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General Rehabilitation

A Pressing Concern: Midodrine Use and Acute Limb Ischemia in Peripheral Arterial Disease

Thursday, October 23, 2025
5:00 PM - 6:30 PM MT
Location: Open Kiosks

    Primary Author(s)

  • Bendik Stenersen, DO, MS

    Resident Physician
    Larkin Community Hospital PM&R Program
    Miami, Florida

    • Co-Author(s)

  • MG

    Maria C. Guerrero, DO

    PGY-2
    Larkin Community Hospital PM&R Program
    Miami, Florida

  • SS

    Sahil Shah, DO

    PGY II
    Larkin Palm Springs PM&R Program
    Miami Lakes, Florida

  • Panayotis Jusakos, MD

    Resident Physician
    One Brooklyn Health System/Kingsbrook Jewish Medical Center PM&R Program
    Brooklyn, New York

    • Poster Presenter(s)

  • Camilo Osorio, MD

    Resident Physician Larkin Community Hospital PM&R Program
    Larkin Community Hospital

Disclosure(s):
Panayotis Jusakos, MD: No financial relationships to disclose
Camilo Osorio, MD: No financial relationships to disclose
Case Diagnosis: An 80-year-old female with extensive cardiovascular comorbidities, including peripheral arterial disease (PAD) with high-grade stenosis of the superficial femoral artery, developed acute limb ischemia (ALI) following midodrine for recurrent hypotension.

Case Description or Program Description: Patient was admitted to hospital for evaluation of left foot swelling following recent left hip hemiarthroplasty. X-ray identified old fifth metatarsal screw as likely culprit, which was surgically removed. She was later transferred to rehabilitation, recommended non-weight bearing of left lower extremity with post-operative shoe. However, due to underlying dementia, had difficulty adhering to precautions. She experienced episodes of hypotension, leading to initiation of midodrine for blood pressure support. Over the following days, worsening left foot pain, followed by bruising, mild swelling, and minimal tenderness. On the final day, received two doses of midodrine for recurrent hypotension. That afternoon, she developed severe, disproportionate pain with clear ischemic demarcation from the first to third toes.

Setting: acute inpatient rehabilitation

Assessment/Results: Development of acute limb ischemia in the setting of PAD and midodrine use. Patient was transferred to acute care hospital for prompt reevaluation and management.

Discussion (relevance): Acute limb ischemia is a life-threatening vascular emergency that can lead to limb loss if not promptly identified and treated. PAD increases risk due to preexisting arterial insufficiency. Midodrine, an α1-adrenergic agonist, increases systemic vascular resistance through vasoconstriction and can exacerbate ischemia in patients with significant arterial disease. The connection between PAD, hypotension, and midodrine likely contributed to development of ischemia.

Conclusions: This case highlights the temporal association between midodrine administration and worsening vascular status, suggesting that drug-induced vasoconstriction exacerbated preexisting arterial insufficiency. This highlights the need for caution when prescribing vasoactive agents to individuals with known arterial disease. Clinicians should explore alternative strategies for managing hypotension and implement monitoring protocols to minimize ischemic risk. Future guidelines should emphasize vascular risk stratification before treating isolated blood pressure values.