Name of the Drugs
- Deoxycorticosterone acetate(DOCA)
- Fludrocortisone
- Aldosterone
1.Fludrocortisone
| Fludrocortisone |
| Availability Tablet 0.1mg |
| Indications and Dosages To treat primary and secondary chronic adrenocortical insufficiency Adults and adolescents. Usual: 100 mcg daily. Dosage may range from 100 mcg three times/wk to 200 mcg daily. Children. 50 to 100 mcg daily To treat salt-losing adrenogenital syndrome Adults. 100 to 200 mcg daily. Children. 50 to 100 mcg daily |
Mechanism of Action
Potent mineralocorticoid with high glucocorticoid activity; promotes increased reabsorption of sodium and excretion of potassium from renal distal tubules
Pharmacokinetics
- Bioavailability: 100%
- Peak plasma time: ≤1.7 hr
- Protein bound: 42%
- Metabolized in liver
- Half-life: Plasma, 3.5 hr; biologic, 18-36 hr
Contraindications
Hypersensitivity to fludrocortisone, adrenocorticoids, or their components; systemic fungal infections
Adverse Reactions
- CNS: Dizziness, headache, mental changes, seizures
- CV: Arrhythmias, heart failure, hypertension, peripheral edema
- EENT: Cataracts (with long-term use), increased intraocular pressure
- ENDO: Adrenal insufficiency, growth suppression in children, hyperglycemia
- GI: Anorexia, nausea, vomiting GU: Menstrual irregularities
- HEME: Easy bruising
- MS: Arthralgia, muscle weakness, myalgia, osteoporosis (with long-term use), tendon contractures
- SKIN: Acne, diaphoresis, rash, urticaria
- Other: Hypokalemia, hypokalemic alkalosis, impaired wound healing, weight gain
Nursing Considerations
- Monitor blood pressure, fluid status, and serum electrolyte levels periodically during fludrocortisone therapy.
- Watch for signs of heart failure, including adventitious breath sounds, peripheral edema, and weight gain.
- Monitor for signs and symptoms of overdose, such as cardiomegaly, edema, excessive weight gain, hypertension, and hypokalemia. These effects usually subside a few days after therapy stops. Potassium supplementation may be needed.
- Notify prescriber if patient has dizziness, headache, hypertension, hypokalemia, signs of infection, or weight gain.
Patient Teaching
- Instruct patient to take a missed dose of fludrocortisone as soon as she remembers if it’s within 12 hours of scheduled time. Warn against double-dosing. Advise her to notify prescriber if she misses more than one dose or if nausea or vomiting prevents her from taking drug.
- Instruct patient to reduce dietary sodium and to eat more potassium-rich foods during therapy.
- Direct patient to weigh herself each morning before breakfast in clothes of similar weight and to notify prescriber if she gains more than 2 lb (0.9 kg) per day or 5 lb (2.3 kg) per week. Instruct her to monitor how tightly her rings and shoes fit.
- Advise patient to notify prescriber about stressful events, such as dental extractions, emotional upset, illness, surgery, and trauma; dosage increase may be required.
- Instruct patient to notify prescriber about dizziness, fever, fluid retention, headache, joint pain, irregular heart rate, muscle weakness, or palpitations.
- Inform patient that drug may delay wound healing.
- Caution patient not to stop taking drug abruptly but to taper dosage gradually, as prescribed.
