Fludrocortisone acetate

• Tablets 100micrograms (£5.40 = 30 tablets)

Indications and dose

• Mineralocorticoid replacement in adrenocortical insufficiency
  • Usually 50-300micrograms once daily (in the morning)
• Adrenocortical insufficiency resulting from septic shock (in combination with hydrocortisone)
  • 50micrograms daily
• Postural hypotension (unlicensed indication).
  • Usually 100-400micrograms daily (in the morning)

Notes

1. Fludrocortisone may be considered for the treatment of postural hypotension if the following strategies do not sufficiently improve the patient's blood pressure:
   1. no obvious cause for the postural drop in blood pressure has been diagnosed (e.g. medication, dehydration/hypovolaemia, electrolyte abnormality, autonomic dysfunction, Addison's disease)
   2. adequate fluid intake has been assured
   3. compression hosiery has been considered and utilised where clinically indicated
   4. the patient has been advised on sleeping position and standing techniques
2. Lying and standing (or sitting and standing) BP should be monitored at regular intervals until the BP is stabilised within normal limits with no postural drop
3. See the most recent edition of BNF for further information on corticosteroid side effects.
4. If pharmacological causes for postural hypotension cannot be addressed, NICE recommends midodrine (non-formulary) as a first line treatment (due to the availability of a licensed product). However local specialists indicate a preference for fludrocortisone (off-label use) as the first line treatment option, taking into account its safety profile. Midodrine tablets (Bramox) are available at significantly increased cost; however there is a lack of evidence of clinical benefit of midodrine over fludrocortisone. Midodrine is reserved for use in patients for whom fludrocortisone is ineffective or not tolerated.