Postural hypotension in adults: fludrocortisone

General background, guidelines and technology assessments:

Broad internet search: allintitle: Florinef OR Fludrocortisone or fluorocortisol or fluorohydrocortisone filetype:pdf

MEDLINE (via Ovid)

1. Hypotension, Orthostatic/

2. ((Postural or orthostatic) adj3 hypotension).ti,ab.

3. 1 or 2

4. Fludrocortisone/

5. (florinef or Fludrocortisone).tw.

6. (fluorocortisol or fluorohydrocortisone).tw.

7. 4 or 5 or 6

8. 3 and 7

9. limit 8 to english language

Embase (via Ovid)

1. Hypotension, Orthostatic/

2. ((Postural or orthostatic) adj3 hypotension).ti,ab.

3. 1 or 2

4. Fludrocortisone/

5. (florinef or Fludrocortisone).tw.

6. (fluorocortisol or fluorohydrocortisone).tw.

7. 4 or 5 or 6

8. 3 and 7

9. limit 8 to (english language and exclude medline journals) (77)

Cochrane Central Register of Controlled Trials (CENTRAL)

#1 MeSH descriptor: [Hypotension, Orthostatic] explode all trees

#2 ((Postural or orthostatic) next hypotension):ti,ab,kw

#3 #1 or #2

#4 MeSH descriptor: [Fludrocortisone] explode all trees

#5 (florinef or Fludrocortisone):ti,ab,kw

#6 (fluorocortisol or fluorohydrocortisone):ti,ab,kw

#7 #4 or #5 or #6

#8 #3 and #7

CRD HTA, DARE and EED database

1. MeSH DESCRIPTOR Fludrocortisone EXPLODE ALL TREES

2. (((Postural or orthostatic) and hypotension)) AND ((florinef or Fludrocortisone or fluorocortisol or fluorohydrocortisone))

3. 1 OR 2

Grey literature and ongoing trials

Manufacturers' websites

Bristol-Myers Squibb

Evidence selection

This evidence summary has included randomised controlled trials (RCTs) that have investigated the efficacy and safety of oral fludrocortisone for treating postural hypotension in adults. Cohort studies, case series or case reports identified by the initial search were excluded.

Two relevant double-blind, crossover RCTs were identified: 1 in people with postural hypotension and autonomic diabetic neuropathy; and 1 in adults with postural hypotension and Parkinson's disease. One additional placebo-controlled RCT was identified in adults with chronic fatigue syndrome who had neurally mediated hypotension (NMH) provoked during a 2‑stage tilt-table test. This study was included in this evidence summary because the definition for NMH was similar to that used for postural hypotension in the other included RCTs (25 mmHg drop in systolic blood pressure sustained at least for 1 minute) despite NMH being provoked during 2‑stage tilt-table testing.

The initial search identified 1 study (Testani et al. 1994) that had a title of 'Clozapine induced orthostatic hypotension treated with fludrocortisone'. Extensive efforts were made to locate the full text of this study to determine if it was an RCT, but it could not be located. Because no abstract or contact details for the authors were available, the study was excluded from this evidence summary.