1. ★ thyroid hormones: levothyroxine sodium (Synthroid)
- Used to replace the thyroid hormone deficit.
- Monitor V/S. Monitor wt. Instruct the client to take the medication at the same time each day, in the morning without food. Instruct the client to avoid foods that can inhibit thyroid secretion, such as strawberries, peaches, pears, cabbage, turnips, spinach, kale, Brussels sprouts, cauliflower, radishes, and peas. Thyroid hormones should be given at least 4 hours apart from other medications. Instruct the client on how to monitor the pulse rate. Advise the client to take a thyroid hormone to report symptoms of hyperthyroidism, such as tachycardia, chest pain, palpitations, and excessive sweating.
2. ★ anti-thyroid medications: methimazole (Tapazole), propylthiouracil (PTU)
- Used to inhibit the synthesis of thyroid hormone.
- side/adverse effect: N/V/D, agranulocytosis, iodism
- Monitor V/S. Monitor wt. Instruct the client to take the medication with meals to avoid GI upset. Instruct the client regarding the importance of medication compliance and that abruptly stopping the medication could cause a thyroid storm. Monitor for signs and symptoms of thyroid storm, Instruct the client to avoid acetylsalicylic acid (Aspirin) and medications containing iodine. If a fever or sore throat develops, notify the HCP.
3. ★ corticosteroids (glucocorticoids)
- side/adverse effects : (쿠싱 신드롬과 유사) hyperglycemia, hypokalemia, hypocalcemia, osteoporosis, sodium and fluid retention, hypernatremia, weight gain, moon face, buffalo hump, truncal obesity, increased susceptibility to infection and masking of the signs and symptoms of infection, cataracts, hirsutism, acne, fragile skin, bruising, growth retardation in children, GI irritation, peptic ulcer, pancreatitis, seizures, psychosis
- cautions: Should be used with caution in clients with DM. Should be used with extreme caution in clients with infections because they mask the signs and symptoms of an infection. Increase the potency of medications taken concurrently, such as aspirin, and NSAIDs, thus increasing the risk of GI bleeding and ulceration. The use of potassium-wasting diuretics increases potassium loss, resulting in hypokalemia.
- Prepare a schedule as needed, for the client with information on short-term tapered doses. Instruct the client not to stop the medication abruptly because abrupt withdrawal can result in severe adrenal insufficiency. Instruct the client that it is best to take the medication in the early morning with food or milk. Note that the client may need additional doses during periods of stress, such as surgery. Instruct the client to avoid individuals with infections.
4. topical glucocorticoids
- anti-inflammatory, antipruritic, and vasoconstrictive actions
- Topical glucocorticoids can be absorbed into the systemic circulation. Absorption is greater in permeable skin areas such as the scalp, axilla, face and neck, eyelids, and perineum, and less in areas where permeability is poor, such as palms, soles, and back.
- local side/adverse effects: burning, dryness, irritation, itching, skin atrophy, thinning of the skin, hypopigmentation, overgrowth of bacteria
- systemic side/adverse effects: growth retardation in children, adrenal suppression, Cushing’s syndrome, skin atrophy, glaucoma, and cataracts
- Wash the area just before application to increase medication penetration. Apply sparingly in a thin film, rubbing gently. Avoid the use of a dry occlusive dressing unless specifically prescribed by the HCP.
5. ★ oral hypoglycemic medication
- Oral hypoglycemic agents are contraindicated in type 1 DM. (type2DM ○)
- β-adrenergic blocking agents may mask signs and symptoms of hypoglycemia associated with hypoglycemic medications. Anticoagulants, chloramphenicol (Chloromycetin), salicylates, propranolol (Inderal), MAOIs, pentamidine, and sulfonamides may cause hypoglycemia. Corticosteroids, sympathomimetics, thiazide diuretics, phenytoin (Dilantin), thyroid preparations, oral contraceptives, and estrogen compounds may cause hyperglycemia. Inform the client that insulin may be needed during stress, surgery, or infection.
5-1. ① sulfonylureas
- Stimulate the beta cells to produce more insulin.
ex) glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta)
- side/adverse effect: GI distress, hepatotoxicity, photosensitivity
- Sulfonylureas can cause a disulfiram type of reaction (antabuse effect) when alcohol is ingested. Cross reacts with sulfa. Amaryl with breakfast, QD. Glucotrol 30 minutes before breakfast.
5-2. ① meglitinides : non-sulfonylureas
- Stimulates the pancreas to produce more insulin
ex) nateglinide (Starlix), repaglinide (Prandin)
- Starlix and Prandin, with meals, bid or qid.
5-3. ② biguanide : non-sulfonylureas
- Suppresses hepatic production of glucose and increases insulin sensitivity.
ex) metformin (Glucophage)
- side/adverse effect: diarrhea (most common), lactic acid (most serious)
- Metformin may need to be withheld temporarily before and for 48 hours after having any radiologic study that involves the administration of IV contrast dye because of the risk of contrast-induced nephropathy and lactic acidosis. Glucophage with breakfast, QD, or bid.
5-4. ② thiazolidinediones : non-sulfonylureas
- Decrease hepatic glucose output.
ex) pioglitazone (Actos), rosiglitazone (Avandia)
- side/adverse effect: hepatotoxicity
- Actos and Avandia, QD.
5-5. ③ α-glucosidase inhibitors: non-sulfonylureas
- Delay absorption of ingested CHO, not increasing insulin production.
ex) acarbose (Precose), miglitol (Glyset)
- side/adverse effect: hepatotoxicity
- Precose and Glyset, given with the first bite of the meal.
6. ★ insulin
- Insulin increases glucose transport into cells and promotes the conversion of glucose to glycogen, decreasing serum glucose levels. (type1DM, type2DM)
- Insulin is contraindicated in clients with hypersensitivity.
- Storing insulin: Avoid exposing insulin to extremes in temperature. Insulin should not be frozen or kept in direct sunlight or a hot car. Before injection, insulin should be at room temperature. If a vial of insulin will be used up in 1 month, it may be kept at room temperature. Otherwise, the vial should be refrigerated.
- The main areas for injections are the abdomen, posterior surface in arms, anterior surface in thighs, and hips. Systematic rotation within one anatomical area is recommended to prevent lipodystrophy. Heat, massage, and exercise of the injected area can increase absorption rates. Injection into scar tissue may delay the absorption of insulin.
- Insulin glargine (Lantus), which is a long-acting insulin, cannot be mixed with any other type of insulin. Rapid (insulin aspart, human lispro injection) and short-acting (regular insulin, humulin R) insulins are the only types of insulin that can be administered intravenously. ① Gently rotate NPH insulin bottle. ② Drawback amount of air into the syringe that equals total dose. ③ Inject air equal to NPH dose into NPH vial. ④ Inject air equal to regular dose into the regular vial. ⑤ Withdraw regular insulin dose. ⑥ Without adding more air to NPH vial, carefully withdraw NPH dose.