Parameters for Holding Midodrine Therapy
Midodrine should be held when supine systolic blood pressure exceeds 180 mmHg, and the last daily dose should always be taken at least 4 hours before bedtime to prevent supine hypertension. 1
Monitoring Parameters and Hold Criteria
Blood Pressure Parameters
- Hold for supine hypertension: Supine systolic BP ≥180 mmHg 1
- Hold for standing hypertension: If standing BP becomes elevated beyond target range
- Timing restriction: Last dose must be taken at least 4 hours before bedtime 2
Other Parameters Requiring Dose Adjustment or Discontinuation
- Urinary retention: Hold if patient develops urinary urgency or retention 1, 3
- Severe adverse effects: Discontinue for intolerable piloerection, scalp itching/tingling, or other significant side effects 4
- Bradycardia: Use with caution or hold in patients taking negative chronotropic agents 5
Special Considerations
Orthostatic Hypotension Management
Midodrine is primarily used for orthostatic hypotension, with dosing typically 5-20 mg three times daily 3. When managing patients with orthostatic hypotension:
- Dosing schedule: Administer at 3-4 hour intervals during daytime hours only 1
- Monitoring frequency: Check supine and standing BP 1 hour after dosing (peak effect time) 1
- Duration of action: Effects typically last 2-3 hours after each dose 1
Hepatorenal Syndrome Management
In hepatorenal syndrome, midodrine is often used in combination with octreotide:
- Starting dose: 7.5 mg three times daily
- Titration: Increase to 12.5 mg three times daily as needed 3
- Hold parameters: Same as for orthostatic hypotension
Contraindications for Midodrine Use
- Pre-existing sustained supine hypertension (>180/110 mmHg) 1
- Severe heart disease
- Acute kidney injury with serum creatinine ≥5 mg/dL 3
- Thyrotoxicosis
- Concomitant use with other alpha-adrenergic agonists 5
Practical Management Tips
- Midodrine's peak effect occurs 1-2 hours after administration 1
- The half-life of the active metabolite (desglymidodrine) is approximately 3-4 hours 1
- Supine hypertension occurs in up to 25% of patients on midodrine therapy 2
- Patients should be instructed to sleep with the head of the bed elevated (10°) when using midodrine 3
By carefully monitoring these parameters and adjusting therapy accordingly, the risks associated with midodrine therapy can be minimized while maintaining its therapeutic benefits for orthostatic hypotension.