Midodrine Pharmacology Podcast

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spk_0 Hey, oh, welcome back to the Real Life Pharmacology Podcast.

spk_0 I'm your host, pharmacist, Eric Christensen.

spk_0 Thank you so much for listening today.

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spk_0 as well as things that will likely show up

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spk_0 All right, the drug of the day today is mid-adren.

spk_0 Brand name of this medication that I see most often is proamitine.

spk_0 I will say at this point, mid-adren has been around a long time,

spk_0 so that's the more common name that I see utilized,

spk_0 which I'll use here.

spk_0 It is an alpha-1 adrenergic agonist.

spk_0 So this is going to have vasopressor type activities.

spk_0 So basically what it does is it closes or clamps down

spk_0 on those blood vessels.

spk_0 That's going to be the ultimate effect from this medication.

spk_0 Okay, so what would that potentially be useful for?

spk_0 Well, by stimulating those alpha-1 receptors,

spk_0 we're going to cause that vasoconstriction

spk_0 and in a setting like orthostatic hypotension,

spk_0 you know, that's symptomatic and clinically problematic.

spk_0 This is where that medication may be used for.

spk_0 There's a couple of disease states too that I see commonly anyway.

spk_0 That can cause some orthostasis.

spk_0 And again, as a pharmacist here, I would strongly encourage you to make sure to go through

spk_0 that medication list. First and foremost, it makes your medications

spk_0 aren't worsening orthostatic hypotension.

spk_0 Okay, so that's step one, and I'll talk about some of those medications coming up here.

spk_0 But once we decide to determine we're going to use midagron,

spk_0 we have some disease states that are more likely

spk_0 for a patient to experience orthostatic blood pressures, lower blood pressures.

spk_0 Cerrosis is a good example.

spk_0 Dialysis is a good example where we're kind of altering that fluid status for that patient.

spk_0 So those are a couple of things to kind of keep in mind there.

spk_0 Now, some of those agents that I wanted to mention.

spk_0 So obviously any type of blood pressure, lowering medication,

spk_0 beta blockers, diuretics, ACE inhibitors, ARBS,

spk_0 and so on and so forth, anything that could lower blood pressure or we're using it to treat

spk_0 hypertension, that obviously has to be looked at first.

spk_0 If we're having a patient experience, dizziness, and symptomatic orthostatic

spk_0 hypotension, low blood pressure, address those blood pressure lowering agents first.

spk_0 There are a couple others that might fly under the radar.

spk_0 Parkinson's drugs can sometimes cause some orthostatic hypotension,

spk_0 as well as the disease state itself.

spk_0 Patients are more prone there.

spk_0 Rectile dysfunction medications and other good example.

spk_0 So you're still down a fill or brand name, by Agra, that's a good example of a medication

spk_0 that can lower blood pressure.

spk_0 So making sure that we rule those out really, really important thing to do there.

spk_0 Moving on to dosing, 2.5 to 10 milligram dosage forms.

spk_0 There's 2.5, 5 and a 10.

spk_0 Typical starting dose that I see,

spk_0 particularly in geriatric patients, probably more 2.5.

spk_0 Occasionally you might see 5 milligrams started as well.

spk_0 Up to 3 times a day, and then maximum typically recommended is going to be in that 10 milligrams,

spk_0 3 times a day range.

spk_0 With dialysis, that's kind of a different animal a little bit,

spk_0 where this medication is sometimes used to

spk_0 reduce or prevent symptomatic hypotension during dialysis.

spk_0 So if you see

spk_0 mid-adren dose, 15 to 30 minutes prior to dialysis,

spk_0 you can probably anticipate that they're having some trouble

spk_0 through their dialysis session

spk_0 in that blood pressure is dropping too far, and they're getting symptomatic,

spk_0 severe dizziness, syncopy, those type of things.

spk_0 All right, adverse effect profile.

spk_0 So I would say, there's kind of some minor things that can happen.

spk_0 Goosebumps have actually been reported.

spk_0 That's also called pyloeirection, paresthesia,

spk_0 paritis, itching.

spk_0 So there's kind of a few kind of nuisance type of things that maybe aren't major major issues,

spk_0 but there's two really, really important ones that I think come up pretty consistently.

spk_0 Well, I guess all out of third here.

spk_0 So obviously this medications meant to raise blood pressure.

spk_0 That blood pressure can get too high for two aggressive with the dosing and those type of things.

spk_0 So pay attention to that.

spk_0 The two other ones are bradycardia.

spk_0 So that can be an issue.

spk_0 So we're going to monitor that heart rate.

spk_0 And the other big one that I've seen in geriatric patients, especially, is urinary retention.

spk_0 So males who have BPH urinary retention can already be a problem.

spk_0 So if we're adding this medication, that alpha agonist action

spk_0 can actually tighten up that passageway basically

spk_0 and cause urinary retention symptoms to be worse.

spk_0 So really, really important to pay attention to that.

