What is the appropriate management for a patient on prednisone and fludrocortisone?

From the Guidelines

The patient on prednisone and fludrocortisone should be managed with careful monitoring of blood pressure, electrolytes, and blood glucose, and should receive education on recognizing signs of adrenal insufficiency and complications, as well as instructions on how to manage their medication during stress, illness, or surgery. This is based on the recommendations from the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 1.

Key Considerations

• Regular assessment of blood pressure, electrolytes (particularly potassium), blood glucose, and weight is essential to monitor for potential side effects of prednisone and fludrocortisone.
• Patients should be monitored for signs of adrenal insufficiency, especially during stress, illness, or surgery, which may require temporary dose increases of hydrocortisone, as recommended by the consensus statement 1.
• For surgery or severe illness, stress-dose steroids are typically needed, such as hydrocortisone 100mg IV followed by 50mg every 8 hours, as suggested by the guidelines 1.
• Patients should carry a steroid emergency card and wear medical alert identification to ensure prompt treatment in case of an emergency.
• Bone health should be protected with calcium and vitamin D supplements, and periodic bone density testing, as recommended by the guidelines 1.
• Blood pressure and edema should be monitored as fludrocortisone causes sodium retention, and interactions with other medications, such as diuretics and NSAIDs, should be avoided or managed carefully, as outlined in the consensus statement 1.

Medication Management

• The dose of prednisone and fludrocortisone should be adjusted as needed to minimize side effects and prevent adrenal crisis, with the goal of using the lowest dose compatible with health and a sense of well-being, as recommended by the consensus statement 1.
• Gradual tapering is necessary when discontinuing therapy to prevent adrenal crisis, and patients should be educated on how to manage their medication during stress, illness, or surgery.
• The patient should be advised to take salt and salty foods ad libitum and avoid liquorice and grapefruit juice, as these can potentiate the mineralocorticoid effect of hydrocortisone, as noted in the consensus statement 1.

Patient Education

• Patient education about infection risk, medication adherence, and recognizing signs of complications is crucial to prevent adverse outcomes.
• Patients should be instructed on how to manage their medication during stress, illness, or surgery, and how to recognize signs of adrenal insufficiency, such as hypotension, vomiting, or diarrhea, as recommended by the consensus statement 1.

From the FDA Drug Label

The initial dosage of PredniSONE tablets may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated. BECAUSE OF ITS MARKED EFFECT ON SODIUM RETENTION, THE USE OF FLUDROCORTISONE ACETATE IN THE TREATMENT OF CONDITIONS OTHER THAN THOSE INDICATED HEREIN IS NOT ADVISED. Periodic checking of serum electrolyte levels is advisable during prolonged therapy; dietary salt restriction and potassium supplementation may be necessary

The appropriate management for a patient on prednisone and fludrocortisone includes:

• Monitoring serum electrolyte levels periodically 2
• Dietary salt restriction and potassium supplementation may be necessary 2
• Prednisone dosage may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated 3
• The patient should be closely monitored for signs of infection, and antimicrobial therapy should be promptly initiated if an infection occurs 2
• The use of fludrocortisone acetate should be carefully monitored to avoid the development of hypertension, edema, or weight gain 2

From the Research

Management of Patients on Prednisone and Fludrocortisone

The management of patients on prednisone and fludrocortisone requires careful consideration of the potential benefits and risks associated with these medications.

• Monitoring for Adverse Effects: Patients on long-term oral corticosteroids (LTOC) like prednisone are at risk for various adverse effects, including weight gain, osteoporosis, cataracts, hypertension, diabetes mellitus, dyspepsia, and psychiatric complaints 4.
• Baseline Monitoring: It is essential to establish a baseline monitoring system for patients starting LTOC, including measurements of weight, blood pressure, triglycerides, glucose, and urea and electrolytes 4.
• Bone Metabolism: Low-dose prednisone (5 mg/day) has been shown to suppress bone formation and may decrease bone resorption in postmenopausal women, highlighting the need for monitoring bone health in patients on long-term prednisone therapy 5.
• Fludrocortisone for Orthostatic Hypotension: Fludrocortisone is used to treat orthostatic hypotension, and while the evidence for its effectiveness is uncertain, it may be beneficial in increasing blood volume and blood pressure 6.
• Low-Dose Prednisone in Rheumatoid Arthritis: Low-dose prednisone has been shown to be effective in controlling inflammatory features of rheumatoid arthritis and retarding bony damage, with minimal side effects when used appropriately 7.
• Minimizing Adverse Effects: Adverse effects associated with prednisone can be minimized by reducing the dosage, and the benefits of treatment often outweigh the risks 8.

Key Considerations

• Regular monitoring for adverse effects and adjustment of medication as needed
• Establishment of a baseline monitoring system for patients starting LTOC
• Consideration of the potential benefits and risks of fludrocortisone in treating orthostatic hypotension
• Appropriate use of low-dose prednisone in rheumatoid arthritis and other conditions
• Minimization of adverse effects through dosage adjustment and monitoring.