Is Florinef (fludrocortisone) a treatment for adrenal crisis?

Florinef (Fludrocortisone) Is NOT a Treatment for Acute Adrenal Crisis

Fludrocortisone is a mineralocorticoid used for chronic maintenance therapy in primary adrenal insufficiency, but it plays no role in the acute treatment of adrenal crisis, which requires immediate high-dose parenteral hydrocortisone. 1

Acute Adrenal Crisis Management

The treatment of adrenal crisis is urgent and requires:

• Parenteral hydrocortisone at 10-15 times physiological doses (not fludrocortisone) 1
• If hydrocortisone is unavailable, prednisolone or methylprednisolone may be used as alternatives 1
• If peripheral venous access cannot be achieved quickly, intramuscular administration should be performed without delay 1
• Correction of fluid deficit, hypoglycemia, hyponatremia, and hyperkalemia 1

The critical point: During acute adrenal crisis, the massive doses of hydrocortisone required (which has inherent mineralocorticoid activity at high doses) provide sufficient mineralocorticoid effect, making fludrocortisone unnecessary in the acute setting. 2

Role of Fludrocortisone in Chronic Management

Fludrocortisone is reserved exclusively for chronic maintenance therapy in primary adrenal insufficiency:

• Standard dosing: 0.05-0.2 mg once daily upon awakening 3, 2
• Higher doses up to 0.5 mg daily may be needed in children, younger adults, or during the last trimester of pregnancy 3, 4
• The medication maintains blood pressure and water/electrolyte homeostasis through sodium retention and vascular effects 4

Common Clinical Pitfall

A major error is attempting to use fludrocortisone during acute adrenal crisis. The mineralocorticoid deficiency in crisis is addressed by the high-dose glucocorticoid therapy itself, not by adding fludrocortisone. 2 Fludrocortisone is only reintroduced or continued as part of the chronic maintenance regimen after the crisis has been stabilized with intravenous hydrocortisone. 3

Monitoring Chronic Fludrocortisone Therapy

Adequacy of mineralocorticoid replacement is assessed by:

• Asking about salt cravings or lightheadedness 3, 5
• Measuring blood pressure in supine and standing positions 3, 5
• Checking for peripheral edema 3
• Plasma renin activity (most objective measure) 5
• Serum electrolytes, particularly sodium and potassium 4

Under-replacement with fludrocortisone is common and may predispose patients to recurrent adrenal crises, sometimes compensated for by over-replacement of glucocorticoids. 3

Drug Interactions Requiring Dose Adjustment

Several medications interact with fludrocortisone and should be avoided or require dose adjustments:

• Avoid: Diuretics, acetazolamide, carbenoxolone, liquorice, NSAIDs 3, 4
• May need more fludrocortisone: Drospirenone-containing contraceptives 3
• Potentiate mineralocorticoid effect: Liquorice and grapefruit juice (should be avoided) 3, 4
• Phenytoin markedly increases fludrocortisone metabolism, potentially requiring doses as high as 0.4-2.0 mg daily 6

Patient Education for Crisis Prevention

Patients should be educated that:

• Stressful conditions require increased glucocorticoid doses (not fludrocortisone adjustments) to prevent crisis 1
• All patients should carry emergency information and have an emergency hydrocortisone injection kit 1
• Patients should be trained on recognizing signs of adrenal crisis and using intramuscular hydrocortisone 1