Adrenocortical Agents

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.

Glucocorticoids & Mineralocorticoids: Generic and Brand Names

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

• Glucocorticoids
  • beclomethasone (Beclovent)
  • betamethasone (Celestone)
  • budesonide (Rhinocort, Entocort EC)
  • dexamethasone (Decadron)
  • hydrocortisone (Cortef)
  • methylprednisolone (Medrol)
  • prednisolone (Delta-cortef)
• Mineralocorticoids
  • fludrocortisone (Florinef)
  • hydrocortisone (Cortef)

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.

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:

Route	Onset	Peak	Duration
PO	Varies	1-2 h	1-1.5 d
T1/2: 3.5 h Metabolism: liver Excretion: urine

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.

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:

Route	Onset	Peak	Duration
PO	Gradual	1.7 h	18-36 h
T1/2: 3.5 h Metabolism: liver Excretion: urine

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.

Practice Quiz: Adrenocortical Agents

Here are some practice questions for this study guide. Please visit our nursing test bank page for more NCLEX practice questions.

1. Glucocorticoids are hormones that:

A. are released in response to high glucose levels
B. help to regulate water balance in the body
C. help to regulate electrolyte levels
D. promote the preservation of energy through increased glucose levels, protein breakdown, and fat formation

1. Answer: D. promote the preservation of energy through increased glucose levels, protein breakdown, and fat formation

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.

2. Glucocorticoids can reduce inflammation and suppress the immune system by:

A. forming complex reactions needed to reduce inflammation
B. activating more lymphocytes to reduce inflammation
C. inhibiting the localization of phagocytes so immune system can rest
D. all of the above

2. Answer: A. forming complex reactions needed to reduce inflammation

They bind to cytoplasmic receptors of target cells to form complex reactions needed to reduce inflammation and suppress the immune system. They also limit the activity of lymphocytes to act within the immune system. Lastly, they inhibit the spread of phagocytes to the bloodstream and injured tissues.

3. A patient on aldosterone can eat all of the following meals, except:

A. egg-and-vegetable breakfast crostini
B. bagels, salad, and cottage cheese
C. dried peas and beans
D. white bean and roasted red bell pepper hummus

3. Answer: B. bagels, salad, and cottage cheese

All of the following are low in sodium except bagels, salad (dressing is high in sodium), and cottage cheese. High-sodium intake should be avoided to prevent severe hypernatremia.

4. A patient is started on a regimen of prednisone because of a crisis in her ulcerative colitis. Nursing care of this patient would need to include:

A. immunizations to prevent infections
B. increased calories to deal with metabolic changes
C. fluid restriction to decrease water retention
D. administration of the drug around 8 or 9 AM to mimic normal diurnal rhythm.

4. Answer: D. administration of the drug around 8 or 9 AM to mimic normal diurnal rhythm.

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).

5. Which of the following patient complaint(s) will alert the nurse for possible aldosterone toxicity?

A. muscle weakness and abdominal fullness
B. BP of 80/60 mmHg
C. parched skin and dry mucous membranes
D. all of the above

5. Answer: A. muscle weakness and abdominal fullness

Signs of toxicity include hypokalemia, weight gain, edema, and hypertension. Muscle weakness and abdominal fullness can be signs and symptoms of hypokalemia.

Hypothalamic Agents

Hypothalamic agents can inhibit or stimulate the release of hormones from the anterior pituitary using hormones or factors. However, not all of these hormones are available for pharmacological use.

Stimulating factors (agonists) include growth hormone-releasing hormone (GHRH), thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH), corticotropin-releasing hormone (CRH), and prolactin-releasing hormone (PRH).

Factors that inhibit (antagonists) include somatostatin (growth hormone-inhibiting factor) and prolactin-inhibiting factor.

Other drugs acting on the endocrine system include the following: pituitary agents, adrenocortical agents, thyroid and parathyroid agents, and agents to control blood glucose levels.

Hypothalamic Agents: Generic and Brand Names

Here is a table of commonly encountered endocrine system drugs, their generic names, and brand names:

Classification	Generic Name	Brand Name
Agonists	goserelin	Zoladex
histrelin	Vantas
leuprolide	Lupron
nafarelin	Synarel
tesamorelin	Egrifta
Antagonists	degarelix
ganirelix	Antagon

Therapeutic Action

The desired and beneficial action of hypothalamic agents is:

• Not clearly identified as there are only minute quantities found.
• Not all of them are used as pharmacological agents. Some are used for diagnostic purposes only and others are primarily used as antineoplastic agents.
• Tesamorelin is used to stimulate GH and its lipolytic effects, helping to decrease the excess abdominal fat in HIV-infected patients with lipodystrophy.

Indications

Hypothalamic agents are indicated for the following medical conditions:

• Hypothalamic hormones are not all available for pharmacological use; those that are available are used mostly for diagnostic testing, for treating some forms of cancer, or as adjuncts in fertility programs.
• Agonists like goserelin, histrelin, leuprolide, and nafarelin are analogues of GnRH. They decrease production of sex hormones. They are used as treatment for precocious puberty, endometriosis, and advanced prostate cancer.
• Antagonists of GnRH like degarelix and ganirelix are used as treatment for advanced prostate cancer and inhibition of premature LH surge in women undergoing controlled ovarian stimulation for fertility.

