What is the proper use of Florinef (fludrocortisone) for hypotension?

From the Guidelines

Florinef (fludrocortisone) should be used to treat orthostatic hypotension at a standard starting dose of 0.1 mg taken orally once daily, usually in the morning, with gradual adjustments based on blood pressure response, as it helps the body retain sodium and water, increasing blood volume and raising blood pressure 1. The goal of using Florinef is to minimize postural symptoms rather than to restore normotension.

• Key considerations when using Florinef include:
  • Increasing salt intake (unless contraindicated) and maintaining adequate hydration
  • Regular monitoring of blood pressure, electrolytes (particularly potassium), and weight due to potential side effects like hypokalemia and fluid retention
  • Common side effects include swelling, headache, and dizziness
  • The medication works by mimicking aldosterone, regulating sodium and potassium balance in the body
  • Florinef should always be taken under medical supervision to avoid serious complications like heart failure or severe electrolyte imbalances 1 It's essential to weigh the potential risks of Florinef against its benefits, considering the balance between increasing standing blood pressure and avoiding marked supine hypertension 1.
• Patients should be educated on behavioral strategies, such as gradual staged movements, mild isotonic exercise, and physical counter-manoeuvres, to help manage orthostatic hypotension 1. If symptoms persist despite non-pharmacological measures, pharmacological treatment with Florinef may be considered, with careful monitoring and adjustment of the dose as needed 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Dosage depends on the severity of the disease and the response of the patient. In Addison’s disease, the combination of fludrocortisone acetate tablets with a glucocorticoid such as hydrocortisone or cortisone provides substitution therapy approximating normal adrenal activity with minimal risks of unwanted effects. The usual dose is 0.1 mg of fludrocortisone acetate tablets daily, although dosage ranging from 0.1 mg three times a week to 0. 2 mg daily has been employed.

The recommended dosage of fludrocortisone for hypotension due to Addison's disease is:

• 0.1 mg daily
• Alternatively, dosage can range from 0.1 mg three times a week to 0.2 mg daily 2

From the Research

Using Florinef for Hypotension

• Florinef, also known as fludrocortisone, is a mineralocorticoid that can be used to treat orthostatic hypotension 3.
• It works by increasing blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 3.
• The treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life, and nonpharmacologic strategies such as dietary modifications, compression garments, and physical maneuvers should be tried first 4.

Administration and Dosage

• The dosage of fludrocortisone for orthostatic hypotension is not specified in the provided studies, but it is typically started at a low dose and gradually increased as needed and tolerated 3.
• It is essential to monitor blood pressure and adjust the dosage accordingly to avoid excessive supine hypertension 5.

Comparison with Other Medications

• Fludrocortisone has been compared to other medications such as midodrine, and studies have shown that midodrine may be associated with a lower risk of all-cause hospitalizations compared to fludrocortisone 6.
• Midodrine is a prodrug that is converted to a selective alpha 1-adrenoceptor agonist, and it has been shown to be effective in increasing standing systolic blood pressure and improving symptoms of orthostatic hypotension 7.

Side Effects and Risks

• The side effects of fludrocortisone are generally minimal, but it can cause excessive supine hypertension, which can be reduced by taking the final daily dose at least 4 hours before bedtime 3.
• Fludrocortisone has also been associated with a higher risk of all-cause hospitalizations compared to midodrine, especially among patients with congestive heart failure 6.