What dietary recommendations are suitable for a patient with Addison's disease who is taking Lasix (furosemide)?

Dietary Management for Addison's Disease Patients on Furosemide

Patients with Addison's disease taking furosemide require liberal salt intake and must avoid sodium restriction to prevent life-threatening electrolyte depletion and adrenal crisis.

Critical Sodium Management

The combination of Addison's disease and furosemide creates a dangerous situation requiring generous salt intake, not restriction. 1, 2

• Advise patients to consume salt and salty foods ad libitum (freely according to taste) to compensate for both mineralocorticoid deficiency and diuretic-induced sodium losses 1
• Sodium restriction is contraindicated in this population, as it increases the risk of hyponatremia, hypovolemia, and adrenal crisis 3, 4
• The FDA label for furosemide explicitly warns that hypokalemia develops especially with "inadequate oral electrolyte intake" and "during concomitant use of corticosteroids" 2

Electrolyte Monitoring and Supplementation

Frequent electrolyte monitoring is mandatory due to the dual risk from both conditions:

• Check serum electrolytes (particularly potassium, sodium) frequently during the first months of furosemide therapy and periodically thereafter 2
• Hypokalemia is particularly dangerous in this population, as furosemide causes potassium wasting while corticosteroid replacement can exacerbate this effect 2
• Monitor for signs of electrolyte depletion: weakness, lethargy, muscle cramps, hypotension, or arrhythmias 2

Fluid Intake Recommendations

During intense physical activity or hot conditions, aggressively increase both fluid and salt intake to replace sweat losses 1

• The evidence from heart failure patients shows that aggressive fluid restriction (800 mL/day) combined with low sodium is unnecessary and potentially harmful 5
• Patients with Addison's disease are already at risk for volume depletion; adding furosemide magnifies this risk 2, 6

Fludrocortisone Dose Adjustment

The fludrocortisone dose may need to be increased when furosemide is added:

• Titrate fludrocortisone (typical range 50-200 μg daily) based on blood pressure, serum electrolytes, and salt cravings—not plasma renin activity 1
• Monitor for postural hypotension, which indicates insufficient mineralocorticoid replacement or inadequate salt intake 1
• If hypertension develops, reduce fludrocortisone dose but never discontinue it completely; add a vasodilator antihypertensive instead 1, 6

Standard Nutritional Framework

Provide a standard, unrestricted diet to prevent malnutrition:

• The 2021 ESPEN guidelines explicitly state that salt restriction should not be recommended in patients on corticosteroid therapy, as the benefits-risk ratio favors higher malnutrition risk 5
• Aim for a balanced diet: 55-60% carbohydrates, 15-20% protein, 25-30% fat 5
• Ensure adequate calcium and vitamin D supplementation for bone health 5

Critical Pitfalls to Avoid

Never apply standard diuretic dietary advice (low sodium) to Addison's patients:

• The evidence shows that unnecessary low-sodium diets are frequently prescribed with long-term glucocorticoid therapy in real-world practice, despite being contraindicated 5
• Furosemide combined with inadequate salt intake in an Addison's patient can precipitate acute adrenal crisis 2, 3
• The FDA label warns that "excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse" particularly when combined with restricted salt intake 2

Patient Education Essentials

All patients must understand stress dosing and emergency protocols:

• Double or triple oral hydrocortisone during febrile illness or stress, continuing for 24-48 hours after resolution 7
• Provide emergency injectable hydrocortisone kit with training 7
• Issue medical alert bracelet and steroid emergency card 7, 1
• Educate on signs of adrenal crisis: severe weakness, confusion, abdominal pain, hypotension 5, 7