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ESRU

Fludrocortisone

Systemic mineralocorticoid

ATC code: H02AA02

Brand names: Florinef

Updated · Methodology

Indications

A

Adrenal insufficiency

First line

Fludrocortisone covers the mineralocorticoid half of replacement therapy in primary adrenal insufficiency. Hydrocortisone answers the glucocorticoid deficit but cannot hold sodium and blood volume, and without the second drug the weakness, salt craving, dizziness on standing and high potassium remain. The AEMPS Astonin label frames the indication as mineralocorticoid replacement in primary and secondary adrenal insufficiency, naming Addison disease and salt-wasting congenital adrenal hyperplasia. The dose is titrated to supine and standing blood pressure, potassium, sodium and plasma renin rather than to how the patient feels: early on, both too much and too little look equally non-specific. In hot weather, with exercise and sweating, the salt requirement rises, and that is covered separately.

Sources

  1. AEMPS: Ficha técnica Astonin 0,1 mg comprimidos (2024)
  2. Endocrine Society: Diagnosis and Treatment of Primary Adrenal Insufficiency: an Endocrine Society Clinical Practice Guideline (2016)

ICD-10: E27 · ICD-11: 5A74

How to read tiers A–F
  • AStrong evidence – first or second line in international guidelines
  • BRecommended in selected cases
  • CStudy data contradict each other
  • DBenefit not proven, no documented harm
  • FDocumented harm, or risk without benefit

Mechanism of action

Fludrocortisone binds the mineralocorticoid receptor in the distal renal tubule and switches on synthesis of proteins that retain sodium and excrete potassium and hydrogen. Sodium pulls water with it, circulating volume grows and blood pressure rises. Its mineralocorticoid potency is roughly 100 times that of hydrocortisone; glucocorticoid activity exists too but stays clinically invisible at replacement doses of 0.05–0.2 mg a day. The flip side of the mechanism is potassium loss: the AEMPS Astonin label gives saluretics, cardiac glycosides and laxatives their own entry as drugs that increase potassium excretion alongside it.

Safety

Contraindications

  • Hypersensitivity to fludrocortisone or to any excipient
  • Systemic fungal infection
  • Use outside replacement therapy in uncontrolled hypertension and severe heart failure

Serious adverse effects

  • Severe hypokalaemia with rhythm disturbance, especially on digoxin or a QT-prolonging drug
  • Hypokalaemic alkalosis
  • Decompensated heart failure from fluid retention
  • Steroid osteoporosis and fractures with prolonged high-dose use

Common adverse effects

  • Sodium and water retention with oedema
  • Rise in blood pressure
  • Hypokalaemia with weakness and muscle cramps
  • Headache

Pregnancy: can you take Fludrocortisone?

Replacement therapy for adrenal insufficiency continues through pregnancy: without it the risk to mother and fetus exceeds any risk from the drug itself. Mineralocorticoid requirements usually rise in the second and third trimesters because of the antimineralocorticoid action of progesterone. Blood pressure, potassium and sodium are checked more often than usual.

Breastfeeding: can you take Fludrocortisone?

At replacement doses breastfeeding is not restricted: only trace amounts reach milk. The infant is followed as usual, with no extra tests required.

Calculate RID

Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.

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Frequently asked

What is Fludrocortisone used for?

Fludrocortisone is evaluated for the following indications with varying evidence strength: Adrenal insufficiency (evidence tier A). See the full indication matrix with dosing and citations above on this page.

What are the side effects of Fludrocortisone?

Common side effects of Fludrocortisone (≥ 1 in 100): Sodium and water retention with oedema, Rise in blood pressure, Hypokalaemia with weakness and muscle cramps, Headache. See the Safety section for uncommon and serious reactions.

Is Fludrocortisone safe during pregnancy?

Replacement therapy for adrenal insufficiency continues through pregnancy: without it the risk to mother and fetus exceeds any risk from the drug itself. Mineralocorticoid requirements usually rise in the second and third trimesters because of the antimineralocorticoid action of progesterone. Blood pressure, potassium and sodium are checked more often than usual.

Is Fludrocortisone compatible with breastfeeding?

At replacement doses breastfeeding is not restricted: only trace amounts reach milk. The infant is followed as usual, with no extra tests required.

Who should not take Fludrocortisone?

Fludrocortisone is contraindicated in: Hypersensitivity to fludrocortisone or to any excipient; Systemic fungal infection; Use outside replacement therapy in uncontrolled hypertension and severe heart failure. Full list in the Safety section.

Other drugs in this group

Betamethasone, Deflazacort, Dexamethasone, Hydrocortisone, Methylprednisolone, Prednisolone, Prednisone