In a patient on fludrocortisone who has just had a cerebrovascular accident (stroke), should the fludrocortisone be continued?

Fludrocortisone Should Be Continued After Stroke in Patients With Adrenal Insufficiency

In a patient on fludrocortisone who experiences a cerebrovascular accident, the fludrocortisone must be continued without interruption, as stopping mineralocorticoid replacement in someone with adrenal insufficiency can precipitate life-threatening adrenal crisis. 1

Rationale for Continuation

• Fludrocortisone treats the underlying mineralocorticoid deficiency, not the stroke itself. The stroke is an intercurrent illness that does not change the patient's need for mineralocorticoid replacement. 1

• Patients with primary adrenal insufficiency require lifelong fludrocortisone replacement (typically 50-200 µg daily) to prevent salt wasting, volume depletion, and cardiovascular collapse. 1

• Discontinuing fludrocortisone during acute illness increases the risk of adrenal crisis, which carries significant mortality risk and requires immediate treatment with IV hydrocortisone and aggressive fluid resuscitation. 1

Management During the Acute Stroke Period

Glucocorticoid Stress Dosing

• Triple the patient's usual hydrocortisone dose (or equivalent glucocorticoid) during the acute stroke period, as cerebrovascular accidents represent significant physiologic stress. 2

• If the patient cannot take oral medications due to dysphagia or altered consciousness, administer hydrocortisone 100 mg IV bolus immediately, followed by 100 mg IV every 6-8 hours until oral intake resumes. 1

• High-dose IV hydrocortisone (≥100 mg every 6-8 hours) provides adequate mineralocorticoid activity during the acute phase, so fludrocortisone can be temporarily held only while receiving these high IV hydrocortisone doses. 1, 3

Resuming Fludrocortisone

• Restart fludrocortisone at the usual maintenance dose as soon as the hydrocortisone dose falls below 50 mg per day, whether given IV or orally. 1

• Once the patient transitions back to oral maintenance glucocorticoid doses, fludrocortisone must be resumed at the pre-stroke dose (typically 50-200 µg daily). 1

Monitoring During Stroke Recovery

Assess for Adequate Mineralocorticoid Replacement

• Check supine and standing blood pressure regularly; orthostatic hypotension (drop >20 mmHg systolic or >10 mmHg diastolic) indicates inadequate mineralocorticoid replacement or volume depletion. 1

• Measure plasma renin activity (PRA) to guide fludrocortisone dosing, targeting values in the upper half of the normal reference range. 1

• Monitor serum sodium and potassium at least every 1-2 days initially; however, recognize that the absence of hyperkalemia does not exclude mineralocorticoid deficiency, as hyperkalemia is present in only ~50% of under-replaced patients. 2

• Assess for clinical signs of volume depletion: weight loss, tachycardia, low urine output, rising blood urea nitrogen, or salt craving all suggest inadequate mineralocorticoid effect. 1, 4

Watch for Over-Replacement

• Monitor for hypertension, peripheral edema, or hypokalemia, which indicate fludrocortisone over-replacement. 1

• If hypertension develops, reduce the fludrocortisone dose but do not stop it entirely. 1

• Hypokalemia occurs in approximately 24% of patients on fludrocortisone and typically appears after several months of therapy; supplement potassium as needed but rarely requires fludrocortisone discontinuation. 5

Critical Pitfalls to Avoid

• Do not stop fludrocortisone simply because the patient had a stroke. There is no contraindication to mineralocorticoid replacement in stroke patients, and stopping it risks adrenal crisis. 1

• Do not rely solely on serum sodium and potassium to assess mineralocorticoid adequacy. Hyponatremia may be subtle and hyperkalemia absent even with significant under-replacement. 2

• Do not confuse the temporary holding of fludrocortisone during high-dose IV hydrocortisone with permanent discontinuation. Fludrocortisone must be restarted once stress-dose steroids are tapered. 1

• Do not assume that blood pressure control for stroke management requires stopping fludrocortisone. If hypertension occurs, reduce the fludrocortisone dose incrementally rather than stopping it. 1

Special Considerations in Stroke Patients

Fluid and Salt Management

• Maintain adequate hydration with 2-3 liters of fluid daily and encourage salt intake of 6-9 grams per day unless contraindicated by severe hypertension or heart failure. 1, 4

• In stroke patients with concurrent hypertension or heart failure, fluid and salt intake require more careful monitoring, but complete restriction is rarely appropriate in patients with adrenal insufficiency. 4

Drug Interactions

• Avoid licorice and grapefruit juice, which potentiate mineralocorticoid effects and can cause hypertension or hypokalemia. 1, 4

• NSAIDs, diuretics, and acetazolamide can diminish fludrocortisone effectiveness and may require dose adjustment. 1

Long-Term Management

• Continue fludrocortisone indefinitely at the maintenance dose once the acute stroke period resolves and glucocorticoid stress dosing is tapered. 1

• Schedule follow-up within 1-2 weeks after hospital discharge to reassess blood pressure, electrolytes, and PRA, adjusting the fludrocortisone dose as needed. 1