Florinef

 A note on Fludrocortisone 

Fludrocortisone is actually 9-alpha-fluorohydrocortisone. It is a synthetic mineralocorticoid. It increases renal sodium and water reabsorption leading to intravascular volume expansion. Fludrocortisone is frequently used in outpatient settings, particularly in End-Stage Renal Disease (ESRD) patients. If possible, it should be continued in ESRD patients in ICU if there is no major contraindication. Independently, it has low efficacy in acute situations. It takes about five to seven days to show clinical effect. The dose is anywhere from 0.05 mg to 0.2 mg per day. 

Said that Dr. Annane showed that the addition of Fludrocortisone with stress dose steroid may reduce 90-days mortality in septic shock (see reference #2) - though the level of evidence is weak. This may be due to the fact that Fludrocortisone by itself provides synergism to the pressor effect of sympathomimetic drugs/drips.  

Fludrocortisone has an interesting side effect of supine hypertension. It may also worsen edema and CHF. It has a tendency to cause hypokalemia, which may be beneficial in renal patients but should be a lookout in other patients.

#hemodynamics

References:

1. Chobanian AV, Volicer L, Tifft CP, et al. Mineralocorticoid-induced hypertension in patients with orthostatic hypotension. N Engl J Med 1979; 301:68. 

2. Annane D, et al. CRICS-TRIGGERSEP Network. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med. 2018 Mar 1;378(9):809-818. doi: 10.1056/NEJMoa1705716. PMID: 29490185. 

3. Veazie S, Peterson K, Ansari Y, et al. Fludrocortisone for orthostatic hypotension. Cochrane Database Syst Rev 2021; 5:CD012868.