrome Does not cause hypoglycemia and protects against CV effects of diabetes. Works mainly by hepatic gluconeogenesis. PPARγ agonist Adjunct to diet & exercise for DMT2 in combo with insulin or sulfonylureas to control blood sugar when one drug alone won t work NEW FDA WARNING: RISK OF BLADDER CANCER A Beale PHRM Endocrine 16

17 Metformin (Glucophage)! Hypoglycemic action Ketoconazole Erythromycin Chloramphenicol NSAIDs, salicylates Probenecid Warfarin Lactic acidosis action Corticosteroids Estrogens INH Phenytoin Thiazides Glucose control destabilized by β blockers PO, SID/BID with meals Quinolones Thyroid hormone Need functional kidneys A Beale PHRM Endocrine 17

18 Pioglitazone (Actos)! Insulin must be present It insulin resistance Activation of PPARγ nuclear receptors modulates transcription of several insulin responsive genes involved in the control of glucose and lipid metabolism. Indicated as an adjunct to diet & exercise to improve glycemic control in adults with type 2 DM ADRs Hypoglycemia risk Edema Weight gain May trigger ovulation Congestive HF PO, SID A Beale PHRM Endocrine 18

19 Nonsulfonylureas Drug Sitagliptin (Januvia)! Indication DPP4 inhibitor - Adjunct to diet & exercise for type 2 diabetes. Acts by inhibiting the enzyme, dipeptidyl peptidase 4, that breaks down incretins (glucagon-like peptide and glucose-dependant insulinotropic polypeptide) Exenatide (Byetta) Liraglutide (Victoza)! Think: Lizard spit Incretin mimics - Adjunct to diet & exercise for type 2 diabetes. Increase insulin secretion, decrease glucagon secretion and gastric emptying time. Boxed warning (Victoza) for thyroid cancer risk. Table adapted from: Focus on Nursing Pharmacology, 4th Ed., by AM Karch. Lippincott, Williams & Wilkins A Beale PHRM Endocrine 19

20 Sitagliptin (Januvia)! Janumet = sitagliptin + metformin ADRs Risk of hypoglycemia Pancreatitis Serious allergic rxns Upper RTI Nasopharyngitis Headache PO, SID Blocks the breakdown of incretins Dipeptidyl peptidase-4 (DPP4) inhibitor Incretins function to: glucagon secretion gastric emptying time appetite insulin secretion A Beale PHRM Endocrine 20

21 Liraglutide (Victoza)! Glucagon-like Peptide-1 (GLP-1) receptor agonist ADRs Severe hypoglycemia risk with sulfonylureas Headache Nausea Diarrhea Anti-liraglutide Ab SC, SID Regardless of meals Causes slow weight loss Hypothalmus interaction Glucose-dependent Only insulin in the presence of glucose Thyroid cancer seen in rodents A Beale PHRM Endocrine 21

22 Nonsulfonylureas Drug Bromocriptine (Cycloset)! Indication Ergot alkaloid, Dopamine agonist Adjunct to diet & exercise for DMT2 Must be given within 2 hours of waking PO, SID May cause nausea, hypotension, somnolence, and worsening of psychotic conditions Canaglifozin (Invokana)! SGLT2 inhibitor PO, SID Adjunct to diet & exercise for DMT2 Also given 1 st thing in the morning, before eating May cause bacterial/fungal UTIs, hypotension, hyperkalemia, hypoglycemia, increased LDL-C A Beale PHRM Endocrine 22

23 Other Diabetes medications Acarbose (Precose)! α-glucosidase inhibitor (inhibits carbohydrate digestion and absorption) - Helps prevent rapid glucose rise after eating. Indication: adjunct to diet and exercise to improve glycemic control in adults with DMT2 PO, up to TID with meals Should be taken with first bite of each meal. wt. gain and insulinotropic effects of sulfonylureas, but since CBH remain in GIT, microbes ferment the CBHs producing GAS A Beale PHRM Endocrine 23

24 Other Diabetes medications Drug Indication T2DM /comments Pramlintide (Symlin) Amylin analog - Adjunct to type 1 or 2 diabetes using meal-time insulin but without glycemic control Repaglinide (Prandon) Insulin secretagogue (stimulates the pancreas to secrete more insulin, similar to sulfonylureas) - Increases circulating insulin. Take tablet(s) with meals. A Beale PHRM Endocrine 24

25 Glucose elevating agents Drug Diazoxide Glucagon (Glucagen)! Indication Oral management of hypoglycemia, IV for severe hypertension Injectable to control severe hypoglycemic reactions (increases blood glucose and relax GIT smooth muscle) Table adapted from: Focus on Nursing Pharmacology, 4th Ed., by AM Karch. Lippincott, Williams & Wilkins A Beale PHRM Endocrine 25

26 Glucose elevating agents Glucagon (Glucagen)! rdna Polypeptide hormone Exogenous glucagon stimulates catecholamine release Must have sufficient liver glycogen. It won t work in states of: Starvation Adrenal insufficiency Chronic hypoglycemia Indications 1. Treatment of severe hypoglycemia 2. As a diagnostic aid in the radiologic exam of GIT when reduced GIT motility is needed. SC, IV, IM A Beale PHRM Endocrine 26

27 Other Endocrine Glands Gland Stomach Small intestine Heart Placenta Hormone Gastrin Stimulates gastric acid & digestive enzyme release Secretin Stimulates pancreas to release bicarb Cholecystokinin Stimulates gall bladder contractions Atrial natriuretic hormone ADH release Chorionic gonadotropin Stimulates ovaries to maintain pregnancy A Beale PHRM Endocrine 27