From the Guidelines
Midodrine should be held if the patient's systolic blood pressure is greater than 160 mmHg or diastolic blood pressure is greater than 100 mmHg. This medication is primarily used to treat orthostatic hypotension by causing peripheral vasoconstriction, which increases blood pressure. Since midodrine is a potent vasoconstrictor, administering it when blood pressure is already elevated could potentially lead to dangerous hypertension. When giving midodrine as needed, it's essential to check the patient's blood pressure before each dose and document both the pre-dose reading and the clinical indication (such as symptomatic low blood pressure or dizziness upon standing) 1.
Some key points to consider when administering midodrine include:
- Monitoring for supine hypertension, which can be a limiting factor in its use 1
- Avoiding administration less than 4 hours before bedtime to minimize the risk of supine hypertension during sleep
- Typical dosing of midodrine is 2.5-10 mg three times daily, with the last dose given no later than 6 PM 1
- Patients should remain upright for at least 4 hours after taking midodrine to avoid supine hypertension
It's also important to note that midodrine can be used in conjunction with other treatments for orthostatic hypotension, such as fludrocortisone and physical counter-pressure maneuvers 1. However, the primary concern when administering midodrine is to avoid exacerbating hypertension, and thus, holding the medication when blood pressure is already elevated is crucial.
From the FDA Drug Label
The supine and standing blood pressure should be monitored regularly, and the administration of midodrine hydrochloride tablets should be stopped if supine blood pressure increases excessively
- A good parameter to hold midodrine is supine hypertension, as indicated by an excessive increase in supine blood pressure.
- The decision to hold midodrine should be based on regular monitoring of supine and standing blood pressure.
- If supine blood pressure increases excessively, midodrine administration should be stopped 2.
From the Research
Parameters to Hold Midodrine
When considering holding midodrine in a patient, especially if it's being given as needed (atc), several parameters should be taken into account to ensure the patient's safety and the effectiveness of the treatment.
- Supine Hypertension: One of the significant side effects of midodrine is supine hypertension, which can occur in up to 25% of patients 3. Monitoring blood pressure, especially when the patient is in a supine position, is crucial. If supine hypertension is detected, holding midodrine or adjusting its dosage might be necessary.
- Standing Systolic Blood Pressure: Midodrine is known to increase standing systolic blood pressure significantly 4, 5. Therefore, monitoring standing systolic blood pressure can help in assessing the need for midodrine and in adjusting its dosage.
- Symptoms of Orthostatic Hypotension: Midodrine is used to manage symptoms of orthostatic hypotension such as dizziness, lightheadedness, and syncope 3, 6, 5. If these symptoms are well-controlled, there might be less need for midodrine, and its administration could potentially be held or reduced.
- Adverse Effects: Common adverse effects of midodrine include piloerection, pruritus, paraesthesias, urinary retention, and chills 3, 6. If a patient experiences any of these side effects, holding midodrine or reducing its dose might be considered to improve the patient's comfort and adherence to the treatment plan.
- Timing of Doses: Given that midodrine can cause supine hypertension, it's recommended to take the final daily dose at least 4 hours before bedtime 3. This timing can help minimize the risk of supine hypertension during sleep.
Clinical Judgment
The decision to hold midodrine should be based on clinical judgment, considering the patient's overall condition, response to treatment, and presence of any side effects. Regular monitoring of blood pressure, both supine and standing, and assessment of symptoms of orthostatic hypotension are essential in making informed decisions about midodrine therapy 4, 5.