Fludrocortisone

Fludrocortisone is a synthetic fluorinated corticosteroid with potent mineralocorticoid activity and weak glucocorticoid activity. It is used in the treatment of Addison's disease, salt-losing forms of congenital adrenal hyperplasia, and orthostatic hypotension.

Uses

Fludrocortisone is a synthetic fluorinated corticosteroid with potent mineralocorticoid activity and weak glucocorticoid activity. It is used in the treatment of the following conditions⁚

• Addison's disease⁚ Fludrocortisone is used to replace the mineralocorticoid hormone that is deficient in Addison's disease. Mineralocorticoids are essential for regulating electrolyte and fluid balance in the body.
• Salt-losing forms of congenital adrenal hyperplasia⁚ Fludrocortisone is used to treat the salt-losing forms of congenital adrenal hyperplasia, a condition in which the body does not produce enough cortisol and aldosterone. Aldosterone is a mineralocorticoid that helps to regulate electrolyte and fluid balance in the body.
• Orthostatic hypotension⁚ Fludrocortisone is used to treat orthostatic hypotension, a condition in which blood pressure drops when a person stands up from a sitting or lying position. This can cause dizziness, lightheadedness, and fainting.

Fludrocortisone is also sometimes used to treat other conditions, such as⁚

• Hyponatremia⁚ Fludrocortisone can be used to treat hyponatremia, a condition in which the sodium levels in the blood are too low.
• Hyperkalemia⁚ Fludrocortisone can be used to treat hyperkalemia, a condition in which the potassium levels in the blood are too high.
• Nephrotic syndrome⁚ Fludrocortisone can be used to treat nephrotic syndrome, a condition in which the kidneys leak protein into the urine.

Fludrocortisone is typically taken orally, once or twice a day. The dosage will vary depending on the condition being treated and the patient's response to the medication.

Dosage and Administration

Fludrocortisone is typically taken orally, once or twice a day. The dosage will vary depending on the condition being treated and the patient's response to the medication. Addison's disease⁚ The usual starting dose of fludrocortisone for Addison's disease is 0.1 mg to 0.2 mg daily. The dose may be increased gradually as needed to maintain normal blood pressure and electrolyte levels. Salt-losing forms of congenital adrenal hyperplasia⁚ The usual starting dose of fludrocortisone for salt-losing forms of congenital adrenal hyperplasia is 0.05 mg to 0.1 mg daily. The dose may be increased gradually as needed to maintain normal blood pressure and electrolyte levels. Orthostatic hypotension⁚ The usual starting dose of fludrocortisone for orthostatic hypotension is 0.1 mg to 0.2 mg daily. The dose may be increased gradually as needed to improve symptoms. Fludrocortisone should be taken with food or milk to reduce the risk of stomach upset. It is important to take fludrocortisone exactly as prescribed by your doctor. Do not take more or less of the medication than prescribed, and do not stop taking the medication without talking to your doctor first. If you forget to take a dose of fludrocortisone, take it as soon as you remember. However, if it is almost time for your next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of fludrocortisone at the same time.

Contraindications

Fludrocortisone is contraindicated in patients with the following conditions⁚

• Hypersensitivity to fludrocortisone or any other component of the medication
• Uncontrolled infection
• Severe heart failure
• Severe kidney disease
• Severe liver disease
• Edema
• Hypertension

Fludrocortisone should be used with caution in patients with the following conditions⁚

• Diabetes mellitus
• Glaucoma
• Osteoporosis
• Peptic ulcer disease
• Thyroid disease

Fludrocortisone may increase blood sugar levels, so patients with diabetes mellitus should be monitored closely. Fludrocortisone may also increase intraocular pressure, so patients with glaucoma should be monitored closely. Fludrocortisone may decrease bone density, so patients with osteoporosis should be monitored closely. Fludrocortisone may increase the risk of peptic ulcer disease, so patients with a history of peptic ulcer disease should be monitored closely. Fludrocortisone may interfere with thyroid function, so patients with thyroid disease should be monitored closely.

