When to start fludrocortisone for postural hypotension?

From the Guidelines

Fludrocortisone should be started for postural hypotension when non-pharmacological measures, such as increased salt and fluid intake, physical counter-pressure maneuvers, and compression garments, have failed and symptoms significantly impact quality of life, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.

Key Considerations

• Before initiating fludrocortisone, patients should have tried non-pharmacological interventions, including increased salt and fluid intake, which can improve blood pressure while decreasing symptoms from orthostatic hypotension (OH) 1.
• Physical counter-pressure maneuvers, such as leg crossing, lower body muscle tensing, and maximal force handgrip, can increase blood pressure and are beneficial in patients with neurogenic OH with syncope 1.
• Compression garments can improve orthostatic symptoms and blunt associated decreases in blood pressure in patients with OH, including older adult patients and those with neurogenic etiologies 1.

Fludrocortisone Therapy

• The typical starting dose of fludrocortisone is 0.1 mg once daily, which can be gradually increased to a maximum of 0.3 mg daily if needed, with dose adjustments made every 1-2 weeks based on symptom response.
• Fludrocortisone works by increasing sodium retention and expanding plasma volume, thereby improving blood pressure regulation upon standing.
• Patients should be monitored for potential side effects, including edema, hypokalemia, and hypertension while supine, as well as more serious adverse reactions, such as adrenal suppression and immunosuppression, which can occur with doses >0.3 mg daily 1.

Monitoring and Contraindications

• Regular blood pressure measurements in both lying and standing positions, along with electrolyte monitoring, are essential during treatment.
• Fludrocortisone is contraindicated in patients with heart failure, uncontrolled hypertension, or significant renal impairment, so these conditions should be ruled out before starting therapy.
• When supine hypertension is present, other medications, such as midodrine or droxidopa, should be used before fludrocortisone, as recommended by the 2017 ACC/AHA/HRS guideline 1.

From the Research

Initiating Fludrocortisone for Postural Hypotension

The decision to start fludrocortisone for postural hypotension depends on various factors, including the severity of symptoms, underlying cause, and presence of other medical conditions.

• Fludrocortisone is considered a first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures such as increasing fluid and salt intake and venous compression methods 2.
• Studies have shown that fludrocortisone can be effective in treating postural hypotension in patients with diabetic autonomic neuropathy 3, 4 and those with Parkinson's disease 5.
• The typical dosage of fludrocortisone for postural hypotension is 0.1-0.2 mg daily, with some studies using doses up to 0.4 mg daily 3, 5, 4.
• It is essential to use fludrocortisone cautiously in patients with congestive cardiac failure or the nephrotic syndrome, as it can exacerbate these conditions 3.
• The evidence for the effectiveness of fludrocortisone in treating postural hypotension is generally of low certainty, and more research is needed to fully understand its benefits and harms 2.

Considerations for Initiating Fludrocortisone

Before starting fludrocortisone for postural hypotension, consider the following:

• The presence of underlying conditions that may be contributing to postural hypotension, such as dehydration, anemia, or medication side effects.
• The severity of symptoms and their impact on daily life.
• The potential for fludrocortisone to interact with other medications or worsen underlying medical conditions.
• The need for regular monitoring of blood pressure, electrolyte levels, and other parameters to minimize the risk of adverse effects 2, 4.

Monitoring and Follow-up

Once fludrocortisone is initiated, regular monitoring and follow-up are crucial to:

• Assess the effectiveness of treatment in improving symptoms and blood pressure control.
• Monitor for potential side effects, such as ankle edema, particularly in patients with low serum albumin 4.
• Adjust the dosage or discontinue treatment if necessary, based on individual response and tolerance 3, 5.