An open learning programme for pharmacists
and pharmacy technicians
Endocrine disorders
– in relation to
pharmacy practice
Educational solutions for the NHS pharmacy workforce
DLP 133
An open learning programme for pharmacists
and pharmacy technicians
Endocrine disorders
– in relation to
pharmacy practice
Educational solutions for the NHS pharmacy workforce
© Copyright controller HMSO 2008
ii
Acknowledgements
Lead writer
Sue Cook, medical writer
CPPE programme developer
Matthew Shaw, assistant director
Project team
Sheila Beaumont, pharmacist, Brighton
Clair Dobson, CPPE tutor, Bromley
Stephen Dubois, PCT adviser, Somerset
Mandy Jackson, head of communications, CPPE
Adele Jones, surgical pharmacist, Cheltenham Hospital
Reviewers
Jenny Silverthorne, senior clinical teaching fellow, School of Pharmacy, University of
Manchester
This learning programme was piloted nationally by the following pharmacists: Kavita
Gupta, Eileen Laughton, Emma Mingins, Clare Tooley
CPPE reviewers
Paula Higginson
Fionnuala McCullough
Thanks
We would like to thank all of those people living with endocrine disorders who have
shared their stories with us.
Production
Outset Publishing Ltd, East Sussex
Published in March 2008 by the Centre for Pharmacy Postgraduate Education,
School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford
Road, Manchester M13 9PT
http://www.cppe.ac.uk
CPPE open learning programmes are printed on paper made only from sustainable forests, forest thinnings and sawmill residues. Chlorine-free pulp is used, and other raw materials
used in the manufacturing cycle are derived from natural products. All papers are also fully biodegradable (or recyclable) without harmful effect to the environment.
Contents
iii
About CPPE open learning programmes
About this learning programme
vii
x
Supporting you, your practice and the NHS
xiii
Glossary of key terms
xiv
Introduction: A time for reflection
1
Exercise
1
Suggested answers
5
Study session 1: The endocrine system – structure
and function
9
1.1 The hypothalamus
10
1.2 The pituitary gland
12
1.3 The pineal gland
14
1.4 Feedback and other control mechanisms
15
1.5 The thyroid gland
16
1.6 The parathyroid glands
18
1.7 The thymus gland
20
1.8 Hormones – chemical classification
22
1.9 The adrenal glands
23
1.10 Stress and the body
25
1.11 Hormone–hormone interactions
26
1.12 The pancreas
27
1.13 The ovaries and the testes
30
1.14 Hormones – further classification
31
1.15 Putting it all together
31
Exercises
11, 12, 13, 14, 16, 17, 19, 20, 21, 24, 25,
27, 28, 33
Summary and intended outcomes
36
Further reading
36
Suggested answers
37
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iv
CONTENTS
Study session 2: The endocrine system – what can go wrong? 48
2.1 Time for reflection
48
2.2 Hypopituitarism
49
Diagnosis
Growth hormone deficiency (children)
Growth hormone deficiency (adults)
Turner’s syndrome
Prader-Willi syndrome
Diabetes insipidus
51
52
52
52
53
54
Treating hypopituitarism
55
2.3 Hyperpituitarism
Diagnosis
Giantism
Acromegaly
Hypersecretion of prolactin
61
62
62
64
Treating hyperpituitarism
65
2.4 Rare and even rarer disorders
69
2.5 Hypothyroidism
71
Diagnosis
Congenital hypothyroidism
Myxoedema
Hashimoto’s disease
Iodine deficiency
71
71
72
73
73
Treating hypothyroidism
73
2.6 Hyperthyroidism
75
Diagnosis
Graves disease
Toxic nodular goitre
De Quervain thyroiditis
Iodine ‘overdose’
TSHoma
75
76
76
77
77
78
Treating hyperthyroidism
78
2.7 Hyperparathyroidism
81
Diagnosis
81
Treating hyperparathyroidism
82
2.8 Hypoparathyroidism
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61
84
Diagnosis
85
Treating hypoparathyroidism
85
CONTENTS
2.9 Hyposecretion of adrenocortical hormones
86
Diagnosis
Autoimmune disease
Mycobacterium tuberculosis
87
87
87
Treating adrenocortical hyposecretion
89
2.10 Hypersecretion of adrenocortical hormones
90
Cushing’s syndrome
Treating Cushing’s syndrome
91
92
Conn’s syndrome
Treating Conn’s syndrome
93
93
2.11 Hypersecretion of adrenal medullary hormones
Treating medullary hypersecretion
2.12 Summary of signs and symptoms
Exercises
v
94
95
96
51, 54, 56, 64, 65, 70, 72, 73, 74, 77,
78, 79, 83, 85, 88, 89, 91, 92, 93, 95
Summary and intended outcomes
98
References
99
Suggested answers
Study session 3: Endocrine in practice – how you can
