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enda-monitor-mineralocorticoid-replacement

This skill outlines monitoring of mineralocorticoid replacement in primary adrenal insufficiency, focusing on clinical assessment of salt craving, postural hypotension, or edema alongside serum electrolyte measurements. It is initiated when evaluating patients on fludrocortisone therapy to ensure adequate dosing and avoid over- or under-replacement.

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dromlakhani/MD2SKILL

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Monitor Mineralocorticoid Replacement via Clinical Assessment and Electrolytes

STEP 1 — Gather Information

Collect history of salt craving, light‑headedness or postural dizziness, peripheral edema; measure supine and standing blood pressure; obtain serum sodium and potassium levels.

STEP 2 — Rule In / Rule Out

If any of the following are present: salt craving, postural hypotension, edema, serum Na⁺ <135 mmol/L, or serum K⁺ >5.0 mmol/L → Rule In (inadequate mineralocorticoid replacement); otherwise → Rule Out (adequate replacement).

STEP 3 — Classify or Stratify

Classify the patient as:

  • Under‑replacement: signs/symptoms of deficiency (salt craving, postural hypotension, edema) with low/normal Na⁺ or high K⁺.
  • Adequate: absence of deficiency signs and electrolytes within normal range.
  • Over‑replacement: hypertension, supine edema, hypokalemia (K⁺ <3.5 mmol/L) or unexplained weight gain.

STEP 4 — Decide

  • Under‑replacement: consider increasing fludrocortisone dose by 50–100 µg daily.
  • Over‑replacement: consider decreasing fludrocortisone dose by 50–100 µg daily and evaluate for hypertension causes.
  • Adequate: maintain current dose and reassess at next routine visit.

Clinical Guardrails / Mimics / Pitfalls

Do not rely solely on electrolytes; avoid using diuretics to treat hypertension from over‑replacement; do not advise salt restriction; be aware that licorice, grapefruit juice, or phenytoin can potentiate fludrocortisone effect; avoid dose changes based only on plasma renin without clinical correlation.

Concrete Clinical Example

A 48‑year‑old man on fludrocortisone 100 µg daily reports new salt craving and mild light‑headedness on standing. Supine BP 118/72 mmHg, standing BP 96/60 mmHg; serum Na⁺ 132 mmol/L, K⁺ 5.3 mmol/L. Findings indicate under‑replacement; fludrocortisone is increased to 150 µg daily with follow‑up in 4 weeks.

Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, doi:10.1210/jc.2015-1710

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