Transcript Free Radicals and Antioxidants in Obstetrics and Gynaecology
Hormonal pharmacotherapy
Ján Mojžiš
GLUCOCORTICOIDS AND MINERALOCORTICOIDS
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Glucocorticoids
well absorbed in GIT (i.v.; i.m.; locally)
90% of hydrocortisone is bound to albumin and
transcortin (specific corticosteroid binding globulin) 70% of cortisole – metabolised in liver by
microsomal enzymes to hydrocortisone synthetic corticoids – the same fate prednisone and methylprednisone (prodrugs) – prednisolone and methylprednisolone
excretion by the kidney as gluco- or sulfoconjugates
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Mechanism of action
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Glucocorticoids actions
glycogenolysis and gluconeogenesis
protein catabolism and
protein synthesis
lipolysis; redistribution of body fat
intestinal calcium absorption; decreased osteoblast formation and activity
secretion of gastric acid and pepsin CVS – restrict capillary permeability, maintain tone of arterioles and myocardial contractility
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Glucocorticoids actions –
cont.
CNS – euphoria, insomnia, anxiety, motor activity; high dose –proepileptic effects blood cells -
of eosinophils, basophils, monocytes, lymphocytes;
in circulating phagocytes -
ability of the body to fight infections
suppression of all types of hypersensitivity
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Glucocorticoids actions –
cont.
inflammatory responses (basis of the most of their clinical uses); nonspecific action, covers all stages and components of inflammation such as:
increased capillary permeability
local exudation
cellular infiltration
phagocytic activity
collagen deposition
fibroblastic activity
scar formation
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Indications
A: Replacement therapy 1. acute adrenal insufficieny 2. chronic adrenal insufficieny (Addison ´s disease) - hydrocortisone is givent to correct the defficiency; 2/3 morning , 1/3 afternoon; failure of therapy - death
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Indications –
cont.
B: Pharmacotherapy of non-endocrinne diseases 1. Arthritis rheumatoid arthritis, osteoarthritis; rheumatic fever, gout (NSAID are trefered) 2. Collagen disease systemic lupus erythematosus, dermatomyositis, glomerulonephritis (therapy started with high dose) 3. Severe allergic reactions for short period in anaphylaxis, urticaria, angioedema
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Indications –
cont.
4. Autoimmune diseases haemolytic anemia, trombocytopenia 5. Respiratory tract bronchial asthma, aspiration pneumonia, pulmonary edema 6. Eye large number of inflammatory ocular diseases topically allergic conjuctivitis, iritis, keratitis etc.
should not be used in infective conditions 7. Skin topicaly – eczematous skin diseases systemicaly – pemfigus vulgaric, exfoliative dermatitis
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Indications –
cont.
8. GIT ulcerative colitis, Crohn ´s disease corticosteroid are indicated in acute exacerbation 9. CNS cerebral edema due to tumor, meningitis, cerebral/spinal injury 10. malignancies essential in acute lymphatic leukemia Hodgkin ´s disease and other lymphomas 11. organ transplantation
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Side effects
suppression of immune system (rendering the patient vulnerable to common infections)
osteoporosis (rendering the patient vulnerable to fractures)
peptic ulcer
suppression of growth in children
reproductive problems
edema, hypertension
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Side effects
– cont.
fragile skin
diabetes mellitus
muscular weakness
delayed healing of wounds and surgical incisions
psychiatric disturbancies
development of cushingoid habitus
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Cushing syndrome
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SEX HORMONES
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sex hormones are necessary for conception, embryonic maturation, and development of primary and secondary sexual characteristics at puberty
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Female sex hormones
Estrogens
major estrogens estradiol , estrone , and estriol
at puberty cause growth of breast, accumulation of fat, pubic and auxillary hair growth, femine body contours and behaviour are affected
estrogens are anabolic, maintain bone mass
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Actions of estrogens
ovaries : stimulate follicular growth; small doses cause an increase in weight of ovary; large doses cause atrophy uterus : endometrial growth vagina : cornification of epithelial cells with thickening and stratification of epithelium cervix : increase of cervical mucous with a lowered viscosity (favoring sperm access)
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Actions of estrogens
skin : increase in vascularization, development of soft, textured and smooth skin bone : increase osteoblastic activity electrolytes : retention of Na + , Cl and water by the kidney cholesterol : hypocholesterolemic effect
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Receptor Actions in Cells E Estrogen Growth Factors GF Peptides and Neurotransmitters E R Signaling E Second Messengers and Protein Kinase Cascades E EREs R E R E Receptor Co-Regulators TAFs A B TBP TATA F pol II Transcription (B. Katzenellenbogen et al.
