Reduce Fludrocortisone Dose if Hypertension Develops
STEP 1 — Gather Information
Measure seated blood pressure, assess for edema or weight gain, check serum sodium and potassium, review current fludrocortisone dose and timing, and screen for other hypertension causes (e.g., renal artery stenosis, essential hypertension).
STEP 2 — Rule In / Rule Out
If new hypertension coincides with fludrocortisone initiation or uptitration and is accompanied by edema, weight gain, or hypokalemia, attribute to fludrocortisone excess; otherwise evaluate for alternative etiologies before adjusting dose.
STEP 3 — Classify or Stratify
Classify hypertension severity (stage 1: 130‑139/80‑89 mmHg; stage 2: ≥140/≥90 mmHg) and confirm euvolemia (absence of orthostatic hypotension or dehydration signs) to guide dose reduction magnitude.
STEP 4 — Decide
Reduce fludrocortisone by 50‑100 µg increments, recheck blood pressure and electrolytes in 1‑2 weeks; if hypertension persists after dose reduction in a euvolemic patient, add an ACE inhibitor or ARB while avoiding diuretics and aldosterone receptor blockers.
Clinical Guardrails / Mimics / Pitfalls
Do not use diuretics or spironolactone/eplerenone as they may worsen adrenal insufficiency; avoid abrupt fludrocortisone discontinuation; monitor for fatigue, hypotension, or hyponatremia after dose reduction indicating over‑correction.
Concrete Clinical Example
A 48‑year‑old woman on fludrocortisone 100 µg daily presents with BP 152/96 mmHg, mild peripheral edema, and serum K+ 3.2 mmol/L. Fludrocortisone is reduced to 50 µg daily; after one week BP is 128/82 mmHg and K+ normalizes.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710