What is the starting dose for midodrine (Midodrine), taken three times a day (tid), for the treatment of orthostatic hypotension in the geriatric population?

From the Guidelines

The starting dose of midodrine for orthostatic hypotension in the geriatric population is 2.5 mg three times daily (TID). This recommendation is based on the most recent and highest quality study available, which suggests that midodrine can be effective in treating orthostatic hypotension while minimizing the risk of adverse effects in older adults 1. The medication should be administered during daytime hours when the patient is upright, with doses typically given in the morning, at midday, and in the late afternoon (no later than 6 PM to avoid supine hypertension during sleep).

Some key points to consider when initiating midodrine therapy in geriatric patients include:

• Starting with a lower dose to minimize the risk of adverse effects, such as supine hypertension, urinary retention, or bradycardia
• Gradually titrating the dose upward based on blood pressure response and tolerability
• Carefully monitoring for side effects and adjusting the dose as needed
• Measuring both standing and supine blood pressures regularly during dose adjustments to ensure effectiveness while avoiding excessive supine hypertension
• Instructing patients to take their last daily dose at least 3-4 hours before bedtime and to avoid lying down for 3-4 hours after each dose to minimize the risk of supine hypertension

It's also important to note that the maximum recommended daily dose is 30 mg (10 mg TID), though many geriatric patients achieve adequate symptom control at lower doses 1. By following these guidelines and carefully monitoring patients, healthcare providers can help ensure the safe and effective use of midodrine in the treatment of orthostatic hypotension in older adults.

From the FDA Drug Label

The recommended dose of midodrine hydrochloride tablets is 10 mg, 3 times daily. Blood levels of midodrine and desglymidodrine were similar when comparing levels in patients 65 or older vs. younger than 65 and when comparing males vs. females, suggesting dose modifications for these groups are not necessary.

The starting dose for midodrine, taken three times a day (tid), for the treatment of orthostatic hypotension in the geriatric population is 10 mg.

• The dose does not need to be modified for patients 65 or older. 2

From the Research

Dosage Information for Midodrine

• The starting dose for midodrine, taken three times a day (tid), for the treatment of orthostatic hypotension is not explicitly stated in the provided studies as a specific starting dose for the geriatric population.
• However, according to the study 3, midodrine was evaluated in a multicenter study where patients were randomized into 4 groups for a 4-week period: placebo, 2.5 mg, 5 mg, or 10 mg three times daily.
• The study 4 also examined midodrine dose-blood pressure response, pharmacokinetics, and duration of action in a double-blind, placebo-controlled, four-way crossover trial, where patients received on successive days placebo or midodrine 2.5,10, or 20 mg.
• The results of these studies suggest that midodrine can be effective in increasing orthostatic blood pressure and ameliorating symptoms in patients with orthostatic hypotension, with a common dosage being 10 mg prescribed two to three times daily 4.

Considerations for Geriatric Population

• While the provided studies do not specifically address the geriatric population, it is essential to consider the potential for increased sensitivity to midodrine in older adults, which may require adjustments to the dosage.
• The study 5 mentions that midodrine is well-tolerated, but the risk of supine hypertension can be reduced by taking the final daily dose at least 4 hours before bedtime, which may be relevant for geriatric patients.
• Further research or clinical guidelines specific to the geriatric population would be necessary to determine the optimal starting dose for midodrine in this age group.