What medication should be altered first in an elderly patient with worsening orthostatic hypotension, who is already on Florinef (fludrocortisone) and Midodrine, and experiences dizziness?

From the Guidelines

When addressing worsening orthostatic hypotension in an elderly patient already on fludrocortisone (Florinef) and midodrine, the midodrine dosing should typically be adjusted first. This approach is based on the fact that midodrine has a more predictable dose-response relationship and is generally easier to titrate compared to fludrocortisone, as noted in the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. The starting approach would be to increase the midodrine dose (if not at maximum) or adjust the timing of doses to better cover periods when symptoms are most problematic, particularly in the morning or after meals. Midodrine is typically dosed at 2.5-10 mg three times daily, with the last dose given at least 4 hours before bedtime to avoid supine hypertension, a common side effect of midodrine as mentioned in the guideline 1. Some key points to consider when adjusting midodrine include:

• Monitoring blood pressure (both sitting and standing) to assess the effectiveness of the dose adjustment and to avoid supine hypertension
• Monitoring electrolytes and renal function, as these can be affected by changes in blood pressure and fluid status
• Reinforcing non-pharmacological approaches, such as:
  • Compression stockings to improve orthostatic tolerance
  • Adequate hydration to help maintain blood volume
  • Slow positional changes to reduce the risk of orthostatic hypotension
  • Salt intake optimization, which may help increase plasma volume and reduce symptoms of orthostatic hypotension, as suggested in the guideline 1 If the patient is already at maximum midodrine dosing (30 mg/day), then fludrocortisone could be cautiously increased, but this requires more careful monitoring due to risks of fluid retention, electrolyte abnormalities, and heart failure exacerbation, all of which are potential side effects of fludrocortisone as discussed in the guideline 1. The rationale for adjusting midodrine first is its more targeted alpha-adrenergic vasoconstrictor effect with less systemic complications compared to the mineralocorticoid effects of fludrocortisone, making it a preferable initial adjustment in the management of worsening orthostatic hypotension in this patient population.

From the FDA Drug Label

Patients who experience any signs or symptoms suggesting bradycardia (pulse slowing, increased dizziness, syncope, cardiac awareness) should be advised to discontinue midodrine and should be re-evaluated.

The medication that should be altered first in an elderly patient with worsening orthostatic hypotension, who is already on Florinef (fludrocortisone) and Midodrine, and experiences dizziness is Midodrine.

• The patient should be advised to discontinue Midodrine and should be re-evaluated due to increased dizziness, which is a sign of potential bradycardia 2.

From the Research

Medication Alteration for Orthostatic Hypotension

In an elderly patient experiencing worsening orthostatic hypotension while on Florinef (fludrocortisone) and Midodrine, and presenting with dizziness, the approach to medication alteration should be guided by the current pharmacological management strategies for orthostatic hypotension.

• The patient is already on Midodrine, which has been shown to be effective in improving standing systolic blood pressure and reducing symptoms of orthostatic hypotension, including dizziness 3, 4.
• Given that Midodrine is generally well-tolerated but can cause supine hypertension, piloerection, pruritus, and other side effects, adjusting its dosage or timing might be considered before altering other medications 3.
• Florinef (fludrocortisone) is another key medication for orthostatic hypotension, acting by increasing blood volume. Adjusting its dose could be an option, but careful consideration of its mineralocorticoid effects is necessary 5.
• Before altering either Midodrine or Florinef, a review of the patient's entire medication regimen is crucial to identify any other drugs that could be contributing to orthostatic hypotension, such as antihypertensives or tricyclic antidepressants 5, 6.
• Non-pharmacological methods, such as increased fluid and sodium intake, compression stockings, and slow position changes, should also be optimized as these are key components of orthostatic hypotension management 5, 7.

Considerations for Medication Adjustment

• Medication Review: A thorough review of the patient's medication regimen to identify potential contributors to orthostatic hypotension 6.
• Dose Adjustment: Consider adjusting the doses of Midodrine or Florinef, taking into account the patient's response and side effects 3, 4.
• Addition of Other Agents: If necessary, consider adding other pharmacological agents that can help manage orthostatic hypotension, such as droxidopa or pyridostigmine, based on the patient's specific needs and responses 6, 7.