Adrenocortical Drugs Nursing Considerations & Management

Adrenocortical agents are drugs used as short-term treatment to suppress immune system in patients with inflammatory disorders. They are also used for replacement therapy to maintain hormone levels when adrenal glands are not functioning adequately. These agents are classified into three: glucocorticoids, mineralocorticoids, and androgens.

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Table of Common Drugs and Generic Names

Here is a table of commonly encountered adrenocortical agents, their generic names, and brand names:

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Disease Spotlight: Adrenal Insufficiency and Crisis

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 when a patient does not produce enough ACTH, when the glands are not able to respond to ACTH, when an adrenal gland is damaged and cannot produce enough hormones (Addison’s disease), or secondary to surgical removal of glands. A prolonged use of corticosteroid hormones is a more common cause of adrenal insufficiency.

• Adrenal crisis occurs when patients who have an adrenal insufficiency experience a period of extreme stress like vehicle accidents, massive infections, or a surgical procedure. The body is not able to supplement the energy-consuming effects of the sympathetic reaction. This is characterized by physiological exhaustion, hypotension, fluid shift, shock, and even death.
• Patients in adrenal crisis are treated with massive infusion of replacement steroids, constant monitoring, and life support procedures.

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Glucocorticoids

Definition

• Glucocorticoids are agents that stimulate an increase in glucose levels for energy. They also increase the rate of protein breakdown and decrease the rate of protein formation from amino acids to preserve energy. They are also capable of lipogenesis, or the formation and storage of fat in the body for energy source.

Therapeutic Action

The desired and beneficial action of glucocorticoids:

• bind to cytoplasmic receptors of target cells to form complex reactions needed to reduce inflammation and to suppress immune system.
• Other glucocorticoids like hydrocortisone, cortisone, and prednisone also have mineralocorticoid activity so they can affect potassium, sodium, and water levels. They can also limit the activity of lymphocytes to act within the immune system. Furthermore, they inhibit the spread of phagocytes to the bloodstream and injured tissues.

Indications

Glucocorticoids are indicated for the following medical conditions:

• short-term treatment of inflammatory disorders by blocking the actions of arachidonic acid leading to decrease in formation of prostaglandins and leukotrienes.
• Local agents are used to treat local inflammation.
• Systemic use is indicated for treatment of some cancers, hypercalcemia associated with cancer, hematological disorders, and some neurological infections.
• When combined with mineralocorticoids, some of these drugs can be used in replacement therapy for adrenal insufficiency.

Pharmacokinetics

Here are the characteristic interactions of glucocorticoids and the body in terms of absorption, distribution, metabolism, and excretion:

Contraindications and Cautions

The following are contraindications and cautions for the use of glucocorticoids:

• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Acute infection. Can be exacerbated by the blocking effects of the drug on inflammation and immune system.
• Diabetes. Glucose-elevating effect of the drug can disrupt glucose control
• Other endocrine disorders. Potential of imbalance.
• Pregnancy. Potential adverse effects on the fetus

Adverse Effects

Use of glucocorticoids may result to these adverse effects:

• increased methylprednisolone toxicity among African Americans
• growth retardation
• local inflammation and infections
• burning and stinging sensation at injection site.

Interactions

The following are drug-drug interactions involved in the use of glucocorticoids:

• Erythromycin, ketoconazole, troleandomycin. Increased toxic effects.
• Salicylates, barbiturates, phenytoin, or rifampin. Decreased serum level and effectiveness if with.

