From the Guidelines
Midodrine is associated with several side effects, including piloerection, scalp itching or tingling, nausea, heartburn, urinary urgency, headache, nervousness, and sleep disturbance, which can be managed by adjusting the dose, avoiding lying down after taking the medication, and monitoring blood pressure regularly 1. The most frequent side effects of midodrine are:
- Piloerection
- Scalp itching or tingling
- Nausea and heartburn
- Urinary urgency
- Headache
- Nervousness
- Sleep disturbance These side effects are due to the alpha-adrenergic stimulating effects of midodrine, which can cause vasoconstriction and increase blood pressure 1. To manage these side effects, patients should:
- Avoid taking midodrine within 4 hours of bedtime
- Not lie down for at least 4 hours after each dose
- Reduce the dose if urinary symptoms occur, particularly in men with prostatic hypertrophy
- Monitor blood pressure regularly, especially when starting treatment or adjusting doses Long-term use of midodrine can lead to supine systolic hypertension in less than 10% of patients, which warrants cessation of therapy 1. Additionally, midodrine can interact with other medications, such as beta-blockers, digoxin, and non-dihydropyridine calcium channel blockers, and should be used cautiously in patients with congestive heart failure 1.
From the FDA Drug Label
The most frequent adverse reactions seen in controlled trials were supine and sitting hypertension; paresthesia and pruritus, mainly of the scalp; goosebumps; chills; urinary urge; urinary retention and urinary frequency The feelings of paresthesia, pruritus, piloerection and chills are pilomotor reactions associated with the action of midodrine on the alpha-adrenergic receptors of the hair follicles. Feelings of urinary urgency, retention and frequency are associated with the action of midodrine on the alpha-receptors of the bladder neck. Less frequent adverse reactions were headache; feeling of pressure/fullness in the head; vasodilation/flushing face; confusion/thinking abnormality; dry mouth; nervousness/anxiety and rash Other adverse reactions that occurred rarely were visual field defect; dizziness; skin hyperesthesia; insomnia; somnolence; erythema multiforme; canker sore; dry skin; dysuria; impaired urination; asthenia; backache; pyrosis; nausea; gastrointestinal distress; flatulence and leg cramps.
The side effects of midodrine include:
- Supine and sitting hypertension
- Paresthesia and pruritus, mainly of the scalp
- Goosebumps and chills
- Urinary urge, urinary retention, and urinary frequency
- Headache and feeling of pressure/fullness in the head
- Vasodilation/flushing face and confusion/thinking abnormality
- Dry mouth and nervousness/anxiety
- Rash and other skin reactions
- Visual field defect, dizziness, and skin hyperesthesia
- Insomnia, somnolence, and erythema multiforme
- Canker sore, dry skin, and dysuria
- Impaired urination, asthenia, and backache
- Pyrosis, nausea, and gastrointestinal distress
- Flatulence and leg cramps
To manage these side effects, patients should be advised to:
- Avoid taking their dose if they are to be supine for any length of time
- Take their last daily dose of midodrine 3 to 4 hours before bedtime to minimize nighttime supine hypertension
- Monitor their blood pressure closely, especially when taking concomitant medications that increase blood pressure
- Report any adverse reactions to their healthcare provider promptly 2 2
From the Research
Midodrine Side Effects
The side effects of midodrine can be significant and may impact patient management. Some of the most commonly reported side effects include:
- Piloerection
- Pruritus
- Paraesthesias
- Urinary retention
- Chills
- Supine hypertension, which can occur in up to 25% of patients 3
- Urologic adverse effects, such as progressive retention of urine, detrusor-sphincter dyssynergia, and hydroureteronephrosis, particularly in patients with spinal cord injury 4
- Gastrointestinal disorders
- Cardiovascular complaints
Management of Side Effects
To manage the side effects of midodrine, the following strategies can be employed:
- Reducing the dosage of midodrine can help control mild side effects such as piloerector reactions, gastrointestinal disorders, and cardiovascular complaints 5
- Taking the final daily dose at least 4 hours before bedtime can reduce the risk of supine hypertension 3
- Stopping midodrine therapy and prescribing alternative pharmacologic agents, such as fludrocortisone, and nonpharmacologic methods can help manage urologic adverse effects in patients with spinal cord injury 4
- Intermittent catheterization combined with antimuscarinic therapy, such as oxybutynin, can be recommended for patients who continue to require midodrine to control postural hypotension 4
Special Considerations
Patients receiving midodrine should be observed for supine hypertension for a prolonged period, as it can persist even after discontinuation of the drug 6. Additionally, midodrine's use in patients with spinal cord injury requires careful monitoring for urologic adverse effects, and alternative management strategies should be considered if these effects occur 4.