Warnings and Precautions

Fludrocortisone can cause serious side effects, including⁚

• High blood pressure
• Heart failure
• Kidney failure
• Liver damage
• Edema
• Weight gain
• Mood changes
• Psychosis

Fludrocortisone should be used with caution in patients with the following conditions⁚

• Diabetes mellitus
• Glaucoma
• Osteoporosis
• Peptic ulcer disease
• Thyroid disease

Fludrocortisone may increase blood sugar levels, so patients with diabetes mellitus should be monitored closely. Fludrocortisone may also increase intraocular pressure, so patients with glaucoma should be monitored closely. Fludrocortisone may decrease bone density, so patients with osteoporosis should be monitored closely. Fludrocortisone may increase the risk of peptic ulcer disease, so patients with a history of peptic ulcer disease should be monitored closely. Fludrocortisone may interfere with thyroid function, so patients with thyroid disease should be monitored closely.

General

Fludrocortisone can cause fluid retention and electrolyte imbalances, so patients should be monitored closely for these side effects. Fludrocortisone may also increase blood pressure, so patients with hypertension should be monitored closely. Fludrocortisone may decrease bone density, so patients with osteoporosis should be monitored closely. Fludrocortisone may increase the risk of peptic ulcer disease, so patients with a history of peptic ulcer disease should be monitored closely. Fludrocortisone may interfere with thyroid function, so patients with thyroid disease should be monitored closely. Fludrocortisone may also cause mood changes and psychosis, so patients should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of mental illness. Fludrocortisone may mask the signs and symptoms of infection, so patients should be monitored closely for any signs of infection. Fludrocortisone may also suppress the immune system, so patients should be vaccinated against common infections before starting treatment with fludrocortisone. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause fluid retention and electrolyte imbalances, which can lead to high blood pressure and heart failure. Fludrocortisone may also increase the risk of arrhythmias. Patients with a history of cardiovascular disease should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with severe heart failure. Fludrocortisone may also mask the signs and symptoms of infection, which can lead to endocarditis. Patients with a history of endocarditis should be monitored closely for any signs of infection. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause Cushing's syndrome, which is a condition characterized by high levels of cortisol in the body. Cushing's syndrome can lead to a variety of health problems, including⁚

• Weight gain
• High blood pressure
• Diabetes mellitus
• Osteoporosis
• Mood changes
• Psychosis

Fludrocortisone may also suppress the hypothalamic-pituitary-adrenal (HPA) axis, which is responsible for regulating the production of cortisol. Suppression of the HPA axis can lead to adrenal insufficiency, which is a condition in which the adrenal glands do not produce enough cortisol. Patients with a history of endocrine disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with diabetes mellitus, hypertension, osteoporosis, and mood disorders. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause a variety of gastrointestinal side effects, including⁚

• Nausea
• Vomiting
• Diarrhea
• Constipation
• Abdominal pain
• Peptic ulcer disease
• Gastrointestinal bleeding

Fludrocortisone may also increase the risk of pancreatitis. Patients with a history of gastrointestinal disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of peptic ulcer disease or gastrointestinal bleeding. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause a variety of metabolic side effects, including⁚

• Weight gain
• Increased appetite
• High blood sugar levels
• Low potassium levels
• High cholesterol levels
• Fluid retention
• Edema

Fludrocortisone may also increase the risk of diabetes mellitus. Patients with a history of metabolic disorders should be monitored closely for these side effects; Fludrocortisone should be used with caution in patients with diabetes mellitus, hypertension, or heart failure. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause a variety of musculoskeletal side effects, including⁚

• Muscle weakness
• Muscle atrophy
• Osteoporosis
• Avascular necrosis
• Fractures

Fludrocortisone may also increase the risk of tendon rupture. Patients with a history of musculoskeletal disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with osteoporosis, avascular necrosis, or a history of tendon rupture. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause a variety of neurological side effects, including⁚

• Headache
• Dizziness
• Confusion
• Mood changes
• Psychosis
• Seizures

Fludrocortisone may also increase the risk of stroke. Patients with a history of neurological disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of stroke, seizures, or psychosis. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause a variety of ophthalmic side effects, including⁚

