From the Guidelines
For a patient with hypotension and cirrhosis, midodrine can be used in combination with octreotide and albumin to treat hepatorenal syndrome, with a recommended starting dose of 2.5 mg orally three times daily, increasing to 5-10 mg three times daily as needed and tolerated, as supported by the most recent guidance from 1.
Dosing and Administration
- Start with 2.5 mg orally three times daily, increasing to 5-10 mg three times daily as needed and tolerated.
- The maximum daily dose should not exceed 30 mg.
- Administer doses approximately 4 hours apart during waking hours, with the last dose taken at least 4 hours before bedtime.
Monitoring and Adjustments
- Monitor blood pressure closely, especially during dose titration, as recommended by 1.
- Adjust the dose based on blood pressure response and patient tolerance.
- Continue treatment as long as it remains effective and well-tolerated.
Additional Considerations
- Assess for supine hypertension before bedtime.
- Discontinue if severe supine hypertension occurs.
- Use with caution in patients with renal impairment, as noted in 1. Midodrine works as an alpha-1 adrenergic agonist, causing vasoconstriction and increasing blood pressure, which helps counteract the vasodilatory state often seen in cirrhosis, improving systemic hemodynamics and potentially reducing complications associated with portal hypertension, as discussed in 1.
Key Points
- Midodrine is used in combination with octreotide and albumin to treat hepatorenal syndrome.
- The treatment should be individualized based on the patient's response and tolerance.
- Close monitoring of blood pressure and renal function is essential during treatment, as emphasized by 1.
From the FDA Drug Label
Midodrine use has not been studied in patients with hepatic impairment. Midodrine should be used with caution in patients with hepatic impairment, as the liver has a role in the metabolism of midodrine
- Key Considerations:
- Midodrine has not been studied in patients with hepatic impairment
- The liver plays a role in the metabolism of midodrine
- Caution is advised when using midodrine in patients with hepatic impairment
- Answer: Midodrine should be used with caution in a patient with hypotension and cirrhosis, as the liver has a role in the metabolism of midodrine and its use has not been studied in patients with hepatic impairment 2.
From the Research
Appropriate Use of Midodrine in Hypotension and Cirrhosis
- Midodrine is an α-agonist prodrug used for managing hypotension and has demonstrated usefulness in hepatorenal syndrome 3.
- In patients with non-azotemic cirrhosis and tense ascites, midodrine therapy resulted in significant reduction in body weight and abdominal girth 3.
- Midodrine, in combination with octreotide, has been shown to increase urinary electrolyte-free water clearance and serum sodium concentration in patients with cirrhosis-associated hyponatremia 4.
- Oral midodrine has been found to be comparable to albumin infusion in cirrhotic patients with refractory ascites undergoing large-volume paracentesis, with no significant difference in renal impairment, hyponatremia, or mortality 5.
- A systematic review and meta-analysis found that midodrine improves mean arterial pressure and MELD score in patients with cirrhotic ascites, and is non-inferior to albumin 6.
- Midodrine is also effective in managing orthostatic hypotension, with benefits including improved standing time and energy level, and reduced clinical symptoms such as dizziness and syncope 7.
Key Considerations
- Midodrine should be used with caution in patients with supine hypertension, and the final daily dose should be taken at least 4 hours before bedtime to reduce this risk 7.
- The efficacy and safety of midodrine in patients with cirrhosis and hypotension should be carefully evaluated, taking into account individual patient characteristics and comorbidities 3, 4, 5, 6.
- Further studies are needed to determine the optimal duration and dosage of midodrine therapy in patients with cirrhosis and ascites 5, 6.