- Urge patient to wear or carry medical identification that documents corticosteroid use
Aldosterone
| Aldosterone |
| Availability Tablets: 25 mg, 50 mg, 100 mg |
| Indications and dosages ➣ Edema caused by heart failure, hepatic cirrhosis, or nephrotic syndrome Adults: As sole diuretic, initially 100 mg/day P.O. (range of 25 to 200 mg) in single or divided doses, continued for 5 or more days and then adjusted to optimal therapeutic level Children: 1 to 3 mg/kg/day P.O. as a single dose or in divided doses ➣ Essential hypertension Adults: Initially, 50 to 100 mg/day P.O. as a single dose or in divided doses, continued for at least 2 weeks Children: 1 to 2 mg/kg P.O. b.i.d. ➣ Hypokalemia Adults: 25 to 100 mg/day P.O. ➣ Diagnosis and treatment of primary hyperaldosteronism Adults: For diagnosis, 400 mg/day P.O. for 4 days in short test or for 3 to 4 weeks in long test. Resolution of hypokalemia and hypertension confirm diagnosis of primary hyperaldosteronism. Dosages of 100 to 400 mg/day P.O. may be used as a bridge to surgical therapy; in patients unsuitable for this therapy, lowest effective dosage may be used for long-term maintenance. |
Mechanism of Action
Aldosterone antagonist with diuretic and antihypertensive effects; competitive binding of receptors at aldosterone-dependent Na-K exchange site in distal tubules results in increased excretion of Na+, Cl-, and water and retention of K+ and H+
Increases testosterone clearance and estradiol production; blocks conversion of potent androgens to weaker ones in peripheral tissues
Pharmacokinetics
- Bioavailability: 73% (tablet)
- Protein bound: 90%
- Metabolized by the liver and kidneys
- Half-life (tablet): 1.3-1.4 hr (parent drug); 16.5 hr (canrenone); 13.8 hr (7-α-[thiomethyl] spirolactone [TMS]); 15 hr (6-ß-hydroxy-7-α-[thiomethyl] spirolactone [HTMS])
- Half-life (PO suspension): 1-2 hr (parent drug); 10-35 hr (canrenone, 7-α-[thiomethyl] spirolactone [TMS], 6-ß-hydroxy-7-α-[thiomethyl] spirolactone [HTMS])
- Excretion (tablet): Urine (47-57%); feces (35-41%)
- Excretion (PO suspension): Urine
Administration
Give single daily dose with breakfast. If two daily doses are prescribed, give second dose with food in mid-afternoon.
Contraindications
- Anuria, acute renal insufficiency, significant impairment of renal excretory function
- Hyperkalemia
Precautions:
- Hepatic dysfunction, diabetes mellitus, fluid and electrolyte imbalances, severe heart failure
- Concurrent use of other potassiumsparing diuretics, such as amiloride and triamterene (avoid use)
- Concurrent use of potassium supplements (avoid use with serum potassium level greater than 3.5 mEq/L)
- Concurrent use of ACE inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDs) (use with extreme caution)
- Concurrent use of lithium (generally avoid use)
- Elderly or debilitated patients
- Pregnant or breastfeeding patients
- Children (safety not established).
Adverse reactions
- CNS: headache, drowsiness, lethargy, ataxia, confusion
- GI: vomiting, diarrhea, cramping, gastritis, GI ulcers, GI bleeding
- GU: gynecomastia, irregular menses or amenorrhea, postmenopausal bleeding, erectile dysfunction, breast cancer
- Hematologic: agranulocytosis
- Metabolic: hyponatremia, hyperchloremic metabolic acidosis, hyperkalemia
- Skin: rash, pruritus, hirsutism, drug rash with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson Syndrome, toxic epidermal necrolysis
- Other: deepening of voice, drug fever, hypersensitivity (including vasculitis, anaphylactic reactions)
Patient monitoring
- Monitor electrolyte levels (especially potassium), particularly in patients with severe heart failure. Watch for signs and symptoms of imbalances and metabolic acidosis. Interrupt or discontinue treatment for serum potassium level greater than 5 mEq/L or serum creatinine greater than 4 mg/dl.
- Monitor weight and fluid intake and output. Stay alert for indications of fluid imbalance.
- Monitor CBC with white cell differential.
Patient teaching
- Tell patient to take daily dose with breakfast. If two daily doses are prescribed, advise him to take second dose with food in mid-afternoon.
- Advise patient to restrict intake of high-potassium foods and to avoid licorice and salt substitutes containing potassium.
- Tell male patient drug may cause breast enlargement.
- Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above.
Nursing Considerations
- Be aware that for children or patients who have trouble swallowing, pharmacist may crush spironolactone tablets, mix with flavored syrup, and dispense as a suspension. It’s stable 1 month when refrigerated.
- In diagnosing primary aldosteronism, test is considered positive if patient’s serum potassium level rises when spironolactone is given and falls when it’s discontinued.
- Expect to evaluate patient’s serum potassium level 1 week after spironolactone therapy begins, after each dosage adjustment, monthly for the first 3 months, quarterly for 1 year, and then every 6 months thereafter or as ordered. Notify prescriber if level exceeds 5 mEq/L or patient’s renal function deteriorates (serum creatinine level exceeding 4 mg/ dl). If patient has severe heart failure, follow closely because hyperkalemia may be fatal in such patients.
- Evaluate spironolactone’s effectiveness by assessing blood pressure and edema.
- Stop drug for several days, as prescribed, before patient undergoes adrenal vein catheterization to measure serum aldosterone level and plasma renin activity
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
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