• Cataracts
• Glaucoma
• Increased intraocular pressure
• Blurred vision
• Double vision
• Eye pain

Fludrocortisone may also increase the risk of blindness. Patients with a history of ophthalmic disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of cataracts, glaucoma, or increased intraocular pressure. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause a variety of renal side effects, including⁚

• Kidney failure
• Nephrotic syndrome
• Edema
• Hyperkalemia
• Hyponatremia

Fludrocortisone may also increase the risk of urinary tract infections. Patients with a history of renal disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of kidney failure, nephrotic syndrome, or urinary tract infections. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. Fludrocortisone can cause a variety of other side effects, including⁚

• Allergic reactions
• Anaphylaxis
• Fever
• Chills
• Fatigue
• Weakness
• Weight loss
• Skin rashes
• Itching
• Hives
• Sweating
• Menstrual irregularities
• Erectile dysfunction

Fludrocortisone may also increase the risk of infection. Patients should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of allergic reactions or infections. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Adverse Reactions

Fludrocortisone can cause a variety of adverse reactions, including⁚

• Cardiovascular
• Dermatologic
• Endocrine
• Gastrointestinal
• Hematologic
• Hepatic
• Metabolic
• Musculoskeletal
• Neurological
• Ophthalmic
• Renal
• Respiratory
• Other

Cardiovascular

Fludrocortisone can cause a variety of cardiovascular side effects, including⁚

• High blood pressure
• Heart failure
• Edema
• Arrhythmias
• Endocarditis

Patients with a history of cardiovascular disease should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with severe heart failure. Fludrocortisone may also mask the signs and symptoms of infection, which can lead to endocarditis. Patients with a history of endocarditis should be monitored closely for any signs of infection. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Dermatologic

Fludrocortisone can cause a variety of dermatologic side effects, including⁚

• Acne
• Hirsutism
• Striae
• Bruising
• Thinning skin
• Skin discoloration
• Delayed wound healing

Patients with a history of dermatologic disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with acne, hirsutism, or striae. Fludrocortisone may also delay wound healing. Patients should be advised to avoid surgery or other invasive procedures while taking fludrocortisone. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Endocrine

Fludrocortisone can cause a variety of endocrine side effects, including⁚

• Cushing's syndrome
• Suppression of the hypothalamic-pituitary-adrenal (HPA) axis
• Adrenal insufficiency
• Diabetes mellitus
• Hypertension
• Osteoporosis
• Mood changes
• Psychosis

Patients with a history of endocrine disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with diabetes mellitus, hypertension, osteoporosis, or mood disorders. Fludrocortisone may also suppress the HPA axis, which can lead to adrenal insufficiency. Adrenal insufficiency is a condition in which the adrenal glands do not produce enough cortisol. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Gastrointestinal

Fludrocortisone can cause a variety of gastrointestinal side effects, including⁚

• Nausea
• Vomiting
• Diarrhea
• Constipation
• Abdominal pain
• Peptic ulcer disease
• Gastrointestinal bleeding
• Pancreatitis

Patients with a history of gastrointestinal disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of peptic ulcer disease or gastrointestinal bleeding. Fludrocortisone may also increase the risk of pancreatitis. Pancreatitis is a condition in which the pancreas becomes inflamed. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Hematologic

Fludrocortisone can cause a variety of hematologic side effects, including⁚

• Thrombocytopenia
• Leukopenia
• Neutropenia
• Anemia
• Eosinophilia

Patients with a history of hematologic disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with thrombocytopenia, leukopenia, or neutropenia. Fludrocortisone may also increase the risk of infection. Infection is a condition in which the body is invaded by bacteria, viruses, or other microorganisms. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Hepatic

Fludrocortisone can cause a variety of hepatic side effects, including⁚

• Hepatitis
• Jaundice
• Elevated liver enzymes

Patients with a history of hepatic disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with hepatitis or elevated liver enzymes. Fludrocortisone may also increase the risk of liver damage. Liver damage is a condition in which the liver is damaged. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Metabolic