Nursing Considerations

Here are important nursing considerations when administering glucocorticoids:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

• Assess for contraindications or cautions (e.g. history of allergy, pregnancy, acute infections, etc.) to avoid adverse effects.
• Assess weight; temperature; orientation and affect; grip strength; eye examination; blood pressure, pulse, peripheral perfusion, and vessel evaluation; respiration and adventitious breath sounds; glucose tolerance, renal function, serum electrolytes to determine baseline status before beginning therapy and for any potential adverse effects.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

• Altered cardiac output related to fluid retention
• Excess fluid volume related to water retention
• Risk for infection related to immunosuppression

Implementation with Rationale

These are vital nursing interventions done in patients who are taking glucocorticoids:

• Administer drug daily at 8 to 9 AM to mimic normal peak diurnal concentration levels and thereby minimize suppression of the hypothalamic-pituitary axis (HPA).
• Space multiple doses evenly throughout the day to try to achieve homeostasis.
• Taper doses when discontinuing to give the adrenal glands a chance to recovr and produce adrenocorticoids.
• Protect patient from unnecessary exposure to infection and invasive procedure because the steroids suppress the immune system and the patient is at increased risk for infection.
• Provide comfort measures to help patient cope with drug effects.
• Provide patient education about drug effects and warning signs to report to enhance patient knowledge and to promote compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

• Monitor patient response to therapy (e.g. relief of signs and symptoms of inflammation, return of adrenal function within normal limits).
• Monitor for adverse effects (e.g. infections, skin changes, fatigue).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.

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Mineralocorticoids

Description

• Mineralocorticoids affect electrolyte levels directly and help maintain homeostasis.
• The classic mineralocorticoid is aldosterone.

Therapeutic Action

The desired and beneficial action of mineralocorticoids:

• aldosterone increases sodium reabsorption in the renal tubules and increases potassium and hydrogen excretion, leading to water and sodium retention.

Indications

Mineralocorticoids are indicated for the following medical conditions:

• partial replacement therapy in cortical insufficiency conditions, treatment of salt-losing adrenogenital syndrome; off-label use: treatment of hypotension.

Pharmacokinetics

Here are the characteristic interactions of mineralocorticoids and the body in terms of absorption, distribution, metabolism, and excretion:

Contraindications and Cautions

The following are contraindications and cautions for the use of mineralocorticoids:

• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Severe hypertension, heart failure, or cardiac disease. Resultant increased blood pressure
• Lactation. Potential adverse effects to the baby.
• Infection. Can alter adrenal response
• High sodium intake. Severe hypernatremia can occur.

Adverse Effects

Use of mineralocorticoids may result to these adverse effects:

• CNS: headache, weakness
• CV: edema, hypertension, heart failure,
• Others: possible hypokalemia, allergic reactions from skin rash to anaphylaxis.

Interactions

The following are drug-drug interactions involved in the use of mineralocorticoids:

• Salicylates, barbiturates, hydantoins, rifampin, and anticholinesterase. Decreased effectiveness of these drugs.

Nursing Considerations

Here are important nursing considerations when administering mineralocorticoids:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

• Assess for contraindications or cautions (e.g. history of allergy to drug, history of heart failure, hypertension, etc.) to avoid adverse effects.
• Assess blood pressure, pulse, and adventitious breath sounds; weight and temperature; tissue turgor; reflexes and bilateral grip strength; and serum electrolyte levels, to determine baseline status before beginning therapy and for any potential adverse effects.

Nursing Diagnoses and Care Planning

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

• Imbalanced nutrition: more than body requirements related to metabolic changes
• Excess fluid volume related to sodium retention
• Impaired urinary elimination related to sodium retention

Implementation with Rationale

These are vital nursing interventions done in patients who are taking mineralocorticoids:

• Use only in conjunction with appropriate glucocorticoids to maintain control of electrolyte balance.
• Increase dose in times of stress to prevent adrenal insufficiency and to meet increased demands for corticosteroids under stress.
• Monitor for hypokalemia (weakness, serum electrolytes) to detect the loss early and treat appropriately.
• Discontinue if signs of overdose (excessive weight gain, edema, hypertension) occur to prevent the development of more severe toxicity.
• Provide comfort measures to help patient cope with drug effects.

Provide patient education about drug effects and warning signs to report to enhance patient knowledge and to promote compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

• Monitor patient response to therapy (maintenance of electrolyte balance).
• Monitor for adverse effects (e.g. fluid retention, edema, hypokalemia, headache).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.

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