From the Guidelines
Fludrocortisone (Florinef) can be used to treat orthostatic hypotension, typically starting at 0.1 mg daily and titrating up to 0.2-0.3 mg daily as needed, and when combined with hydrochlorothiazide (HCTZ) for hypertension management, careful monitoring is essential as these medications have opposing effects. According to the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1, Fludrocortisone increases plasma volume, with a resultant improvement in symptoms of orthostatic hypotension. However, supine hypertension may be a limiting factor, and other side effects commonly seen include edema, hypokalemia, and headache.
Key Considerations
- The dosing of Florinef should be individualized based on the patient's response, with the goal of maintaining adequate standing blood pressure without causing supine hypertension.
- HCTZ, typically dosed at 12.5-25 mg daily, works as a diuretic to reduce blood pressure in hypertensive patients, and its use with Florinef requires close blood pressure monitoring in both seated and standing positions.
- Regular electrolyte checks (particularly potassium and sodium) and assessment for peripheral edema are necessary when using this combination.
- Patients should be advised to increase salt and fluid intake while on Florinef and to rise slowly from sitting or lying positions to minimize orthostatic symptoms.
Monitoring and Adjustments
- Blood pressure should be monitored regularly in both seated and standing positions to adjust the dosing of Florinef and HCTZ as needed.
- Electrolyte levels, particularly potassium and sodium, should be checked regularly to avoid imbalances.
- Patients should be educated on the importance of gradual position changes and increasing salt and fluid intake to minimize orthostatic symptoms.
From the Research
Orthostatic Hypotension Treatment
- The treatment of orthostatic hypotension (OH) can involve pharmacological and non-pharmacological strategies 2.
- Non-pharmacological strategies are the primary treatment, including discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, adding salt to diet, and so on 2.
- Pharmacotherapy can help ameliorate symptoms, including midodrine, droxidopa, fludrocortisone, pyridostigmine, atomoxetine, sympathomimetic agents, and octreotide 2.
Florinef (Fludrocortisone) for Orthostatic Hypotension
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 3.
- There is very low-certainty evidence about the effects of fludrocortisone on drop in blood pressure and orthostatic symptoms in people with orthostatic hypotension and diabetes or Parkinson disease 3.
- A study found that symptoms in patients with postural tachycardia syndrome improved greatly after treatment with fludrocortisone or bisoprolol, or both 4.
Combination Therapy with HCTZ for Hypertension
- There is no direct evidence in the provided studies on the use of Florinef (fludrocortisone) in combination with HCTZ for hypertension.
- However, a study on the treatment of primary orthostatic hypotension mentions that medication management should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions 2.