What is the best approach to tapering fludrocortisone (a synthetic corticosteroid) from 0.1mg daily?

Fludrocortisone Tapering from 0.1mg Daily

In patients with primary adrenal insufficiency on fludrocortisone 0.1mg daily, do not routinely taper or discontinue this medication, as mineralocorticoid replacement is lifelong and essential for maintaining blood pressure and electrolyte homeostasis. 1

Key Principles for Fludrocortisone Management

When NOT to Taper

• Fludrocortisone is replacement therapy, not suppressive therapy - patients with Addison's disease and other forms of primary adrenal insufficiency require lifelong mineralocorticoid replacement 1
• The standard maintenance dose of 0.1mg daily is often insufficient for many patients, with evidence showing that doses of 0.05-0.1mg frequently result in sodium and water depletion with elevated plasma renin activity 2
• Most patients with primary adrenal insufficiency actually require 0.2mg daily to maintain adequate sodium and water balance 2

Dose Adjustment Rather Than Tapering

Monitor and adjust the dose based on clinical parameters rather than attempting to taper: 1

• Clinical assessment: Ask about salt cravings, lightheadedness, measure blood pressure (supine and standing), check for peripheral edema 1
• Laboratory monitoring: Plasma renin activity (target upper half of reference range), serum sodium, potassium, and 24-hour urinary sodium excretion 1, 2
• Dose range: 50-200 µg (0.05-0.2mg) daily is usually sufficient in adults with primary adrenal insufficiency 1

Situations Requiring Dose Reduction (Not Discontinuation)

If hypertension develops as a consequence of fludrocortisone therapy: 3

• Reduce dose to 0.05mg daily 3
• Consider adding a vasodilator rather than stopping mineralocorticoid replacement 1
• A dose reduction should be considered, but complete discontinuation is inappropriate 1

If peripheral edema develops: 1

• This suggests over-replacement
• Reduce dose incrementally (e.g., from 0.2mg to 0.15mg to 0.1mg)
• Continue monitoring clinical and laboratory parameters

Special Circumstances Requiring Dose Increases

• Pregnancy (third trimester): May need up to 0.5mg daily due to progesterone's anti-mineralocorticoid effects 1
• Children and younger adults: May require higher doses (up to 0.5mg daily) 1
• Drospirenone-containing contraceptives: May require dose increase 1

Critical Drug Interactions to Avoid

The following medications should be avoided or require careful monitoring: 1

• Diuretics (avoid) 1
• Acetazolamide (avoid) 1
• NSAIDs (avoid) 1
• Carbenoxolone and licorice (avoid - potentiate mineralocorticoid effect) 1

Common Pitfall

Under-replacement with fludrocortisone is common and often compensated for by over-replacement of glucocorticoids, which predisposes patients to recurrent adrenal crises. 1 Many clinicians mistakenly believe 0.1mg is the "standard" dose when evidence shows most patients need 0.2mg daily for adequate replacement 2.

Practical Monitoring Algorithm

1. Assess clinical status: salt cravings, orthostatic symptoms, blood pressure (lying and standing) 1
2. Check labs: serum sodium, potassium, plasma renin activity 1, 2
3. If plasma renin activity is elevated: increase fludrocortisone by 0.05mg increments 2
4. If signs of over-replacement (edema, hypertension): decrease by 0.05mg 3
5. Target: plasma renin activity in upper half of reference range, no orthostatic symptoms, normal electrolytes 1, 2