support patients in your professional
setting
3.1 It’s my life
101
120
120
Gordon’s story
120
Chloe’s story
121
Alice’s story
122
Fred’s story
122
Jerry’s story
123
Felicity’s story
123
Janine’s story
124
Sasha’s story
125
William’s story
125
Jack’s story
125
Denise’s story
126
George’s story
126
Katie’s story
127
More patient experiences
128
3.2 Some final reflections
128
Exercise
129
Summary and intended outcomes
132
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vi
CONTENTS
Index
134
List of figures
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Figure 1 The hypothalamus
10
Figure 2 The pituitary gland
12
Figure 3 The pineal gland
14
Figure 4 The thyroid gland
16
Figure 5 The parathyroid glands
18
Figure 6 The thymus gland
20
Figure 7 The adrenal glands
23
Figure 8 The pancreas
27
Figure 9 The ovaries
30
Figure 10 The testes
30
About CPPE open learning programmes
vii
About CPPE
The Centre for Pharmacy Postgraduate Education (CPPE) is funded by the Department of Health to provide continuing education for practising pharmacists and
pharmacy technicians providing NHS services in England. We are based in the
School of Pharmacy at the University of Manchester within the multidisciplinary
teaching environment of the Faculty of Medicine, Dentistry, Nursing and Pharmacy.
CPPE offers a wide range of learning opportunities for the pharmacy workforce.
Our full learning portfolio is available on the internet at: http://www.cppe.ac.uk
Themes
We have allocated themes to all our learning programmes. There are 28 themes in
total and they allow you to navigate easily through our full learning portfolio. Each
theme has been assigned a different colour, and this is used to identify the theme in
the annual prospectus, in CPPE news&events, on our website, and on the covers of
all the learning programmes.
This learning programme is part of the Diabetes and endocrine theme. You will find
additional learning programmes within this theme in our prospectus and on our
website.
You can download this and other e-learning programmes from the CPPE
website.
We recognise that people have different learning needs and not every CPPE learning
programme is suitable for every pharmacist or pharmacy technician. Some of our
programmes contain core learning while others deliver more complex learning that
is only required to support certain roles. So we have created three categories of
learning – CPPE 1 2 3 – and allocated each programme to an appropriate category.
The categories are:
Core learning (limited expectation of prior knowledge).
Application of knowledge (assumes prior learning).
Supporting specialisms (CPPE may not be the provider and will signpost
you to other appropriate learning providers).
This is a
learning programme.
Continuing professional development
You can use this learning programme to support your continuing professional
development (CPD). Consider what your learning needs are in this area. You may
find it useful to work with the information and activities here in a way that is
compatible with the Royal Pharmaceutical Society of Great Britain’s approach to
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viii
ABOUT CPPE OPEN LEARNING PROGRAMMES
continuing professional development (http://www.rpsgb.org.uk/registrationand
support/continuingprofessionaldevelopment) because you will be able to relate
it to your personal circumstances more closely. Use your CPD record sheets or go
to: http://www.uptodate.org.uk/home/welcome.shtml to plan and record the
actions you have taken.
Activities
E
Exercises
We include exercises throughout this programme as a form of self-assessment. Use
them to test your knowledge and understanding of key learning points.
Assessment
The assessment for this programme can only be accessed through our website at:
http://www.cppe.ac.uk You must submit your answers online.
Reference sources and further reading
Reference sources for all the books, articles, reports and websites mentioned in the
text, together with a list of further reading to support your learning, can be found at
the end of each study session. References are indicated in the text by a ‘superscript’
3
number (like this ). For clarity, CPPE uses its own simplified format for references.
