What happens with abrupt discontinuation of Florinef (fludrocortisone)?

Abrupt Discontinuation of Fludrocortisone (Florinef)

Abrupt discontinuation of fludrocortisone (Florinef) should be avoided as it can lead to adrenal crisis, which is potentially life-threatening. 1, 2

Risks of Abrupt Discontinuation

• Adrenal crisis characterized by hypotension, hyponatremia, hyperkalemia, and potentially life-threatening cardiovascular collapse 1, 3
• Immediate natriuresis (excessive sodium excretion) with further increase in plasma-renin activity 4
• Rapid fluid and electrolyte imbalances that can precipitate cardiovascular instability 2
• Worsening of pre-existing adrenal insufficiency symptoms including fatigue, weakness, dizziness, and nausea 5

Proper Discontinuation Protocol

• Fludrocortisone should be tapered rather than abruptly discontinued 1
• Tapering should occur over at least 1-3 days when discontinuing mineralocorticoid replacement 1
• For patients on long-term therapy, a more gradual taper over 2-4 weeks may be necessary to allow the body to adjust 2
• During tapering, close monitoring of blood pressure, serum electrolytes, and clinical symptoms is essential 6

Monitoring During Discontinuation

• Regular blood pressure measurements in both supine and standing positions to detect orthostatic hypotension 6
• Serum electrolyte determinations (particularly sodium and potassium) 2
• Assessment for clinical symptoms of mineralocorticoid deficiency (salt craving, lightheadedness, fatigue) 6, 3
• Plasma renin activity measurements to assess adequacy of mineralocorticoid status 4

Special Considerations

• Patients with primary adrenal insufficiency are at higher risk for severe consequences from abrupt discontinuation compared to those with secondary adrenal insufficiency 1, 3
• Under-replacement with fludrocortisone is common and may predispose patients to recurrent adrenal crises if medication is stopped 6, 4
• Patients should be educated to carry medical identification indicating steroid dependence and the need for stress dosing 2
• Supportive dosage may be required in times of stress (trauma, surgery, severe illness) both during treatment and for up to a year after discontinuation 2

Clinical Pearls and Pitfalls

• Abrupt discontinuation can trigger acute adrenal crisis even in previously stable patients 5
• Some medications (like psyllium) may interfere with gastrointestinal absorption of fludrocortisone and precipitate adrenal crisis 5
• Patients should be advised to avoid potassium-containing salt substitutes and liquorice, which can interfere with mineralocorticoid effects 6
• Even patients who have been stable on fludrocortisone for years can experience crisis with sudden discontinuation 3

Resuming Treatment After Discontinuation

• If symptoms of adrenal insufficiency develop after discontinuation, prompt reinitiation of fludrocortisone is necessary 1
• Most patients with primary adrenal insufficiency require 0.05-0.2 mg of fludrocortisone daily as a single morning dose 6, 3
• Dose should be adjusted based on blood pressure, electrolytes, and clinical symptoms 6
• Some patients may require higher doses (0.2 mg or more) to maintain adequate sodium and water balance 4