6.3.1 Replacement therapy

Fludrocortisone acetate
  • Tablets 100 micrograms (£13.60 = 30 tablets)

Indications and dose

  • Mineralocorticoid replacement in adrenocortical insufficiency
    • Usually 50-300 micrograms once daily (in the morning)
  • Adrenocortical insufficiency resulting from septic shock (in combination with hydrocortisone)
    • 50 micrograms daily
  • Postural hypotension (unlicensed indication) (specialist input)
    • Usually 100-400 micrograms daily (in the morning)


  1. Fludrocortisone may be considered for the treatment of postural hypotension if the following strategies do not sufficiently improve the patient's blood pressure:
    1. no obvious cause for the postural drop in blood pressure has been diagnosed (e.g. medication, dehydration/hypovolaemia, electrolyte abnormality, autonomic dysfunction, Addison's disease)
    1. adequate fluid intake has been assured
    1. compression hosiery has been considered and utilised where clinically indicated
    1. the patient has been advised on sleeping position and standing techniques
  2. Lying and standing (or sitting and standing) BP should be monitored at regular intervals until the BP is stabilised within normal limits with no postural drop
  3. See the BNF for further information on corticosteroid side effects
  4. If pharmacological causes for postural hypotension cannot be addressed, NICE recommends midodrine (non-formulary) as a first line treatment (due to the availability of a licensed product). However local specialists indicate a preference for fludrocortisone (off-label use) as the first line treatment option, taking into account its safety profile. Midodrine is available at significantly increased cost; however there is a lack of evidence of clinical benefit of midodrine over fludrocortisone. Midodrine is reserved for use in patients for whom fludrocortisone is ineffective or not tolerated


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  • First line
  • Second line
  • Specialist
  • Hospital