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• Anatomy and Physiology of the Endocrine System
• Diabetes
• Thyroid Disorders
• Adrenal Gland Disorders
• Herbal and Alternative Therapies
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Anatomy and Physiology of the Endocrine System
• A collection of glands in various parts of the body that produce hormones that regulate bodily functions
 Hormones are secreted substances that regulate metabolism, growth, and fluid balance in various ways
• A negative feedback system regulates hormone release; often is a series of hormones, with one activating the next
 As more hormones are released into the bloodstream, receptors detect the rise in concentration of the hormone and signal the gland to slow production
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Anatomy and Physiology of the Endocrine System
• It controls other endocrine glands and bodily functions
• Part of the hypothalamic-pituitary axis
• Pituitary gland plays a key role in growth, onset of puberty, and reproduction cycles
 Core feedback mechanism that controls endocrine function
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Anatomy and Physiology of the Endocrine System
• This gland stimulates other glands in the endocrine system to release hormones into the bloodstream
• These hormones trigger responses in target tissues
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Anatomy and Physiology of the Endocrine System
• It releases T
3 and T pituitary gland
4 in response to TSH released from the
• T
3 controls most of the physiological action
• Both T
3 and T
4 regulate basal metabolic rate and affect metabolism of carbohydrates, fats, and proteins
• Thyroid hormones increase conversion of food to energy which raises body temperature
 Iodine is required for formation of thyroid hormones
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Anatomy and Physiology of the Endocrine System
• Glands are located on top of the kidneys
• Adrenal cortex (outer layer) releases corticosteroids
 Mineralocorticoids regulate fluid and electrolyte balance
 Glucocorticoids affect day/night cycles and metabolism
• Adrenal medulla (inner layer) produces adrenaline
(epinephrine)
 Adrenaline increases blood pressure, diverts blood from organs to muscles, releases stored glucose and fat
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Anatomy and Physiology of the Endocrine System
(continued)
• Adrenaline readies the body for “fight or flight”
• It can give someone tremendous strength or speed when encountering a fearful situation
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Anatomy and Physiology of the Endocrine System
• Hypothalamus produces corticotropin-releasing factor that stimulates the pituitary gland to make ACTH
• ACTH stimulates adrenal glands to release cortisol (the primary glucocorticoid) in a circadian rhythm
• Cortisol affects glucose metabolism, fat deposition, water retention, and anti-inflammatory action of the immune system
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Anatomy and Physiology of the Endocrine System
• It produces and releases digestive enzymes into intestine
• Alpha islet cells of pancreas produce glucagon, which
 activates liver cells to break down stored glycogen into glucose and release it into the blood
 raises blood glucose levels
 facilitates breakdown of fats and proteins into alternative sources of energy, producing ketones
• Beta islet cells of pancreas produce insulin, which
 is released in response to a rise in blood glucose
 allows glucose to enter cells and provide energy
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Anatomy and Physiology of the Endocrine System
• The pancreas releases insulin after eating to lower blood glucose and releases glucagon when fasting to maintain adequate blood glucose
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Anatomy and Physiology of the Endocrine System
• Various hormones produced in the endocrine system maintain blood glucose levels after eating and between meals
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Diabetes
• Diabetes is elevated blood glucose that results in damage to small blood vessels and nerve tissue
 It has significant and life-threatening effects
• Three types: Type 1, Type 2, and gestational diabetes
• Least common type; affects about 10% of patients with diabetes (sometimes called juvenile diabetes)
• Autoimmune process impairs body’s ability to make insulin
• Without insulin, glucose climbs to dangerous blood levels; body uses alternative energy sources, producing ketones
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Diabetes
• In the absence of insulin, ketones accumulate to toxic levels in the blood, producing a lifethreatening emergency called ketoacidosis
• Therefore, insulin is given to patients with
Type 1 diabetes
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Diabetes