Recent Prog. Horm. Res
.,2000)
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Therapeutic uses of estrogens
a) for replacement therapy in deficient patients b) for contraception c) therapy of prostatic cancer and some brest cancer d) menstrual disorders e) suppression of lactation
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Postmenopausal hormone therapy
estrogen therapy is used in women experiencing „hot flashes“, „atrophic vaginitis“ and in women who wish to reduce risk of osteoporosis
the doses of estrogens are approximately 1/5 of doses used in oral contraception
less risk of adverse reactions
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FDA
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Primary hypogonadism
estrogen therapy (in combination with progestin) stimulates development of secondary sex characteristic in young women (11-13 years of age) with hypogonadism
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Estrogens: direct effects on the vascular wall
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Treatment of metastatic breast cancer
if estrogen receptors can be demonstrated in the neoplastic tissue - administration of large doses of estrogens may lead to arrest or regression of breast tumor growth
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Pharmacology
naturally occuring estrogens and their derivates - well absorbed from GIT, skin, mucous membranes, and also if given intramusculary
significant first-pass effect
synthetic estrogens (ethinyl estradiol, mestranole) -well absorbed, metabolized more slowly
inactive metabolits are eliminated in urine
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Adverse reactions
nausea and vomiting
breast tenderness, endometrial hyperplasia, postmenopausal bleeding
hyperpigmentation, hypertension, migraine headache
edema - sodium and water retention
decreased bile flow - cholestasis and gallbladder diesease
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Contraindications
estrogen-dependent neoplasia
thromboembolic disease
liver disease
coronary or cerebral arterial diesease
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Antiestrogens
modify or oppose the action of estrogens
tamoxifen, clomiphene
they have been used to treat infertility
tamoxifen is currently used in the treatment of breast cancer in postmenopausal women
side effect - ovarian enlargement
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Female sex hormones
Progestins
most important progestin -
progesterone
mechanism of action - similar to estrogen
therapeutic uses
major clinical use – contraception
other - control of uterine bleeding, endometrial carcinomas
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PROGESTERONE
CH 3 C O Natural hormone secreted by the corpus luteum and the placenta H O H H PROGESTERONE it is also an important intermediate in steroid biogenesis in all tissues that produce steroids (testes, adrenal cortex) Intestinal absorption is quite erratic; must be micronized for most effective absoption
Pharmacology
rapid absorption after administration by any route
short half-life - rapidly metabolized
synthetic progestins (medroxyprogesterone, norethindrone) are less rapidly metabolized
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Adverse reactions
weight gain
edema
depression
rare thrombophlebitis and pulmonary embolism
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Antiprogestin
mifepristone - progestin antagonist
in early pregnancy - abortus of the fetus
side effect - uterine bleeding
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Ligands for Progesterone Receptor H 3 C O O Progesterone [natural] Progestins OH H O Norethindrone [oral contraceptives] Et O Et H H 3 C O OAc O O CH 3 Medroxyprogesterone Acetate (MPA) [HRT] R5020 (Promegestone) H 3 C O H Et O ORG2058 Antiprogestins H 3 C N CH 3 OH CH 3 O RU486 (Mifepristone) H 3 C N CH 3 OH OH O ZK98299 (Onapristone)
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Oral contraceptives
– cont.
Combination pills
products containing estrogen + progestin most common oral contraceptives
the pills are taken for 21 days followed by a 7 days withdrawal period to induce menses
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Oral contraceptives
– cont.
Progestin pills
only progestin is present (norethindrone, norgestrel)
less effective than combination pills
may produce irregular menstrual cycle Progestin implants
subdermal capsules (levonorgestrel) - long term
contraception six capsules are placed subcutaneously in upper arm - progestin is slowly released - contraceptive protection approximately 5 years
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Oral contraceptives
– cont.
Postcoital contraception
high doses of estrogen (diethylstilbestrole) is administered within 72 hours of coitus and continued twice daily for 5 days
should be reserved for unexpected or accidental exposure only (rape, condom rupture) – higher failure rate and side effects
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Adverse effects
Major adverse effects
breast fullness, depression, dizziness, edema, headache, nausea, vomiting Cardiovascular
in women who smoke and over 35 years of age thromboembolism, thrombophlebitis, hypertension, myocardial infarction, coronary thrombosis Metabolic
decreased dietary carbohydrate absorption
abnormal glucose tolerance test progestin causes increase LDL and decrease HDL - estrogen has the opposite effect
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Male sex hormones
Androgens prototype is testosterone (produced by interstitial cells of testis)
main function: development and maintenance of primary and secondary sex characteristics in males (androgenic)
protein retention (anabolic action)
other naturally occuring androgens: androsterone, isoandrosterone, dehydroandrosterone, dehydroisoandrosterone
Physiological effects of testosterone
enlargement of testes, penis and scrotum
pubic and axillary hair
bone growth
red cell mass increase
skeletal muscle mass increase
larynx enlarges - deepening of the voice
increase in sebaceous glands - often cause of acne
beard development
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Uses for androgens
replacement therapy in hypogonadism
delayed puberty
cryptorchidism
metastatic breast cancer in women
postpartum breast pain/engorgement
male climacteric
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Pharmacology
testosterone cannot be given orally - first pass effect
inactive metabolits are excreted in urine
testosterone is administered intramuscularly
testosterone derivate (fluoxymesterone) has longer half-life
it may be given orally
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Adverse effects
in females
masculinization
growth of facial hair
deepening of the voice
acne
excessive muscle development
menstrual irregularity
contraindicated in pregnancy - virilization of female fetus
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Adverse effects –
cont .
