From the Guidelines
Midodrine therapy should be discontinued if patients experience supine systolic hypertension in less than 10% of patients, as this side effect warrants cessation of therapy. This is based on the study by 1, which highlights the importance of monitoring for this specific side effect. When considering discontinuation of midodrine, several factors should be taken into account, including:
- Development of significant adverse effects that cannot be managed, such as piloerection, scalp itching or tingling, nausea and heartburn, urinary urgency, headache, nervousness, and sleep disturbance, as reported in the study by 1
- Lack of improvement in orthostatic hypotension symptoms after an adequate trial of midodrine
- Development of new contraindications, such as severe heart disease, acute kidney injury, urinary retention, or pheochromocytoma It is essential to regularly monitor blood pressure in both standing and supine positions to evaluate treatment efficacy and safety, as suggested by the study by 1. If discontinuation is necessary, alternative treatments such as fludrocortisone, droxidopa, or non-pharmacological measures like compression stockings, increased salt and fluid intake, and physical countermaneuvers should be considered.
From the FDA Drug Label
Because of the risk of supine hypertension, midodrine hydrochloride tablets should be continued only in patients who appear to attain symptomatic improvement during initial treatment. The supine and standing blood pressure should be monitored regularly, and the administration of midodrine hydrochloride tablets should be stopped if supine blood pressure increases excessively
The administration of midodrine should be stopped if:
- Supine blood pressure increases excessively
- The patient does not attain symptomatic improvement during initial treatment 2
From the Research
Discontinuation of Midodrine Therapy
Midodrine, an alpha-1 adrenergic receptor agonist, is used to treat orthostatic hypotension in patients. The decision to discontinue midodrine therapy depends on various factors, including the patient's response to treatment, development of adverse effects, and the presence of underlying conditions.
Adverse Effects Leading to Discontinuation
- Urologic adverse effects, such as urinary retention, vesical diverticula, and hydroureteronephrosis, may require discontinuation of midodrine therapy 3.
- Supine hypertension, which can occur in up to 25% of patients, may necessitate discontinuation or adjustment of midodrine dosage 4.
Tapering Midodrine Dosage
- A retrospective cohort study found that tapering midodrine dosage before discontinuation in critically ill patients reduced the frequency of inotrope or vasopressor re-initiation 5.
- Tapering midodrine dosage may be a reasonable approach in ICU patients, unless contraindicated 5.
Clinical Benefit and Discontinuation
- A phase 4, double-blind, placebo-controlled study demonstrated the clinical benefit of midodrine in symptomatic orthostatic hypotension, with a significant delay in time to syncopal symptoms or near-syncope 6.
- Discontinuation of midodrine therapy should be considered when the patient's symptoms are adequately controlled, or when alternative treatments are available.
Patient-Specific Factors
- Patients with spinal cord injury who develop urologic adverse effects while taking midodrine may require discontinuation of the drug and alternative management strategies 3.
- Patients with orthostatic hypotension who experience adverse effects or have underlying conditions may need to discontinue midodrine therapy and explore other treatment options 7, 4.