• A multifactorial disorder causing high blood glucose; accounts for around 90% of patients with diabetes
• It begins with central obesity (accumulation of abdominal fat) that causes insulin insensitivity
 Pancreas still makes insulin, but the insulin does not work as well
• Insulin insensitivity triggers overproduction of glucagon, which increases blood glucose
• Beta cells try to produce more insulin but can’t keep up
• First treated with oral agents; eventually insulin is needed
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Diabetes
(continued)
• Progressive disease that causes insulin insensitivity, impaired insulin production, and altered glucagon release
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Diabetes
• Many patients with Type 2 diabetes have metabolic syndrome
• Condition refers to a triad of problems: high BP, high cholesterol and triglycerides, and high blood glucose
• Patients may not have high blood glucose all of the time
 May have impaired fasting glucose or impaired glucose tolerance
• Condition puts patients at high risk for cardiovascular disease
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Diabetes
• Insulin resistance caused by excess hormones produced during pregnancy; preserves glucose for developing fetus
• It mimics Type 2 diabetes and often precedes it
• Common: increased urination (polyuria), excessive urination at night (nocturia), glucose in the urine
(glycosuria), thirst (polydipsia), hunger (polyphagia), blurred vision, fatigue
• Other: frequent infections, slow wound healing, weight gain or loss, numbness and tingling in fingers and toes
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Diabetes
• Age over 45 years
• Family history of diabetes
(parents/siblings)
• Overweight (BMI over 25 kg/m2)
• Habitual physical inactivity
• Race/ethnicity
• Impaired fasting glucose or glucose intolerance
• Hypertension (BP over
140/90 mmHg)
• Low HDLs and high triglycerides
• History of gestational diabetes or birth of baby over 9 pounds
• Polycystic ovary syndrome
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Diabetes
•
Nephropathy: damage to kidneys, affecting their ability to filter the blood
 If untreated, can lead to kidney failure and transplant
• Neuropathy: damage to tiny nerves in the extremities; in the feet, loss of sensation can lead to ulcers
 If untreated, can lead to infection and amputation
• Retinopathy: damage to retinal tissue in the eyes
 If untreated, can progress to blindness
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Diabetes
•
Macrovascular complications for Type 2 diabetes
 Heart disease
 Heart attack
 Patient with diabetes half as likely to survive as someone without diabetes
 Strokes
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Diabetes
• Low blood glucose or low blood sugar reaction
• Commonly results from injecting too much insulin or skipping meals when taking medication for diabetes
• Symptoms: shakiness, dizziness, sweating, headache, irritability, confusion, vision changes, hunger
• If have symptoms, test blood glucose and consume simple sugar right away
 15–30 g of carbohydrate such as nondiet soda, juice, hard candy, glucose tablets
 Do not ingest large amounts of food
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Diabetes
• Diabetes is detected by measuring blood glucose (sugar) concentrations via lab blood tests or fingerstick at home
• Blood glucose levels
 Normal: 70–120 mg/dL
 Indicative of diabetes: 200 mg/dL or greater or a fasting result (8 + hours since eating) of 126 mg/dL or greater
• Glucose meters
 Available for home use; technicians can help patients with selection and demonstration
 Goal is to maintain blood glucose within normal range
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Diabetes
• Test used to assess overall blood glucose control
• Measures the percentage of RBCs with glucose stuck to the hemoglobin molecules contained inside
 Glucose binds to hemoglobin for life of RBCs (3 months)
 This test provides an overall average of glucose concentration over the previous 3 months
• Normal range for an A1C is 4–6%; patients with untreated diabetes can have an A1C of 10% or greater
• The test can be run via a blood draw in the laboratory or fingerstick technology in a clinic or pharmacy setting
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Diabetes
• Drug therapy treats but does not cure disorder
• Treatment for Type 1 diabetes is insulin
• Initial treatment for Type 2 diabetes is lifestyle changes
 Reduction of carbohydrate, fat, and calorie intake; regular exercise; smoking cessation; weight loss
• Drug therapy for Type 2 diabetes begins with metformin, followed by combination therapy, and eventually leading to insulin
 Insulin is required to achieve goals for blood glucose and A1C
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Question 1: What is the function of glucose in the body?
