Fludrocortisone Dosage for Adrenal Insufficiency
For patients with adrenal insufficiency, the recommended dosage of fludrocortisone (Florinef) is 0.1 mg daily as a single morning dose, with a typical range of 0.05-0.2 mg daily based on clinical response and laboratory parameters. 1, 2
Standard Dosing Recommendations
- The FDA-approved starting dose for primary adrenal insufficiency (Addison's disease) is 0.1 mg daily, although dosages ranging from 0.1 mg three times weekly to 0.2 mg daily may be employed 1
- For salt-losing adrenogenital syndrome, the recommended dosage is 0.1 mg to 0.2 mg daily 1
- Most patients with primary adrenal insufficiency require 50-200 μg (0.05-0.2 mg) daily as a single morning dose 2
- Children and younger adults may require higher doses (up to 500 μg/0.5 mg daily) 2
Dose Adjustment Parameters
When to Increase Dose
- Orthostatic hypotension (low blood pressure when standing) 2, 3
- Persistent salt cravings despite adequate sodium intake 2
- Low serum sodium or high serum potassium 2
- During pregnancy, particularly in the third trimester (due to progesterone's anti-mineralocorticoid effects) 3, 2
- When using drospirenone-containing contraceptives 3
When to Decrease Dose
- If transient hypertension develops, reduce to 0.05 mg daily 1
- Development of peripheral edema 2
- Essential hypertension (reduce dose but do not stop completely) 3, 2
Monitoring Parameters
- Blood pressure in both supine and standing positions 3, 2
- Serum electrolytes (sodium and potassium) 2
- Clinical symptoms: salt cravings, lightheadedness, peripheral edema 2
- Patients should be reviewed at least annually 2
Important Medication Interactions
- Avoid diuretics, acetazolamide, carbenoxolone, and NSAIDs as they interact with fludrocortisone 3
- Avoid liquorice and grapefruit juice as they potentiate the mineralocorticoid effect of hydrocortisone 3, 2
- Avoid potassium-containing salt substitutes 2
Special Situations
Surgery and Medical Procedures
- During major surgery, continue fludrocortisone when enteral feeding is established 3
- For minor procedures, continue normal fludrocortisone dosing 3
Adrenal Crisis Management
- In adrenal crisis, focus on immediate glucocorticoid administration (hydrocortisone 100 mg IV/IM) 3
- Resume fludrocortisone once patient is stabilized and able to take oral medications 3
Common Pitfalls to Avoid
- Under-replacement is common and may predispose patients to recurrent adrenal crises 3, 2
- Completely stopping fludrocortisone when hypertension develops (reduce dose instead) 3, 2
- Failing to adjust fludrocortisone during pregnancy or periods of increased physical stress 2
- Over-replacement with glucocorticoids to compensate for mineralocorticoid deficiency 3
Comprehensive Management
- Fludrocortisone should be administered in conjunction with glucocorticoid therapy (hydrocortisone 15-25 mg daily or prednisone 3-5 mg daily) 1, 4
- Patients should be advised to take salt and salty foods ad libitum 2
- All patients need education on stress dosing and should wear a medical alert bracelet for adrenal insufficiency 3