Terminology used in this programme
To aid your learning we have compiled a glossary of terms you may not be familiar
with (it is assumed that you are familiar with terms routinely used within pharmacy).
CPPE uses the nomenclature structure used in the British national formulary.
Programme guardians
CPPE has adopted a quality assurance process called ‘programme guardians’. A
programme guardian is a recognised expert in an area relevant to the content of a
learning programme who will review the programme every six months. Any corrections, additions, deletions or further supporting materials that are needed will be
posted as an update to the programme on the CPPE website.
We recommend that you refer to these updates if you are using this (or any other)
learning programme significantly after its initial publication date. A full list of
programme guardians is available on our website. You can e-mail your comments
about this programme to them at: [email protected]
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ABOUT CPPE OPEN LEARNING PROGRAMMES
ix
Brand names and trademarks
CPPE acknowledges the following brand names and registered trademarks which
®
®
®
are mentioned throughout the programme: Adobe Photoshop , Aldactone , Art
®
®
®
®
®
®
®
Explosion , Cabaser , Choragon , Cordarone X , Florinef , Fosamax , Inspra ,
®
®
®
®
®
®
®
Microsoft , Microsoft Encarta , Mimpara , Neo-Mercazole , Norprolac , Ovitrelle ,
®
®
®
®
®
®
Parlodel , Pregnyl , Sandostatin , Sandostatin LAR , Somavert , Vecon .
External websites
CPPE is not responsible for the content of any non-CPPE websites mentioned in
this programme or for the accuracy of any information to be found there. The fact
that a website or organisation is mentioned in the programme does not mean that
CPPE either approves of it or endorses it.
Disclaimer
CPPE recognises that local interpretation of national guidance may differ from the
examples used in this learning programme and you are advised to check with your
own relevant local guidelines. You are also advised to use this programme with other
established reference sources. If you are reading this programme significantly after
the date of initial publication you should refer to current published evidence. CPPE
does not accept responsibility for any errors or omissions.
Feedback
We hope you find this learning programme useful for your practice. Please help us
to assess its value and effectiveness by completing the feedback form (if enclosed)
and returning it in the prepaid envelope. Otherwise, please e-mail us at:
[email protected]
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x
About this learning programme
Welcome to the CPPE open learning programme on endocrine disorders in relation
to pharmacy practice, which has been designed as a key element of the Diabetes and
endocrine theme. The aim is to give you an overview of the endocrine system and
endocrine disorders, and of the contribution that the pharmacy team can make to
their management.
When you’ve finished this programme you should be able to:
●
list the endocrine glands and describe their main functions, both as individual
glands and as part of an interrelated endocrine system
●
describe the most common endocrine disorders and the impact they have on
patients and their day-to-day lives
●
describe the management of the most common endocrine disorders
●
outline the symptoms and management of the less prevalent endocrine disorders
●
identify communication techniques that will help you to raise the issue of
endocrine disorders with patients
●
list potential areas for discussion with patients who have long-term endocrine
disorders
●
describe your potential roles in supporting patients with endocrine disorders in
your professional setting.
By the time you’ve worked through the material you will feel confident about your
knowledge of the endocrine system. Your confidence should enable you to deal
sensitively and effectively with patients with suspected or actual endocrine disorders.
The study time will depend on you, but we estimate that the reading and case studies
will take a total of 10 -12 hours.
Target audience
This programme is aimed at pharmacists and pharmacy technicians working in any
area of practice.
Learning style adopted in this programme
The programme is split into three study sessions:
●
The endocrine system – structure and function.
●
The endocrine system – what can go wrong?
●
Endocrine in practice – how you can support patients in your professional
setting.
This programme contains enough information to give you a comprehensive overview
of the endocrine system. However, in order to boost your understanding of the
subject we suggest that you do some further reading. In particular, we recommend
that you read the endocrine chapter in any anatomy and physiology textbook. We’ve
included a list of the references that we’ve used at the end of each study session.