Answer: Glucose provides the energy for all the cells in the body to live.
Question 2: A patient who has Type 2 diabetes has made various lifestyle changes. She has lost excess weight, watches her carbohydrate and fat intake, and exercises most days. What is likely to happen next?
Answer: Because Type 2 diabetes is progressive, the patient will eventually need drug therapy, beginning with metformin.
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Diabetes
• Indication (initial): Type 2 diabetes, alone or in combination with other agents
• Mechanism of Action: inhibits excess hepatic glucose production, increases insulin sensitivity in body tissues
• Route: all are oral; take with food or milk
• Side Effects (common): stomach upset, abdominal cramps, nausea, diarrhea, flatulence, metallic taste
• Side Effects (severe, rare): lactic acidosis (potentially fatal)
• Cautions: Contraindicated in patients with kidney dysfunction, liver problems, heart failure
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Diabetes
• Two classes: sulfonylureas and glinides
• Indication (sulfonylureas and glinides): Type 2 diabetes, alone or in combination with other agents
• Mechanism of Action: stimulate insulin production from the pancreas to directly lower blood sugar
• Route: all are oral; different onsets and durations of action
 Sulfonylureas: 30 minutes or more to start working, last
8 hours or longer
 Glinides): 10 minutes to start working, last for about 2 hours
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Diabetes
(continued)
• Side Effects (common): hypoglycemia
• Side Effects (other): nausea, diarrhea, constipation
• Cautions: patients should know the symptoms of low blood sugar and how to treat it; monitor regularly
• Cautions: patients with liver or kidney disease may not be able to take sulfonylureas
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Diabetes
• Also called glitazones or TZDs
• Indication: Type 2 diabetes, used in combination with metformin or sulfonylureas
• Mechanism of Action: cause increased production of insulin receptors to increase insulin sensitivity in body
• Route: all are oral; onset varies (weeks or months)
• Side Effects (common): fluid accumulation (edema), weight gain
• Side Effects (severe, rare): liver toxicity, macular edema
• Caution: patients with heart failure should not take TZDs
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Diabetes
• Indication: Type 2 diabetes, in combination with metformin or sulfonylureas
• Mechanism of Action: either mimic endogenous incretin hormones or change their metabolism to increase activity
• Route: SC or oral
• Side Effects (GLP-1, common): nausea, vomiting, diarrhea, dizziness, fatigue, headache
• Side Effects (DPP-4 inhibitors, common): headache, nasopharyngitis, upper RTIs
• Caution: refrigerate injectables until dispensed or used
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Diabetes
• Indication (Type 1): combination of basal and bolus insulin
• Indication (Type 2): same as Type 1 or an injection of longacting insulin at bedtime added to oral medications
• Four types of insulin: rapid-acting, short-acting, intermediate-acting, long-acting (see Table 17.6)
• Route: SC injection only; self-injections used
 Abdomen is preferred injection site due to consistent rate of absorption into blood
 Insulin available in vials (for syringes) and self-injector pen devices; patients must be instructed on use
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Diabetes
(continued)
 Insulin pumps also available; deliver insulin through a tiny tube just under the skin
• Side Effects (common): serious hypoglycemia
• Side Effects (severe): diabetic coma if blood glucose levels are lower than 40 mg/dL
 Diabetic coma (loss of consciousness and brain damage) is a medical emergency
• Caution: insulin should be refrigerated until dispensed or used; do not use if insulin clumps or looks frosty
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Diabetes
• Indication: adjunctive treatment for Type 2 diabetes, but is limited by side effects
• Mechanism of Action: inhibit digestion of carbohydrates within the GI system, which reduces glucose absorption
• Route: oral; taken with first bite of each meal to keep carbohydrates in the food from entering the bloodstream in high amounts
• Side Effects (common): abdominal pain, gas, bloating, diarrhea
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Thyroid Disorders
• Too little thyroid hormone is produced (more common than hyperthyroidism)
• Causes: pituitary or hypothalamus dysfunction, removal of thyroid, Hashimoto’s disease; radioactive iodine therapy
