What symptoms should be monitored when decreasing the dose of fludrocortisone (mineralocorticoid)?

Symptoms to Monitor When Decreasing Fludrocortisone Dose

When decreasing fludrocortisone dose, patients should be closely monitored for symptoms of mineralocorticoid deficiency including orthostatic hypotension, salt cravings, lightheadedness, fatigue, hyponatremia, and hyperkalemia. 1

Key Symptoms to Monitor

Cardiovascular Symptoms

• Orthostatic hypotension - Check blood pressure in both sitting and standing positions
• Dizziness or lightheadedness upon standing
• Increased heart rate
• Fatigue or weakness

Electrolyte Disturbances

• Hyponatremia (low sodium) - May present as confusion, headache, nausea
• Hyperkalemia (high potassium) - May present as muscle weakness, palpitations
• Metabolic acidosis

Fluid Balance

• Salt cravings
• Increased thirst
• Dehydration
• Weight loss (due to fluid loss)

Gastrointestinal Symptoms

• Nausea
• Vomiting
• Abdominal pain
• Decreased appetite

Monitoring Protocol During Tapering

Laboratory Monitoring

• Serum sodium and potassium (weekly during tapering)
• Plasma renin activity (target: upper half of normal range) 1, 2
• Basic metabolic panel

Clinical Monitoring

• Blood pressure measurements (both sitting and standing)
• Weight changes
• Assessment for peripheral edema
• Symptom review at each visit

Tapering Approach

Fludrocortisone tapering should be done gradually to prevent adrenal insufficiency:

1. Initial reduction: Decrease by 0.05 mg every 1-2 weeks 3
2. Monitoring period: Allow 1-2 weeks at each dose level to assess for symptoms
3. Frequency of evaluation: Weekly during active tapering

Warning Signs of Under-Replacement

Under-replacement with fludrocortisone is common and can lead to:

• Recurrent adrenal crises
• Persistent salt cravings
• Postural hypotension
• Fatigue and weakness
• Electrolyte abnormalities 1

Special Considerations

Medications to Avoid During Tapering

• Diuretics
• Acetazolamide
• Carbenoxolone
• Licorice
• NSAIDs
• Drospirenone-containing contraceptives 1

Risk Factors for Complications

• History of adrenal crisis
• Concurrent illness
• Medication changes affecting fluid/electrolyte balance
• Hot weather (increased risk of sodium depletion)

Management of Symptoms During Tapering

If symptoms of mineralocorticoid deficiency develop:

• Return to the previous effective dose
• Recheck electrolytes and renin levels
• Consider maintaining at the lowest effective dose rather than complete discontinuation
• Ensure adequate salt intake 1

Potential Complications of Tapering Too Rapidly

• Adrenal crisis (medical emergency)
• Severe hypotension
• Electrolyte disturbances
• Cardiovascular collapse

Remember that under-replacement with mineralocorticoids is common and may predispose patients to recurrent adrenal crises 1. Careful monitoring of symptoms and laboratory values is essential for safe dose reduction.