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ABOUT THIS LEARNING PROGRAMME
xi
We also recommend that you visit websites set up by patient groups. Some of these
organisations have local branches. If there is one in your area then why not get in
touch with them? We found it fascinating to talk to endocrine patients and a great
opportunity to get a ‘real world’ insight into living with an endocrine disorder. We’ve
given you references and web addresses where appropriate throughout this
programme.
Learning objectives
CPPE has linked all its learning programmes to the Royal Pharmaceutical Society of
Great Britain’s competences for pharmacists and pharmacy technicians. This will
make it easier for you to connect your professional practice to your learning needs
and learning activities. We have selected only the competences for general
pharmacists and pharmacy technicians, but we are aware that others exist.
We have also linked the learning to the dimension of the NHS Knowledge and Skills
framework (KSF).
The competences and dimensions relevant to this programme are:
Learning objectives
RPSGB competences
KSF dimensions
Pharmacists
Pharmacy
technicians
List the endocrine glands and
describe their main functions, both
as individual glands and as part of
an interrelated endocrine system.
G1, G3
TG2
Personal and people development
Level 1 or 2
Describe the most common
endocrine disorders and the impact
they have on patients and their
day-to-day lives.
G1, G3
TG2
Personal and people development
Level 1 or 2
Describe the management of the
most common endocrine disorders.
G1, G3
TG2
Personal and people development
Level 1 or 2
Outline the symptoms and
management of the less prevalent
endocrine disorders.
G1, G3
TG2
Personal and people development
Level 1 or 2
G2
TG1
Communication Level 2
List potential areas for discussion
with patients who have long-term
endocrine disorders.
G2, G9
TG10
Health and well-being
HWB7 Level 3
Describe your potential roles in
supporting patients with endocrine
disorders in your professional
setting.
G7, G9
TG1, TG4
Identify communication techniques
that will help you to raise the issue
of endocrine disorders with patients.
Services and project management
G5 Level 1 or 2
Service improvement
Level 1
You may also wish to order our open learning programmes on diabetes and women’s
health.
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xii
ABOUT THIS LEARNING PROGRAMME
Working through this programme
We’d advise you to work flexibly with the materials to suit your own style of learning.
There is no right or wrong approach, but remember that the aim of your hard work
is to enable you to feel confident to meet the challenges facing you. Bear this in mind
as you work through the programme – it will help you to decide if your approach to
study is working.
We have designed the programme for self-study, but as you progress through the
study sessions it will be essential for you to talk through some of the issues with your
staff and colleagues.
Online resources
Some of the references in this programme are to material that is only available online,
and we assume that you have access to a computer connected to the internet. If you
do not wish to retype all the web addresses into your browser you may find it helpful
to download this programme from the CPPE website as a PDF document containing ‘live’ web links. Log on to: http://www.cppe.ac.uk
Where we think it will be helpful we have provided the URL to take you directly to
an article or specific part of a website. However, we are also aware that web links can
change (eg, the Department of Health links) so in some cases we have provided the
URL for the organisation’s home page only. If you have difficulty accessing any web
links, please go to the organisation’s home page and use appropriate key words to
search for the relevant item.
Note on NICE guidance:To find any of the NICE guidelines or technology appraisals
mentioned in this programme visit the NICE website at http://www.nice.org.uk
On their home page, under ‘Search NICE guidance’, enter the relevant topic and click
‘Search’.
Note on articles: If you have difficulty locating an article on the internet, search via:
http://www.google.co.uk by typing in the title, author, date and name of the journal.
It can also be helpful if you add in, at the end of the search criteria, the website where
you think the information may be, eg, dh.gov.uk
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xiii
Supporting you, your practice
and the NHS
When devising this programme we paid special attention to how it would contribute
both to your own professional development and to the overall improvement of NHS
services. We have illustrated some of these benefits in the diagram below (you will find
more detail as you progress through the programme).
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xiv
Glossary of key terms
Circadian rhythm
The roughly 24-hour cycle in physiological processes.
Distress
A term used to describe the stress placed on the body due to major shock and trauma.
Endocrine gland
A ductless gland which secretes hormones into the blood stream via the fluid
surrounding the secretory cells (rather than through a duct into another system or
organ).
Eustress
A term used to describe the stress placed on the body due the vague sense of pressure
that we are put under by our day-to-day lives.
