| name | enda-fludrocortisone-aldosterone-deficiency |
| description | Recommends initiating fludrocortisone 50–100 µg daily for mineralocorticoid replacement in adults with confirmed aldosterone deficiency (e.g., low aldosterone, elevated renin) and no salt restriction. Use when aldosterone deficiency is confirmed in a patient with primary adrenal insufficiency (PAI) presenting with salt craving or postural hypotension. |
Initiate Fludrocortisone for Aldosterone Deficiency with Specific Starting Dose
STEP 1 — Gather Information
Confirm primary adrenal insufficiency (PAI) diagnosis; measure morning plasma aldosterone and renin to demonstrate low aldosterone with elevated renin; assess for symptoms of mineralocorticoid deficiency (salt craving, postural hypotension, hyponatremia, hyperkalemia); ensure no concurrent salt restriction; review blood pressure for hypertension.
STEP 2 — Rule In / Rule Out
Is aldosterone deficiency confirmed (low aldosterone with inappropriately normal or high renin)?
- Yes → Proceed to STEP 3.
- No → Do not initiate fludrocortisone; reassess etiology.
STEP 3 — Classify or Stratify
Is the patient an adult (≥18 years)?
- Adult → Use starting dose 50–100 µg daily.
- Pediatric → Refer to pediatric dosing (e.g., 100 µg/d for children, infant salt supplements).
STEP 4 — Decide
Initiate fludrocortisone at 50–100 µg once daily in the morning; counsel patient not to restrict salt intake; schedule follow‑up in 2–4 weeks to assess symptoms, blood pressure, and electrolytes.
Clinical Guardrails / Mimics / Pitfalls
Avoid in patients with uncontrolled hypertension or edema; monitor for signs of over‑replacement (hypertension, supine edema, hypokalemia); do not combine with licorice, grapefruit juice, or potent CYP3A4 inducers that may alter fludrocortisone metabolism; fludrocortisone is not indicated for secondary adrenal insufficiency; if hypertension develops, reduce dose before adding antihypertensives.
Concrete Clinical Example
A 34‑year‑old woman with newly diagnosed PAI (low cortisol, high ACTH) has serum aldosterone 2 ng/dL (low), renin 45 mIU/L (high), reports salt craving and occasional light‑headedness on standing. She is normotensive. Start fludrocortisone 100 µg daily, advise liberal salt intake, and re‑evaluate in 3 weeks.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710
TODO: consider adding scripts/calc.py for the enda-fludrocortisone-aldosterone-deficiency calculator
