From the FDA Drug Label
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 [seeDOSAGE AND ADMINISTRATION]. Renal function should be assessed prior to initial use of midodrine.
Midodrine should be used with caution in patients with renal impairment, including those with CKD 4. The recommended starting dose is 2.5 mg, and renal function should be assessed prior to initial use.
- Key considerations:
- Higher blood levels are expected in patients with renal impairment
- Renal function should be assessed prior to initial use
- Starting dose should be 2.5 mg 1
From the Research
Midodrine can be used cautiously in patients with stage 4 chronic kidney disease (CKD) to treat orthostatic hypotension, but requires careful monitoring. The typical starting dose is 2.5 mg three times daily, which may be titrated up to 10 mg three times daily based on blood pressure response and tolerability 2. Doses should be given during waking hours (morning, midday, and late afternoon, but not after 6 PM) to avoid supine hypertension while sleeping. For CKD stage 4 patients, dose adjustment is generally not required as midodrine is primarily eliminated through urinary excretion as unchanged drug and metabolites, but starting at the lower dose range is prudent. Monitor for potential side effects including supine hypertension, urinary retention, bradycardia, and piloerection (goosebumps). Regular blood pressure checks in both standing and supine positions are essential. Midodrine works by activating alpha-1 adrenergic receptors, causing arterial and venous constriction which increases blood pressure. This mechanism helps counteract the orthostatic hypotension that is common in CKD patients due to autonomic dysfunction, medication effects, or volume depletion. Renal function should be monitored regularly as midodrine could potentially affect renal perfusion in advanced CKD.
Some studies have compared midodrine to other treatments for orthostatic hypotension, such as fludrocortisone, and found that midodrine may have a lower risk of hospitalizations 3. However, the evidence is not conclusive, and more research is needed to determine the optimal treatment for orthostatic hypotension in CKD patients.
In terms of management of orthostatic hypotension, nonpharmacologic measures are key to success, and pharmacologic options such as midodrine should be used in conjunction with these measures 4. The goal of treatment is to improve quality of life and reduce symptoms, rather than to normalize blood pressure.
It's also important to note that patients with CKD are at risk of progressing to end-stage renal disease (ESRD), and management of orthostatic hypotension should be part of a comprehensive approach to managing CKD and preventing progression to ESRD 5.
Overall, midodrine can be a useful treatment for orthostatic hypotension in CKD patients, but requires careful monitoring and should be used in conjunction with nonpharmacologic measures and other treatments as needed.