spk_0 Obviously, particularly more so in our male patients.

spk_0 A few things to be careful for, elaborating on that urinary retention.

spk_0 Kind of a case example, I saw recently, was we're actually

spk_0 needing a catheter for this resident because they had so much urinary retention.

spk_0 And we're using midagreine to manage orthostatic hypotension.

spk_0 Okay, so that's a situation where midagreine is probably, for sure,

spk_0 causing more harm than good in that situation.

spk_0 So we need to find an alternative in those type of things.

spk_0 So pay attention to that urinary retention issue.

spk_0 We've got to balance the cardiovascular risk.

spk_0 So if you've got to severe cardiovascular patient,

spk_0 obviously if we get too aggressive, we raise that blood pressure.

spk_0 That's going to put them at risk for cardiac concerns,

spk_0 stroke concerns, things of that nature too.

spk_0 So pay attention to the cardiovascular risk and weighing that risk versus benefit there.

spk_0 A couple of the rare things,

spk_0 VO-chromositoma,

spk_0 thyrootoxicosis.

spk_0 So again, things that don't happen too often,

spk_0 but have the tendency to potentially raise blood pressure and exacerbate it from the use of

spk_0 midagreine. A couple things on monitoring and kinetics.

spk_0 So obviously blood pressure, obviously heart rate, alluded to the bradycardia risk potentially.

spk_0 Renofunction, that is something that you probably want to monitor there.

spk_0 And that kind of ties in with kinetics.

spk_0 This medication actually is a pro drug.

spk_0 So it is converted to an active metabolite.

spk_0 And with that, that active metabolite is primarily

spk_0 renally eliminated or eliminated through the kidneys.

spk_0 So you could imagine the patient has poor renal function.

spk_0 We need to be a little bit more cautious with the dosing of this medication.

spk_0 So for initiating this medication, we definitely want to start at the lowest possible dose of two and

spk_0 a half if they got a poor renal function. And that's generally defined in this situation as

spk_0 GFR less than 30 ml per minute.

spk_0 All right, let's take a quick break from our sponsors and we'll wrap up with drug interactions.

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spk_0 All right, wrapping up with drug interactions.

spk_0 So first thing I think about is mid-adrened can raise blood pressure.

spk_0 So what other medications can raise blood pressure?

spk_0 So Sympathomometics, those type of medications, you know, CNS stimulants,

spk_0 amphetamines, drugs with alpha-1 agonist activity, so de-congestant like pseudo-ofedrine.

spk_0 That's really what I think about first, okay?

spk_0 Then on the flip side, if we've got drugs that have alpha blocking activity,

spk_0 so tamselocin, doxazocin, that's doing the exact opposite effect of what we're trying to do with

spk_0 mid-adren. So again, pay attention to that. We may be able to reduce or stop orthostatic

spk_0 hypotension simply by getting rid of, let's say, doxazocin for, you know, prostate issues,

spk_0 or reducing the dose or whatever the case may be, okay? So there's always kind of that risk versus

spk_0 benefit. And if we're using two medications that are doing two opposite things on the same

spk_0 receptor, whether it's blocking it or stimulating it, that's a problem. And I mean, that's a classic

spk_0 example of polypharmacy in the prescribing cascade. So again, pay attention to those drugs for sure.

spk_0 And then the others that I kind of alluded to a little bit, obviously any blood pressure

spk_0 lowering medication. And then some of those cinematics are good example that can cause some orthostatic

spk_0 hypotension and kind of counteract the effects of mid-adren. You know, in a situation like that,

spk_0 there might not be anything we can do. You know, we may need to manage those symptoms of Parkinson's

spk_0 disease, you know, but making sure the dose is right and correct and we're not, you know, overly

spk_0 aggressive those type of things. That's important as well. Are there cardiac meds? Nitrates can

spk_0 certainly lower blood pressure as well. And kind of counteract what we're trying to do. The PDE5

spk_0 inhibitors like Sildina Filnet I mentioned, and even medications like anti-psychotics can have

spk_0 some alpha blocking activity and cause some orthostasis, which would kind of directly oppose what we're

spk_0 trying to do with the use of mid-adren. The classic example, probably the anti-psychotic, that's one

spk_0 of the worst as far as causing causing orthostatic hypotension is clasiping. That's definitely something

spk_0 I've seen come up on board exams a little bit here and there. So with that said, that's going to

spk_0 wrap up the podcast for today. Do me a huge favor. Go support the sponsor, medit101.com slash store,

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spk_0 favor. Leave a rating review on iTunes or wherever you're listening. And of course, feel free to drop

spk_0 me an email. Mededucationoneser1 at gmail.com. If you've got suggestions, questions, shoot me a message,

spk_0 I do my best to try to respond to all of those in a timely manner. With that said, thank you so

spk_0 much for listening. Take care and have a great rest of your day.

Midodrine Pharmacology Podcast

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