Homeostasis
The process by which the body’s systems are kept in balance despite variations in the
external environment.
Hormone
Chemical messengers generally secreted by one gland to have an effect on target cells,
tissues and organs throughout the body.
Hyposecretion
A level of secretion which is lower than normal.
Hypersecretion
A level of secretion which is higher than normal.
Resorption
Loss of substance from a tissue.
Stressor
Any factor that disturbs the body. Examples include heat, trauma, illness and strong
emotions.
Virilisation
The induction or development of male secondary sexual characteristics, especially in
the female.
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Introduction: A time for reflection
1
When we first sat down to plan what an open learning programme on endocrine
should contain, we started by considering our own knowledge. This was quite a
daunting task!
In this programme we compare the endocrine system to a skilled juggler at work.
Just as a juggler must maintain a complex and delicate balance between hand and eye
to keep all the balls in the air, so the endocrine system has to maintain a complex and
delicate balance between the glands and their numerous hormones.
When we started to look at exactly how the endocrine system juggles these hormones
in order to regulate the body we were both amazed and appalled – amazed at the
profound and dazzling interrelationships between the endocrine hormones and the
rest of the body; appalled at the amount of brain-power that we’d need to expend in
order to understand those interrelationships!
In this programme we try to reflect the process that we’ve gone through to reach our
understanding of the endocrine system. It’s fair to say that we’ve found more
acronyms and jargon in this subject than in many others. Because of this, we’ve
included a glossary and some ‘jargon busters‘ within the text.
We hope that our approach will help you to understand the basic workings of the
endocrine system. We also hope that you’ll gain confidence with the language of the
endocrine system so that you can communicate effectively with patients and other
healthcare professionals.
You’ll also notice that we have included a number of exercises asking you to consider
what is happening in the endocrine system during a range of daily activities. We want
you to think about the endocrine system and its impact on your own life – to ‘think
endocrine’ every time you get hot, have a meal, do an exercise class or whatever.
E xercise 1
We mentioned that we started writing this programme by considering our own
knowledge. We found this very helpful, so why not start with your own audit too?
On a scale of 0 -10, how would you rate your knowledge of the endocrine system?
0 1 2 3 4 5 6 7 8 9 10
‘I’ve never
heard of
the endocrine
system.’
‘I’m an endocrine
expert and
I subscribe to
Endocrine Monthly
magazine.’
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2
INTRODUCTION: A TIME FOR REFLECTION
Once you’ve rated yourself on our scale the next task is to prove it. Have a go at the
following self-assessment questions.
a. What does the endocrine system do?
b. What does an endocrine gland do?
c. What do the endocrine hormones do?
d. There are nine discrete endocrine glands in the human body. Eight of these are the
same in men and women, but the ninth is different. Try to name as many as you
can.
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In men
In women
i.
i.
ii.
ii.
iii.
iii.
iv.
iv.
v.
v.
vi.
vi.
vii.
vii.
viii.
viii.
ix.
ix.
INTRODUCTION: A TIME FOR REFLECTION
3
e. Can you identify their correct places in the body? Have a go at labelling the
diagram below.
f. There are numerous endocrine hormones. Can you name three?
i.
ii.
iii.
A
Turn to the end of the section for suggested answers.
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INTRODUCTION: A TIME FOR REFLECTION
How did you get on?
I did better than I expected.
I did worse than I expected.
I did exactly as I expected.
At the beginning of this exercise we asked you to scale your current knowledge. Now
that you’ve had a chance to test your knowledge, consider how far up that scale you’d
like to move.
List up to five things that you’d like to gain from this programme.
1.
JARGON BUSTER:
Homeostasis
2.
The process by which the
3.
body’s systems are kept in
balance despite variations in
the external environment.
4.
5.
Now that you have an idea of where you’re starting from (and where you’d like to get
to), let’s start filling in the gaps…
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INTRODUCTION: A TIME FOR REFLECTION
5
Suggested answers
A
Exercise 1 (page 1)
a. What does the endocrine system do?
The endocrine system works closely with the autonomic nervous system to regulate
homeostasis. It also plays an important role in helping the body to cope with stress and
shock.