in males
gynecomastia (conversion testosterone to estradiol in patints vith liver disease)
decreased spermatogenesis
painful erection at the beginig of the therapy in children
growth disturbances
abnormal sexual maturation
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Adverse effects –
cont .
androgens increase serum LDL and lower HDL levels
they can cause fluid retention - edema
use of anabolic steroids by athletes - premature closing of the epiphysis of the long bone
hepatic abnormalities, jaundice hepatic carcinoma – longterm therapy with methyltestosterone
increased agression
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Antiandrogens
cyproterone, flutamide
they inhibit action of the androgens at the target cell
they are used to treat hirsutism in females and prostatic carcinoma in males
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THYROID HORMONES
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Introduction
the thyroid gland facilitates normal growth and maturation by maintaining of metabolism major thyroid hormones - T3 - triiodotyronine T4 - thyroxine
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T3 and T4 actions
1. Growth and development
essential for normal growth and development 2. Intermediary metabolism
indirectly enhanced lipolysis (potentiating of catecholamines)
stimulation of lipogenesis (conversion of chol. to bile acids)
stimulation of carbohydrate metabolism
catabolism of proteins (T4)
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T3 and T4 actions
– cont .
3. Calorigenesis - increased basal metabolic rate by stimulation of cellular metabolism 4. CVS - stimulation of heart 5. GIT 6. CNS – constipation (hypo), diarrhea (hyper) – mental retardation (hypothyr.), nervousness, excitability, tremor (hyperthyr.) 6. Haemopoesis – T4 simulates erythropoesis 7. Reproduction – impaired feritility (hypo)
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Thyroid gland is not essential for life, but…..
hypothyroidsm
low metabolic rate
slow speach
deep hoarse voice
lethargy
bradycardia
poor resistance to cold
during development - cretinism
mental deficiency
retardation of growth
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hyperthyroidism
tachycardia and cardiac arrhytmias
nervousnes
tremor
excess heat production
increased appetite associated wit loss of weight several drugs may depress thyroid function NSAID, glucocorticoides, X-ray contrast agents,
- and
-antagonists, sulphonylurea
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Treatment of hyperthyreoidism
(Thyreotoxicosis) goal of therapy - decrease synthesis and/or release hormone a) removal part or all of the thyroid gland b) inhibition of synthesis of the hormone c) blocking release of the hormones from the follicle
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Removal part or all of the thyroid gland
either surgically or by destruction of the gland by radioactive iodine ( 131 I)
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Inhibition of synthesis of the hormone
thioamides (carbimazole, propylthiouracil, methimazole) inhibit synthesis of hormones (
inhibit thyroid peroxidase)
they have no effect on the thyreoglobulin alredy stored in the gland - clinical response may take several weeks or even month
they may be used as the main treatment of diffuse goitre or before surgery
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Adverse effects
skin (exanthema, erythema, urtica)
GIT (pain, nausea, vomiting, cholestatic hepatitis)
blood (leuko- and thrombocytopenia, aplastic a.
most severe complication
agranulocytosis
Lyell ´s syndrome (drug-induced skin toxic reaction - 50% lethality) Lyell ´s syndrome
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PROPYLTHIOURACIL dose to dose less potent highly plasma protein bound transfer to placenta, milk
plasma t 1/2 1-2 hours single dose acts for 4-8 hours no active metabolites 2-3 daily doses needed CARBIMAZOLE about 3x more potent less boud transfer to placenta, milk
6-10 hours 12-24 hours active metabolite - methimazole single daily dose
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Blockage of hormone release
iodide inhibits release of thyroid hormone mechanism not clear
it is rarely used as monotherapy
main use of iodine - preparation of hyperthyreoid subject for surgery
treatment of severe thyreotoxic crisis
iodide is not useful for long-term therapy
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Iodide
–
cont.
it is administerd orally
adverse effects - minor
sore mouth
metallic taste in the mouth
ulceration of mucous membranes
oversalivation
acne
alergy
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Drugs used in hypothyroidism
thyroid hormones are used
thyroxine
and
triiodothyronine
are given orally thyroxine - peak action is in 9 days triiodothyronine - peak action is in 1-2 d.
thyroxine is a drug of choice side effects - similar to those of hyperthyroidism
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Maine indications
1. Cretenism
thyroxine 6-8
g/kg – ASAP, because mental
retardation is only partially reversible dramatic response – growth and development are restored 2. Adult hypothyroidism
thyroxine, 50
g daily
g/day after 2-3 weeks 100-200 3. Nontoxic goiter
may be endemic (iodine deficiency) or sporadic (defect in hormone synthesis); T4 is used
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