To the Editor.
—Dr Bou-Holaigah and colleagues1 observed that nearly half of patients treated with fludrocortisone reported complete or nearly complete resolution of CFS symptoms. Although partial, this response represents good success, if we consider that no previously tried therapy, except licorice,2,3 has been reported to be consistently effective.Fludrocortisone is the typical mineralocorticoid supplementation for Addison's disease,4 which also has been treated with licorice.5 Both this common therapeutic effectiveness and the recently confirmed hypocortisolism in CFS patients6 suggest that the NMH that occurs in CFS is a mere consequence of an underlying atypical adrenal insufficiency. Therefore, the failure of fludrocortisone, which has only mineralocorticoid activity,4 to resolve symptoms in approximately half of patients who received it in the study by Bou-Holaigah et al1 simply reflects its lack of glucocorticoid potency. Intuitively, fludrocortisone plus hydrocortisone would have been more effective. In fact, for
Baschetti R. Chronic Fatigue Syndrome and Neurally Mediated Hypotension. JAMA. 1996;275(5):359. doi:10.1001/jama.1996.03530290029022