Endocrine

Replace or supplement the body’s own insulin to lower blood glucose. High-alert — hypoglycemia is the #1 risk.

Non-insulin agents for type 2 diabetes — each subclass targets a different broken "lever." Metformin is first-line.

Four smaller groups of type 2 diabetes drugs, each with its own lever: pioglitazone sensitizes tissues to insulin, acarbose and miglitol slow carbohydrate digestion in the gut, repaglinide and nateglinide give a short burst of insulin at meals, and pramlintide adds amylin alongside mealtime insulin. Their signature risks follow the lever: fluid retention and heart failure, gas and diarrhea, hypoglycemia with skipped meals, and severe hypoglycemia with insulin.

Glucagon is the rescue drug for severe hypoglycemia when the patient cannot safely take sugar by mouth; dasiglucagon, a glucagon analog, is used the same way. Given by injection or as a nasal powder, glucagon makes the liver release glucose from glycogen — so it works only if the liver has glycogen to give. It also relaxes the gut and is used as a diagnostic aid in radiology.

Replace thyroid hormone in hypothyroidism, or block its synthesis — or destroy the gland with radioactive iodine — in hyperthyroidism. TSH is the monitoring dial.

Powerful anti-inflammatory/immunosuppressive hormones. Never stop abruptly after prolonged use — taper.

Fludrocortisone replaces the missing mineralocorticoid in primary adrenal insufficiency, so it retains sodium and loses potassium — watch blood pressure, swelling and potassium. Osilodrostat and metyrapone block the last step of cortisol synthesis, and mifepristone (Korlym) blocks cortisol at its receptor; all three can tip a patient into adrenal insufficiency.

Replace antidiuretic hormone to conserve water (diabetes insipidus) or stop bleeding. The defining danger is the opposite: water intoxication and hyponatremia.

Drugs that work the anterior pituitary’s hormone lines: somatostatin analogs (octreotide, lanreotide) switch off growth hormone and gut hormones; somatropin replaces growth hormone and pegvisomant blocks its receptor; dopamine agonists (cabergoline, bromocriptine) switch off prolactin. Watch the gallbladder and glucose with the analogs, glucose and growth with somatropin, the liver with pegvisomant, and the heart valves with the ergot dopamine agonists.