Mineralocorticoid effects of fludrocortisone and hydrocortisone in primary adrenal insufficiency: EU-AIR patient data

TL;DR

This study examines how fludrocortisone and hydrocortisone interact in treating adrenal insufficiency, finding no clear link between their doses and blood pressure or electrolyte levels.

Contribution

The study provides new insights into the independent use of fludrocortisone and the differing mineralocorticoid effects of immediate- and modified-release hydrocortisone.

Findings

No clear associations were found between fludrocortisone and hydrocortisone-equivalent doses and blood pressure or electrolyte levels.

Higher systolic blood pressure was observed in patients using immediate-release hydrocortisone compared to modified-release hydrocortisone.

Fludrocortisone use appears independent of glucocorticoid therapy in adrenal insufficiency patients.

Abstract

Patients with primary adrenal insufficiency (PAI) require mineralocorticoid replacement therapy in addition to glucocorticoids. These therapies should be considered in combination because most glucocorticoids also possess mineralocorticoid activity. We aimed to investigate the relationship between fludrocortisone and hydrocortisone-equivalent dosing in patients with PAI.

Data were obtained from the European Adrenal Insufficiency Registry (EU-AIR), a multinational, multicenter, observational study conducted between August 7, 2012, and October 31, 2020, in endocrinology centers in Germany, Italy, the Netherlands, Sweden, and the UK. Patients with PAI (excluding congenital adrenal hyperplasia or known hypertension) and treated with immediate-release hydrocortisone (IRHC), modified-release hydrocortisone (MRHC), or cortisone acetate were included. The relationship between hydrocortisone-equivalent and fludrocortisone doses and mineralocorticoid potency corrected for body surface area (BSA) was examined.

Overall, 670 (mean age: 46.2 years; 453 [67.6%] women) of 924 patients with PAI in EU-AIR were analyzed. Of those who received at least one dose of fludrocortisone (n = 350), 45 patients (12.9%) were receiving hydrocortisone-equivalent doses/BSA of ≤ 10 mg/day/m2, 170 patients (48.6%) > 10–15 mg/day/m2, and 133 patients (38.0%) > 15 mg/day/m2. No clear associations were found between total daily fludrocortisone dose/BSA and hydrocortisone-equivalent dose/BSA, or between combined mineralocorticoid potency/BSA and systolic or diastolic blood pressure and sodium or potassium levels. Higher systolic blood pressure was found in IRHC than MRHC groups.

Fludrocortisone prescription in PAI appears to be independent of glucocorticoid replacement therapy. IRHC and MRHC might differ in mineralocorticoid effect owing to different pharmacokinetic profiles.

NCT01661387.

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