Can midodrine be ordered for a patient with hypotension, who is taking Roxicodone (oxycodone) every 4 hours, and has a history of asthma, chronic obstructive pulmonary disease (COPD), supraventricular tachycardia (SVT), smoking, methamphetamine use, marijuana use, and methicillin-resistant Staphylococcus aureus (MRSA) infection, diagnosed with cellulitis?

From the Guidelines

I would not recommend ordering midodrine for this patient at this time. The patient's low blood pressure is likely due to the vasodilatory effects of roxicodone, and midodrine is not indicated for opioid-induced hypotension. According to the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1, midodrine is reasonable in patients with recurrent vasovagal syncope (VVS) with no history of hypertension, heart failure, or urinary retention, which is not the case here. The patient's history of substance use (methamphetamine and marijuana) and medical conditions (asthma, COPD, SVT, MRSA) further complicates medication management.

Instead, I recommend:

• Reducing the roxicodone dosage or frequency to minimize its vasodilatory effects
• Considering alternative pain management strategies
• Ensuring adequate hydration
• Close monitoring of vital signs to address the underlying cause of hypotension Adding midodrine could potentially interact with these conditions, particularly SVT (supraventricular tachycardia), as midodrine can increase blood pressure and potentially exacerbate cardiac issues. The guideline suggests that in selected patients with VVS, it may be reasonable to reduce or withdraw medications that cause hypotension when appropriate 1. In this case, adjusting the roxicodone regimen would be a more appropriate approach than adding midodrine.

From the FDA Drug Label

The potential for supine and sitting hypertension should be evaluated at the beginning of midodrine therapy. Blood pressure should be monitored carefully when midodrine is used concomitantly with other agents that cause vasoconstriction, such as phenylephrine, ephedrine, dihydroergotamine, phenylpropanolamine, or pseudoephedrine. Midodrine should be used cautiously in patients with urinary retention problems, as desglymidodrine acts on the alpha-adrenergic receptors of the bladder neck Midodrine should be used with caution in orthostatic hypotensive patients who are also diabetic, as well as those with a history of visual problems who are also taking fludrocortisone acetate, which is known to cause an increase in intraocular pressure and glaucoma. Midodrine use has not been studied in patients with renal impairment Because desglymidodrine is eliminated via the kidneys, and higher blood levels would be expected in such patients, midodrine should be used with caution in patients with renal impairment, with a starting dose of 2. 5 mg

The patient has low blood pressure (in the low 90s or below 100), and midodrine is used to treat orthostatic hypotension. However, the patient is taking roxicodone, which is not a direct contraindication, but caution should be exercised when midodrine is used concomitantly with other agents. Given the patient's complex medical history, including asthma, COPD, SVT, smoker, meth use, marijuana, and MRSA, it is essential to carefully evaluate the potential benefits and risks of midodrine therapy. Key considerations include:

• Monitoring blood pressure carefully
• Starting with a low dose (2.5 mg) if renal impairment is suspected
• Avoiding concomitant use of drugs that increase blood pressure
• Cautious use in patients with urinary retention problems or visual problems Based on the information provided, midodrine can be ordered, but with caution and close monitoring of the patient's blood pressure and overall condition 2.

From the Research

Patient Information

• The patient has a diagnosis of cellulitis and a history of asthma, COPD, SVT, smoking, meth use, and marijuana use, as well as MRSA.
• The patient is currently taking roxicodone every 4 hours and has a blood pressure in the low 90s or below 100.

Midodrine Use

• Midodrine is an oral, peripherally acting alpha-adrenergic agonist that can be used to treat hypotension 3.
• It has been shown to be effective in increasing standing blood pressure and improving symptoms of orthostatic hypotension, such as weakness, syncope, blurred vision, and fatigue 4, 5.
• Midodrine is generally well-tolerated, with common side effects including piloerection, pruritus, paresthesias, and urinary retention 4, 5.

Comparison to Other Treatments

• Midodrine has been compared to other treatments for orthostatic hypotension, such as fludrocortisone, and has been shown to have a lower risk of all-cause hospitalizations 6.
• Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, but its use has been associated with a higher risk of hospitalizations compared to midodrine 6.
• A Cochrane review of fludrocortisone for orthostatic hypotension found very low-certainty evidence for its effects on blood pressure, orthostatic symptoms, and adverse events 7.

Ordering Midodrine

• Based on the patient's low blood pressure and history of hypotension, midodrine may be a suitable treatment option.
• However, it is essential to consider the patient's individual needs and medical history before ordering midodrine, and to monitor their blood pressure and symptoms closely while taking the medication 3, 4, 5.