Fludrocortisone can cause a variety of metabolic side effects, including⁚

• Weight gain
• Increased appetite
• High blood sugar levels
• Low potassium levels
• High cholesterol levels
• Fluid retention
• Edema
• Diabetes mellitus

Patients with a history of metabolic disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with diabetes mellitus, hypertension, or heart failure. Fludrocortisone may also increase the risk of diabetes mellitus. Diabetes mellitus is a condition in which the body does not produce enough insulin. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Musculoskeletal

Fludrocortisone can cause a variety of musculoskeletal side effects, including⁚

• Muscle weakness
• Muscle atrophy
• Osteoporosis
• Avascular necrosis
• Fractures
• Tendon rupture

Patients with a history of musculoskeletal disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with osteoporosis, avascular necrosis, or a history of tendon rupture. Fludrocortisone may also increase the risk of osteoporosis. Osteoporosis is a condition in which the bones become weak and brittle. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Neurological

Fludrocortisone can cause a variety of neurological side effects, including⁚

• Headache
• Dizziness
• Confusion
• Mood changes
• Psychosis
• Seizures
• Stroke

Patients with a history of neurological disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of stroke, seizures, or psychosis. Fludrocortisone may also increase the risk of stroke. Stroke is a condition in which the blood supply to the brain is interrupted. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Ophthalmic

Fludrocortisone can cause a variety of ophthalmic side effects, including⁚

• Cataracts
• Glaucoma
• Increased intraocular pressure
• Blurred vision
• Double vision
• Eye pain
• Blindness

Patients with a history of ophthalmic disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of cataracts, glaucoma, or increased intraocular pressure. Fludrocortisone may also increase the risk of blindness. Blindness is a condition in which the person loses the ability to see. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks. user

Renal

Fludrocortisone can cause a variety of renal side effects, including⁚

• Kidney failure
• Nephrotic syndrome
• Edema
• Hyperkalemia
• Hyponatremia
• Urinary tract infections

Patients with a history of renal disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of kidney failure, nephrotic syndrome, or urinary tract infections. Fludrocortisone may also increase the risk of kidney failure. Kidney failure is a condition in which the kidneys are unable to function properly. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Respiratory

Fludrocortisone can cause a variety of respiratory side effects, including⁚

• Pulmonary edema
• Dyspnea
• Cough
• Wheezing
• Pneumonia

Patients with a history of respiratory disorders should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of pulmonary edema, dyspnea, or pneumonia. Fludrocortisone may also increase the risk of pulmonary edema. Pulmonary edema is a condition in which fluid accumulates in the lungs. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Other

Fludrocortisone can cause a variety of other side effects, including⁚

• Allergic reactions
• Anaphylaxis
• Fever
• Chills
• Fatigue
• Weakness
• Weight loss
• Skin rashes
• Itching
• Hives
• Sweating
• Menstrual irregularities
• Erectile dysfunction
• Infection

Patients should be monitored closely for these side effects. Fludrocortisone should be used with caution in patients with a history of allergic reactions or infections. Fludrocortisone should not be stopped abruptly, as this can lead to adrenal insufficiency. The dose of fludrocortisone should be tapered gradually over a period of several days or weeks.

