14. Diabetes, Thyroid, Steroids, Transplant.pptx

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1. TREATMENT OF ENDOCRINE CONDITIONS By: Lily Klasing, PharmD 2021 WSU College of Pharmacy and Pharmaceutical Sciences

2. TREATMENT OF DIABETES

3. TREATMENT OF TYPE 1 DIABETES Calculate TDD 0.5 units/kg/day, using TBW Total Basal Insulin Dose Total Prandial Dose Breakfast Lunch Dinner ~50% ~50%

4. DRUG TREATMENT OPTIONS FOR TYPE 2 DIABETES

5. Continuation… Metformin is FIRST-LINE A1C > 1.5% above goal CONTRAINDICATION : eGFR < 30

6. WHEN and HOW to use insulin in T2D

7. Continuation…

8. Continuation…

9. TREATMENT OF THYROID DISORDERS HYPOTHYROIDISM Drugs NAPLEX must KNOWS! Levothyroxine (T4)- DOC - Synthroid, Levoxyl , Tirosint -SOL PO: Should be taken with water same time daily for consistent absorption, at least 60 minutes before breakfast or at bedtime (at least 3 hours after the last meal). IV : IV to PO ratio is 0.75:1, use immediately upon reconstitution. Dosing: Full replacement dose = 1.6 mcg/kg/day (IBW) in “healthy” adults <50 y.o . If known CAD, start with 12.5-25 mcg daily Warning: - Decrease dose if CVD , decreased bone mineral density Monitor: TSH levels every 4-6 weeks until levels are normal, then yearly; serum FT4 in select patients. Thyroid (T3 and T4) - Armour Thyroid Liothyronine (T3) Cytomel Shorter half life causes fluctuations in T3 levels. Litrix (T3 and T4 in 1:4 ratio)

10. HYPERTHYROIDISM Drug MOA NAPLES must KNOW! Thioamides Propylthiouracil ( PTU ) Methimazole ( DOC ) Inhibit synthesis of thyroid hormones by blocking the oxidation of iodine in the thyroid gland. PTU also inhibits peripheral conversion of T4 to T3 Boxed warning : Severe liver injury and acute liver failure. Pregnancy: PTU preferred in 1 st trimester; Methimazole preferred in 2 nd and 3 rd trimesters. Warnings: Hepatotoxicity, agranulocytosis, drug induced lupus erythematosus ( DILE ) SE : GI upset NOTE: PTU is preferred in thyroid storms Iodides Potassium iodide solution Temporarily inhibit secretion of thyroid hormones; T4 and T3 levels will be reduced for several weeks but effect will not be maintained. SE: metallic taste, GI upset, sore throat/gums

11. SYSTEMIC STEROIDS Steroid LOWEST POTENCY Short acting Side Effects: Short term : increased appetite/weight gain, emotional instability, insomnia, fluid retention, acute rise in blood glucose and blood pressure levels. Long term : Adrenal suppression/Cushing’s syndrome, glaucoma, impaired wound healing, diabetes, hypertension, osteoporosis, growth retardation in children. Warning: Adrenal suppression: If taking longer than 14 days, must taper slowly. NOTES: Cortisone is a prodrug of cortisol Prednisone is a prodrug of prednisolone Cortisone Hydrocortisone Prednisone Intermediate acting Prednisolone Methylprednisolone Triamcinolone Dexamethasone Long acting HIGHEST POTENCY Betamethasone

12. TREATMENT OF ORGAN TRANSPLANT REJECTIONS Induction Immunosuppression Given before or at the time of transplant to prevent acute rejection during the early posttransplant period. Drugs: Basiliximab Anti-thymocyte globulin (For patients at higher risk of rejection) Maintenance Immunosuppression Provided by a combination of drugs: Calcineurin inhibitor + Tacrolimus Anti-proliferative agent + Mycophenolate With OR without steroids Treatment of Rejection Steroid Pulse High dose 250-500 mg Prednisone Thymoglobulin Alemtuzumab

13. Class Immunosuppressant MOA/Target Side Effects Polyclonal antibody Thymoglobulin, Atgam Binds to antigens on T-lymphocytes and interferes with their function. SE : Infusion-related reactions that can be lessened by premedication. IL-2 α receptor antagonist basiliximab Chimeric monoclonal antibody that inhibits the IL2 receptors on the surface of activated T-lymphocytes preventing cell medicated allograft rejection. Well tolerated. Corticosteroid prednisone, methylprednisolone Blocks IL-1 production and other cytokines Anti-proliferative agents azathioprine Inhibit T-lymphocyte proliferation by altering purine synthesis SE : Diarrhea, GI upset. Mycophenolate mofetil ( CellCept ) Mycophenolate sodium ( Myfortic ) NOT INTERCHANGABLE Calcineurin inhibitor Cyclosporine Tacrolimus Suppress cellular immunity by inhibiting T-lymphocyte activation . TACROLIMIS: ↑ BP, nephrotoxicity, ↑ BG, hyperkalemia, hyperlipidemia. CYCLOSPORIN : (above) + QT prolongation, hirsutism, gingival hyperplasia, edema mTOR kinase inhibitor Sirolimus, Everolimus Inhibit T-lymphocyte activation and proliferation Peripheral edema, Co-stimulation blocker Belatacept Binds to CD80 and CD86 to block T-cell stimulation and production of inflammatory mediators.

14. THANK YOU!