Fludrocortisone (Florinef) Dosing for Orthostatic Hypotension
The typical starting dose of fludrocortisone (Florinef) for treating orthostatic hypotension is 0.1 mg once daily. 1
Dosing Guidelines
- Initial dose: 0.1 mg once daily 1
- Titration: Can be gradually increased based on symptoms and blood pressure response 1
- Maximum recommended dose: 1.0 mg per day 1
- Maintenance dose typically ranges from 0.05-0.3 mg daily 1
Mechanism of Action
- Fludrocortisone is a mineralocorticoid that increases blood volume by promoting sodium retention 2
- It expands fluid volume and helps maintain upright blood pressure by limiting the decrease in cardiac output during standing 3
- Treatment works by reducing the orthostatic decrease in cardiac output rather than by increasing peripheral resistance 3
Monitoring Requirements
- Monitor blood pressure (both supine and standing) regularly 1
- Check serum electrolytes (particularly potassium) and renal function at baseline and periodically during treatment 1
- Initial follow-up within 1-2 weeks to assess response and adjust dosing 1
- Monitor for development of supine hypertension, which is a common complication 1
Precautions and Contraindications
- Use with caution in patients with heart failure as it may worsen fluid retention 1, 4
- Higher risk of all-cause hospitalizations compared to midodrine, particularly in patients with congestive heart failure 4
- Avoid in patients with severe renal impairment 1
- Use cautiously in elderly patients due to increased risk of fluid retention and electrolyte disturbances 1
- Contraindicated in patients with systemic fungal infections 1
Common Side Effects
- Supine hypertension (particularly concerning in patients who already have hypertension) 1
- Fluid retention and edema 1
- Hypokalemia 1
- Headaches 1
- Weight gain 1
Combination Therapy
- Often combined with non-pharmacological measures such as increased salt and fluid intake 1
- May be used with other medications for orthostatic hypotension such as midodrine or pyridostigmine when monotherapy is insufficient 1, 5
- Consider adding compression stockings or abdominal binders for additional benefit 1
Evidence Quality
- Despite widespread use, evidence for fludrocortisone's efficacy is based primarily on small studies 2
- A Cochrane review found very low-certainty evidence about the effects of fludrocortisone on blood pressure and orthostatic symptoms 2
- One study showed that compared to midodrine, fludrocortisone users had higher rates of all-cause hospitalizations (adjusted incidence-rate ratio: 1.20) 4
Clinical Pearls
- Sleeping with the head of the bed elevated (10°) may enhance the effectiveness of fludrocortisone therapy 1, 3
- Patients should be educated about potential symptoms of fluid overload that require dose adjustment 1
- The drug may take several days to reach full therapeutic effect due to its mechanism of expanding plasma volume 3
- In patients with primary adrenal insufficiency, fludrocortisone is typically used at lower doses (0.05-0.1 mg daily) 1