Drug Interactions

Fludrocortisone can interact with a variety of other drugs, including⁚

• Amphotericin B⁚ Fludrocortisone can increase the risk of hypokalemia when taken with amphotericin B.
• Anticholinergics⁚ Fludrocortisone can increase the risk of anticholinergic side effects when taken with anticholinergics.
• Anticoagulants⁚ Fludrocortisone can increase the risk of bleeding when taken with anticoagulants.
• Antidiabetics⁚ Fludrocortisone can increase blood sugar levels when taken with antidiabetics.
• Barbiturates⁚ Fludrocortisone can decrease the effectiveness of barbiturates.
• CYP3A4 inhibitors⁚ Fludrocortisone can increase the risk of side effects when taken with CYP3A4 inhibitors.
• CYP3A4 inducers⁚ Fludrocortisone can decrease the effectiveness of fludrocortisone when taken with CYP3A4 inducers.
• Digitalis glycosides⁚ Fludrocortisone can increase the risk of arrhythmias when taken with digitalis glycosides.
• Diuretics⁚ Fludrocortisone can increase the risk of hypokalemia when taken with diuretics.
• Lithium⁚ Fludrocortisone can increase the risk of lithium toxicity when taken with lithium.
• Nonsteroidal anti-inflammatory drugs (NSAIDs)⁚ Fludrocortisone can increase the risk of gastrointestinal bleeding when taken with NSAIDs.
• Salicylates⁚ Fludrocortisone can increase the risk of salicylate toxicity when taken with salicylates.
• Vaccines⁚ Fludrocortisone can decrease the effectiveness of vaccines when taken with vaccines.

Patients should tell their doctor about all of the medications they are taking, including prescription drugs, over-the-counter medications, and herbal supplements.

Pregnancy and Lactation

Pregnancy⁚ Fludrocortisone should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Fludrocortisone has been shown to cause birth defects in animals when given in high doses. There are no adequate and well-controlled studies in pregnant women. Lactation⁚ Fludrocortisone is excreted in breast milk. Because of the potential for adverse effects on the infant, breastfeeding should be discontinued during treatment with fludrocortisone.

Overdosage

In case of overdose, the following symptoms may occur⁚

• Nausea
• Vomiting
• Diarrhea
• Abdominal pain
• Muscle weakness
• Fatigue
• Headache
• Dizziness
• Confusion
• Seizures
• Coma

Treatment of overdose is supportive and may include⁚

• Gastric lavage
• Activated charcoal
• Intravenous fluids
• Electrolyte replacement
• Corticosteroids

Fludrocortisone is not dialyzable.

Pharmacology

Fludrocortisone is a synthetic fluorinated corticosteroid with potent mineralocorticoid activity and weak glucocorticoid activity. It is approximately 10 times more potent than deoxycorticosterone acetate (DOCA) and 100 times more potent than hydrocortisone as a mineralocorticoid. Fludrocortisone has minimal glucocorticoid activity, approximately 1/15th that of hydrocortisone. Fludrocortisone binds to the mineralocorticoid receptor in the kidney, leading to increased reabsorption of sodium and decreased reabsorption of potassium. This results in increased plasma volume and blood pressure. Fludrocortisone also has some glucocorticoid activity, which can lead to increased blood sugar levels, decreased bone density, and muscle weakness. Fludrocortisone is rapidly absorbed after oral administration. Peak plasma levels are reached within 1-2 hours. The bioavailability of fludrocortisone is approximately 80%. Fludrocortisone is metabolized in the liver and excreted in the urine. The half-life of fludrocortisone is approximately 3-4 hours.

Pharmacokinetics

Fludrocortisone is rapidly absorbed after oral administration. Peak plasma levels are reached within 1-2 hours. The bioavailability of fludrocortisone is approximately 80%. Fludrocortisone is highly bound to plasma proteins (90%). It is metabolized in the liver and excreted in the urine. The half-life of fludrocortisone is approximately 3-4 hours. Fludrocortisone crosses the placenta and is excreted in breast milk. The following table summarizes the pharmacokinetic parameters of fludrocortisone⁚ | Parameter | Value | |---|---| | Absorption | Rapid | | Peak plasma levels | 1-2 hours | | Bioavailability | 80% | | Protein binding | 90% | | Metabolism | Liver | | Excretion | Urine | | Half-life | 3-4 hours | | Placental transfer | Yes | | Breast milk excretion | Yes |

Storage and Handling

Fludrocortisone should be stored at room temperature (25°C/77°F) in a tight container. Protect from light and moisture. Fludrocortisone tablets should not be stored in the bathroom or near a sink. Do not store fludrocortisone tablets in a place where they could be accidentally ingested by a child or pet. Unused fludrocortisone tablets should be disposed of properly. Do not flush fludrocortisone tablets down the toilet or pour them down a sink. Ask your pharmacist how to properly dispose of fludrocortisone tablets.