Here are some important aspects to remember for indication of hypothalamic agents in different age groups:

Children

• Monitor closely for adverse effects associated with changes in overall endocrine function, particularly growth and development and metabolism.
• Standard part of treatment plan should include periodic radiograph of long bones and monitoring of blood sugar and electrolytes.

Adults

• Monitor blood sugar and electrolytes.
• Review proper administration of nasal forms of drugs for diabetes insipidus to prevent complications.
• Review proper storage, preparation, and administration of regular injections.
• Drugs should not be used among pregnant and lactating women unless benefits clearly outweigh the risks.

Older adults

• Evaluate hydration, nutrition, and electrolyte balance periodically.
• Review proper administration technique because they are at high risk for dehydrated membranes and ulcerations.

Pharmacokinetics

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

Route	Onset	Peak	Duration
IM depot	4 h	Variable	1,2,3, or 4 mo
T1/2: 3 h Metabolism: unknown Excretion: unknown

Contraindications and Cautions

The following are contraindications and cautions for the use of hypothalamic agents:

• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Peripheral vascular disorders. Can alter absorption of drugs.
• Rhinitis. Alters absorption of nafarelin nasal spray.
• Renal or hepatic impairment. Interfere with drug metabolism and excretion.
• Pregnancy or lactation. Potential adverse effects to fetus or neonates.

Adverse Effects

Use of hypothalamic agents may result to these adverse effects:

• Agonists: increased release of sex hormones, ovarian overstimulation, flushing, increased temperature and appetite, fluid retention
• Antagonists: decreased testosterone level, loss of energy, decreased sperm count and activity, alterations in secondary sex characteristics (decrease in female sex hormones, amenorrhea), fluid and electrolyte changes, insomnia, irritability

Interactions

Drug interactions of hypothalamic agents are related to the specific hormones that the drug is affecting. They will be discussed in detail as each agents for specific hormones will be covered in this study guide.

Nursing Considerations

The specific nursing care of patient who is receiving hypothalamic releasing factor is related to the hormone(s) that the drug is affecting. This will be discussed further as each drugs affecting certain hormones will be covered in this study guide.

Practice Quiz: Hypothalamic Agents

Here are some practice questions for this study guide. Please visit our nursing test bank page for more NCLEX practice questions.

1. All of these drugs can decrease the production of sex hormones, except:

A. goserelin
B. histrelin
C. degarelix
D. tesamorelin

1. Answer: C. degarelix

Options A, B, and D are all hypothalamic agonists and can, therefore, decrease the production of sex hormones. Agonists inhibit pituitary gonadotropin secretion, with a resultant drop in the production of sex hormones.

2. Which of the following health history data will alert the nurse to question the use of hypothalamic agents in a short-term therapy?

A. history of hepatic lobe transplant three years ago
B. a mother who practices mixed feeding to her newborn baby
C. a chest x-ray suggestive of pneumonia
D. fever probably caused by post-surgical wound infection

2. Answer: B. a mother who practices mixed feeding to her newborn baby

Hypothalamic agents should be cautioned in lactating mothers because of potential adverse effects to the neonate. All other options are not contraindicated.

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

3. 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.

4. This drug decreases the abdominal fat in HIV-infected patients with lipodystrophy.

A. tesamorelin
B. histrelin
C. leuprolide
D. nafarelin

4. Answer: A. tesamorelin

It does this through stimulating the lipolytic effect of growth hormones.

5. Which of the following should be monitored closely in patients receiving hypothalamic agents?

A. serum sodium and potassium levels
B. blood sugar level
C. all of the above
D. none of the above

5. Answer: C. all of the above

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.

Recommended Resources

Our recommended nursing pharmacology resources and books:

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See Also

Here are other nursing pharmacology study guides:

• Nursing Pharmacology – Study Guide for Nurses
  Our collection of topics related to nursing pharmacology
• Pharmacology Nursing Mnemonics & Tips
  These nursing mnemonics aim to simplify the concepts of pharmacology through the use of a simple, concise guide.
• Generic Drug Name Stems Cheat Sheet
  Learn about these generic drug name stems to help you make sense of drugs easier!
• Common Drugs and Their Antidotes
  A guide to drug antidotes that nurses should be familiar about.
• IV Fluids and Solutions Guide & Cheat Sheet
  Get to know the different types of intravenous solutions or IV fluids in this guide and cheat sheet.
• Drug Dosage Calculations NCLEX Practice Questions (100+ Items)
  Care to take the challenge? This quiz aims to help students and registered nurses alike grasp and master the concepts of medication calculation.

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References and Sources

References and sources for study guide:

• Karch, A. M., & Karch. (2011). Focus on nursing pharmacology. Wolters Kluwer Health/Lippincott Williams & Wilkins. [Link]
• Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.
• Lehne, R. A., Moore, L. A., Crosby, L. J., & Hamilton, D. B. (2004). Pharmacology for nursing care.
• Smeltzer, S. C., & Bare, B. G. (1992). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: JB Lippincott.