ADRENOCORTICAL AGENTS

• Types of Adrenocortical Agents

  • Glucocorticoids
  • Mineralocorticoids
  • Androgens
• Adrenocortical agents are drugs used as short-term treatment to suppress the immune system in patients with inflammatory disorders
• Adrenocortical agents are also used for replacement therapy to maintain hormone levels when adrenal glands are not functioning adequately
• Adrenocortical agents are classified into three categories: glucocorticoids, mineralocorticoids, and androgens
• Adrenal insufficiency is a condition when patients experience a shortage of adrenocortical hormones and develop signs and symptoms like confusion, hyperpigmentation, hypoglycemia, and poor response to stress. This can occur due to various reasons such as not producing enough ACTH, glands not responding to ACTH, damaged adrenal gland (Addison’s disease), or secondary to surgical removal of glands. Prolonged use of corticosteroid hormones is a common cause of adrenal insufficiency.
• Adrenal crisis occurs when patients with adrenal insufficiency experience extreme stress like vehicle accidents, massive infections, or surgical procedures. It is characterized by physiological exhaustion, hypotension, fluid shift, shock, and even death. Treatment involves massive infusion of replacement steroids, constant monitoring, and life support procedures.
• Glucocorticoids


  Agents that stimulate an increase in glucose levels for energy, increase protein breakdown rate, decrease protein formation rate, and are capable of lipogenesis. They bind to cytoplasmic receptors of target cells to reduce inflammation, suppress the immune system, affect potassium, sodium, and water levels, limit lymphocyte activity, and inhibit the spread of phagocytes.
• Indications for Glucocorticoids


  • Short-term treatment of inflammatory disorders, local inflammation, some cancers, hypercalcemia associated with cancer, hematological disorders, some neurological infections, and in replacement therapy for adrenal insufficiency when combined with mineralocorticoids
• Drug-drug interactions with glucocorticoids

  • Erythromycin, ketoconazole, troleandomycin result in increased toxic effects
  • Salicylates, barbiturates, phenytoin, rifampin result in decreased serum level and effectiveness
• Mineralocorticoids

  Affect electrolyte levels directly and help maintain homeostasis
• Aldosterone


  Classic mineralocorticoid that increases sodium reabsorption in the renal tubules, increases potassium and hydrogen excretion, leading to water and sodium retention
• Indications for mineralocorticoids


  • Partial replacement therapy in cortical insufficiency conditions
  • Treatment of salt-losing adrenogenital syndrome
  • Off-label use: treatment of hypotension
• High sodium intake can result in severe hypernatremia
• Mineralocorticoids can cause potential adverse effects on the baby during lactation
• Adverse effects of mineralocorticoids

  • CNS: headache, weakness
  • CV: edema, hypertension, heart failure
  • Others: possible hypokalemia, allergic reactions from skin rash to anaphylaxis
• Glucocorticoids promote the preservation of energy through increased glucose levels, protein breakdown, and fat formation
• Glucocorticoids reduce inflammation and suppress the immune system by forming complex reactions needed to reduce inflammation
• Glucocorticoids limit the activity of lymphocytes to act within the immune system
• Hypothalamic agents can inhibit or stimulate the release of hormones from the anterior pituitary using hormones or factors
• Stimulating factors (agonists)

  • growth hormone-releasing hormone (GHRH)
  • thyrotropin-releasing hormone (TRH)
  • gonadotropin-releasing hormone (GnRH)
  • corticotropin-releasing hormone (CRH)
  • prolactin-releasing hormone (PRH)
• Factors that inhibit (antagonists)

  • somatostatin (growth hormone-inhibiting factor)
  • prolactin-inhibiting factor
• Commonly encountered endocrine system drugs

  • goserelin (Zoladex)
  • histrelin (Vantas)
  • leuprolide (Lupron)
  • nafarelin (Synarel)
  • tesamorelin (Egrifta)
  • degarelix
  • ganirelix (Antagon)
• Tesamorelin is used to stimulate GH and its lipolytic effects, helping to decrease the excess abdominal fat in HIV-infected patients with lipodystrophy
• Hypothalamic agents are indicated for diagnostic testing, treating some forms of cancer, or as adjuncts in fertility programs
• Indications for hypothalamic agents

  • Used mostly for diagnostic testing, treating some forms of cancer, or as adjuncts in fertility programs
• Agonists of GnRH

  • goserelin, histrelin, leuprolide, nafarelin
• Antagonists of GnRH

  • degarelix, ganirelix
• Agonists decrease production of sex hormones and are used as treatment for precocious puberty, endometriosis, and advanced prostate cancer
• Antagonists of GnRH are used as treatment for advanced prostate cancer and inhibition of premature LH surge in women undergoing controlled ovarian stimulation for fertility
• Adverse effects of hypothalamic agents include increased release of sex hormones, ovarian overstimulation, flushing, increased temperature and appetite, fluid retention for agonists. For antagonists, effects include decreased testosterone level, loss of energy, decreased sperm count and activity, alterations in secondary sex characteristics, fluid and electrolyte changes, insomnia, irritability
• Use of hypothalamic agents

  May result in adverse effects
• Specific nursing care of patients receiving hypothalamic releasing factor is related to the hormone(s) that the drug is affecting
• Practice Quiz: Hypothalamic Agents
• Question 3: Knowing hypothalamic agonists’ effect to the sex hormones, which of the following medical conditions can they be used? A. infertility B. endometriosis C. precocious puberty D. Both B and C Answer: D. Both B and C Agonists can decrease the production of sex hormones. Medical conditions like endometriosis and precocious puberty are characterized by increased sex hormones. Infertility will best benefit from hypothalamic antagonists.
• Medical conditions like endometriosis and precocious puberty are characterized by increased sex hormones
• Infertility will best benefit from hypothalamic antagonists
• This drug decreases the abdominal fat in HIV-infected patients with lipodystrophy: tesamorelin
• Tesamorelin stimulates the lipolytic effect of growth hormones
• In patients receiving hypothalamic agents, serum sodium and potassium levels, blood sugar level, and all of the above should be monitored closely
• In patients receiving hypothalamic agents, the nurse should monitor closely for adverse effects associated with changes in overall endocrine function, particularly growth and development and metabolism. Other aspects to be monitored include periodic radiograph of long bones, hydration, and nutrition