JARGON BUSTER:
Hormone
Derived from the Greek
b. What does an endocrine gland do?
word ‘Hormon’, which
Endocrine glands secrete a range of hormones which have a profound and widespread
literally means to excite or
effect on a range of body systems. Most endocrine hormones are widely distributed via
set in motion. They are
the bloodstream and act on their specific target tissues and organs to exert their effect.
chemical ‘messengers’,
c. What do the endocrine hormones do?
generally secreted by one
gland to have an effect on
We will explain the functions of each of the endocrine hormones in detail in the follow-
target cells, tissues and
ing study sessions. But here’s an overview to get you started. Broadly speaking,
organs throughout the body.
endocrine hormones:
●
play an essential part in maintaining electrolyte levels in the body
●
regulate metabolism and body temperature
●
control and influence the secretion of other hormones
●
control growth and physical development
●
regulate the reproductive systems in both males and females
●
influence the circadian rhythm.
We have only listed some of the key functions – you may have thought of many more
– but it’s hard to underestimate the influence of these hormones on the human body.
d. There are nine discrete endocrine glands in the human body. Try to name as
many as you can.
JARGON BUSTER:
Endocrine gland
Here’s our list:
A ductless gland which
i.
Hypothalamus
secretes hormones into the
ii. Pituitary
blood stream via the fluid
iii. Pineal gland
surrounding the secretory
iv. Thyroid
cells (rather than via a duct
v.
Parathyroid
into another system
or organ).
vi. Thymus
vii. Pancreatic islets
viii. Adrenal glands
ix. Testes (male)/Ovaries (female)
Endocrine hormones are also secreted by endocrine cells within other organs such as
the stomach and kidneys.
As we suggested earlier, this is a complex system which has a profound effect on the
body.
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INTRODUCTION: A TIME FOR REFLECTION
e. Can you identify their correct places in the body? Try to label the diagram
below.
Here’s where the main glands are located:
JARGON BUSTER:
Circadian rhythm
The roughly 24-hour cycle in
physiological processes.
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INTRODUCTION: A TIME FOR REFLECTION
7
f. There are numerous endocrine hormones. Can you name three?
There is a large list to choose from. Here’s our list, together with their abbreviations.
Don’t panic – we’ll revisit these as we go along and make sense of what they do and
how they work together.
The main control hormones are:
●
growth hormone-releasing hormone (GHRH)
●
thyrotropin-releasing hormone (TRH)
●
gonadotropin-releasing hormone (GnRH)
●
prolactin-releasing hormone (PRH)
●
corticotropin-releasing hormone (CRH)
●
growth hormone-inhibiting hormone (GHIH)
●
prolactin-inhibiting hormone (PIH)
●
human growth hormone (hGH) (also known as somatotropin)
●
thyroid-stimulating hormone (TSH) (also known as thyrotropin)
●
follicle-stimulating hormone (FSH)
●
lutenising hormone (LH)
●
prolactin (PRL)
●
adrenocorticotropic hormone (ACTH) (also known as corticotropin)
●
melanocyte-stimulating hormone (MSH)
●
oxytocin (OT)
●
antidiuretic hormone (ADH) (also known as vasopressin).
We’re not finished yet...
●
triiodothyronine (T3)
●
thyroxine (T4)
●
calcitonin (CT)
●
parathyroid hormone (PTH)
●
mineralocorticoids such as aldosterone
●
glucocorticoids such as cortisol (also known as hydrocortisone)
●
epinephrine (also known as adrenaline)
●
norepinephrine (also known as noradrenaline)
●
glucagon
●
insulin
●
somatostatin
●
pancreatic polypeptide
●
androgens.
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INTRODUCTION: A TIME FOR REFLECTION
We’re down to the last few now...
●
melatonin
●
oestrogen
●
progesterone
●
relaxin
●
inhibin
●
thymosin
●
thymic humoral factor (THF)
●
thymic factor (TF).
As we mentioned, there are endocrine cells embedded in other non-endocrine organs
such as the stomach and kidneys. Here are a few of the endocrine hormones secreted
by such cells:
●
gastrin
●
human chorionic gonadotropin
●
renin
●
erythropoietin
●
calcitriol.
Have we missed any? What did you come up with?
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