• Symptoms: constipation, bradycardia, dry skin, tremors, weight gain, cold intolerance, depression, fatigue, reduced mental acuity, memory loss
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Thyroid Disorders
• Too much thyroid hormone is produced
• Causes: Graves’ disease, thyroid nodules or tumors, pituitary nodules or tumors
• Symptoms: diarrhea, skin flushing, nervousness, insomnia, hyperactivity, heat intolerance, tachycardia, weight loss
• Sign: exophthalmos (fat collects behind the eyeball, causing protrusion and inability for eyelids to fully close)
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Thyroid Disorders
• TSH is the lab test used to monitor thyroid disorders
• TSH, released by the pituitary gland, stimulates thyroid to make T
3 and T
• High TSH results
4 means that T
3
T
4 are low
(hypothyroid) and
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Thyroid Disorders
• Treatment for hypothyroidism involves oral thyroid hormone supplementation
• Treatment for hyperthyroidism involves
 Surgery to remove or reduce the malfunctioning gland or ablation (destroys thyroid via radioactive iodine)
 Afterward, oral thyroid supplementation is given to artificially provide adequate hormone levels
• Route: daily oral doses; doses are individualized to each patient using blood tests to measure hormone levels
 Each tablet strength of thyroid hormone is color-coded
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Thyroid Disorders
(continued)
• Side Effects (common): usually related to therapeutic overdose; patient exhibits hyperthyroid symptoms such as heart palpitations, elevated BP, fever, tremors, headache
• Side Effects (long-term overdosage): loss of bone density and impaired fertility; for gross overdosing, cardiac arrest
• Caution: when filling thyroid hormone products, use the same product for the same patient for each refill
 Do not switch between brands and generic forms
 Various brands may contain slightly different amounts, enough for changes to be felt by individual patients
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Question 1: A patient who has diabetes is taking insulin. Because he is very busy at work, he decides to skip breakfast and lunch.
Now he feels like he might pass out. His blood glucose concentration is 40 mg/dL. What will likely happen next?
Answer: The patient may be experiencing a diabetic coma, requiring emergency care.
Question 2: How is drug therapy for hypothyroidism and hyperthyroidism alike?
Answer: In hypothyroidism, thyroid hormone supplementation is accomplished with the same oral medications as used after thyroid removal or ablation in hyperthyroidism.
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Adrenal Gland Disorders
• Disorders can be categorized by either the overproduction or the underproduction of hormones
• Two types of adrenal gland disorders include Addison’s disease and Cushing’s disease
• Deficiency (underproduction) of glucocorticoids and mineralocorticoids; this condition can be serious
• Symptoms: weakness; hyperkalemia, hyperpigmentation of skin, low blood sodium and glucose, low BP, weight loss
• Treatment: oral corticosteroids
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Adrenal Gland Disorders
• Overproduction of steroid hormones; often caused by tumors in the adrenal glands, but overmedication with corticosteroids is also a cause
• Symptoms: moon face, abdominal weight gain, buffalo hump, osteoporosis, mood changes, hypertension, cataracts, PUD
• Normal sleep and wake cycles may also be affected
• Treatment: surgery to remove tumors; sometimes cytotoxic drug therapy
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Herbal and Alternative Therapies
• Chromium
 An essential trace element used for diabetes prevention and treatment
 Patients with diabetes have a chromium deficiency
 Patients with kidney or liver disease should avoid
• Cinnamon
 Taken for Type 2 diabetes
 Research shows that it has minimal effects on blood glucose
 Patients with liver diseases should avoid
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• The endocrine system regulates metabolism, growth, and fluid in various ways
• Insulin is used exclusively to treat Type 1 diabetes
• Type 2 diabetes is treated with oral agents first; most patients need insulin at some point
• Metformin, sulfonylureas, TZDs, and incretins are oral agents used to treat Type 2 diabetes
• Oral thyroid hormones are used to treat hypothyroidism
• Addison’s disease and Cushing’s disease are adrenal gland disorders
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