Maximum Daily Dosing of Midodrine
The maximum daily dose of midodrine is 30 mg, typically administered as 10 mg three times daily, with the last dose taken no later than 6 PM to avoid supine hypertension during sleep. 1
Dosing Guidelines
Standard Dosing
- Starting dose: 10 mg three times daily 1
- Dosing intervals: Approximately 4 hours apart (e.g., morning, midday, late afternoon) 1
- Alternative interval: Can be given at 3-hour intervals if needed for symptom control, but not more frequently 1
- Maximum single dose: 20 mg has been given to patients, but causes severe and persistent supine hypertension in about 45% of cases 1
Timing Considerations
- Last dose should be taken no later than 6 PM 1
- Doses should not be given less than 4 hours before bedtime 1
- Medication should be taken during daytime hours when the patient needs to be upright 1
Special Populations
- Renal impairment: Start with 2.5 mg doses in patients with abnormal renal function 1
- Elderly patients: No dose modifications necessary based on age 1
- Gender: No dose adjustments needed based on gender 1
Clinical Applications and Alternative Dosing
Hepatorenal Syndrome
When used for hepatorenal syndrome in combination with octreotide:
- Starting dose: 7.5 mg three times daily 2
- Can be titrated up to 12.5 mg three times daily if needed 2
Orthostatic Hypotension
- Typical dosing range: 5-20 mg three times daily 3, 4
- Efficacy demonstrated at 10 mg three times daily for orthostatic hypotension 4
Higher Frequency Dosing
Some evidence suggests that increasing dosing frequency to every 6 hours may optimize the pharmacokinetic profile without compromising safety, particularly in critical care settings 5. However, this exceeds the FDA-approved dosing frequency.
Safety Considerations
Monitoring Requirements
- Regular monitoring of supine and standing blood pressure is essential 1
- Discontinue if supine blood pressure increases excessively 1
- Risk of supine hypertension occurs in up to 25% of patients 6
Common Side Effects
- Piloerection (goosebumps)
- Pruritus (itching)
- Paresthesias
- Urinary retention
- Chills 6
Contraindications
- Severe cardiac disease
- Acute kidney injury with serum creatinine ≥5 mg/dL 3
- Severe supine hypertension
Important Precautions
- Total daily doses exceeding 30 mg have been tolerated by some patients but safety and efficacy have not been systematically established 1
- One case report documented a patient tolerating up to 90 mg daily (60 mg maintenance plus 30 mg intradialytic doses) for treprostinil-induced hypotension, but this is far outside standard dosing and should not be considered routine practice 7
- Continue treatment only in patients who demonstrate symptomatic improvement during initial treatment 1
While some patients may tolerate higher doses in specific clinical scenarios, the maximum FDA-approved daily dose remains 30 mg, and exceeding this should be approached with extreme caution and close monitoring.