What are the dose increments for Fludrocortisone (Florinef)?

From the Guidelines

Fludrocortisone dose increments should be made in increments of 0.1 mg per day, starting with a low dose of 0.1 mg once daily and titrating gradually based on clinical response, with a maximum dosage of 1.0 mg/d, as indicated in the 2023 ACC expert consensus decision pathway on comprehensive multidisciplinary care for the patient with cardiac amyloidosis 1. When adjusting the dose, it is essential to monitor blood pressure, serum electrolytes, and edema, aiming for resolution of orthostatic symptoms and normalization of blood pressure. Key considerations for fludrocortisone dose adjustments include:

• Starting with a low dose and titrating gradually based on clinical response
• Monitoring blood pressure, serum electrolytes, and edema
• Adjusting the dose in increments of 0.1 mg per day
• Maintaining a maximum dosage of 1.0 mg/d
• Being cautious in patients with heart failure, as fludrocortisone may be poorly tolerated in these patients, as noted in the study by Watson et al. and Freeman et al. 1. It is also important to note that fludrocortisone works by increasing sodium reabsorption and water retention in the kidneys, thereby expanding plasma volume and increasing blood pressure, which helps manage conditions like adrenal insufficiency or orthostatic hypotension. Morning doses are preferred to minimize sleep disruption, and patients should be advised to increase salt intake while on fludrocortisone and to monitor for signs of fluid retention, such as weight gain, ankle swelling, or worsening hypertension, which may indicate the need for dose reduction, as recommended in the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 2, 3.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Dosage depends on the severity of the disease and the response of the patient. In the event transient hypertension develops as a consequence of therapy, the dose should be reduced to 0.05 mg daily. The fludrocortisone dose increments are not explicitly stated in the label, but it does mention that the dose can be reduced to 0.05 mg daily in case of transient hypertension.

• The usual dose is 0.1 mg of fludrocortisone acetate tablets daily.
• Dosage can range from 0.1 mg three times a week to 0.2 mg daily. 4

From the Research

Fludrocortisone Dose Increments

• The provided studies do not directly address fludrocortisone dose increments, but rather its use and effects in treating orthostatic hypotension 5, 6, 7, 8.
• Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 5.
• The studies suggest that fludrocortisone can be effective in increasing blood pressure and reducing symptoms of orthostatic hypotension, but the evidence is often of low certainty and more research is needed to fully understand its effects 5, 8.
• In terms of dosing, one study mentions that fludrocortisone was used at a dose of 0.05-0.2 mg per day 8, but does not provide information on dose increments.
• Another study notes that fludrocortisone has been associated with adverse events, including renal and cardiac failure, and increased risk of all-cause hospitalization, which may be relevant to considerations of dose increments 6, 7.
• Overall, while the studies provide some information on the use and effects of fludrocortisone in treating orthostatic hypotension, they do not provide direct guidance on dose increments.