What are the contraindications for midodrine?

Midodrine Contraindications

Midodrine is contraindicated in patients with severe organic heart disease, acute renal disease, urinary retention, pheochromocytoma, thyrotoxicosis, and persistent and excessive supine hypertension. 1

Absolute Contraindications

• Severe organic heart disease: Due to risk of exacerbating cardiac conditions
• Acute renal disease: Can worsen renal function or lead to increased adverse effects
• Urinary retention: Midodrine's alpha-1 adrenergic effects increase vesical sphincter tone 2
• Pheochromocytoma: Risk of dangerous blood pressure elevation
• Thyrotoxicosis: Can exacerbate hypertensive effects
• Persistent and excessive supine hypertension: Midodrine can significantly worsen this condition 1

Relative Contraindications and Precautions

Cardiovascular Considerations

• Congestive heart failure: May be poorly tolerated in heart failure patients 3
• Severe autonomic dysfunction requiring midodrine that cannot be weaned: This is considered a contraindication to heart transplantation in cardiac amyloidosis patients 3

Urologic Considerations

• Prostatic hypertrophy or urinary outflow obstruction: Particular caution in older males due to potential urinary outflow issues 4
• History of urinary problems: Midodrine can cause progressive urinary retention, especially in patients with spinal cord injury 2

Medication Interactions

• MAO inhibitors or linezolid: Avoid concurrent use 4
• Close monitoring required with:
  • Cardiac glycosides
  • Beta blockers
  • Alpha-adrenergic blocking agents
  • Salt-retaining steroids (e.g., fludrocortisone) 4
  • Other alpha-adrenergic agents (avoid concomitant use)

Special Population Considerations

Elderly Patients

• Higher risk of urinary retention and supine hypertension
• May require lower starting doses and more careful monitoring

Patients with Spinal Cord Injury

• Increased risk of developing insidious urologic adverse effects
• May aggravate detrusor-sphincter dyssynergia leading to hydroureteronephrosis 2

Monitoring Recommendations

When prescribing midodrine, the following monitoring is essential:

• Blood pressure: Regular monitoring in both supine and standing positions to detect supine hypertension (occurs in up to 25% of patients) 5
• Urinary function: Monitor for signs of urinary urgency or retention, particularly in at-risk patients
• Last daily dose timing: Should be taken at least 4 hours before bedtime to minimize risk of supine hypertension during sleep 4
• Sleeping position: Patients should be instructed to sleep with the head of the bed elevated (10°) 4

Common Adverse Effects to Monitor

• Piloerection (goosebumps)
• Scalp itching or tingling
• Urinary urgency or retention
• Headache
• Supine hypertension
• Nausea
• Chills

By understanding these contraindications and implementing appropriate monitoring, clinicians can safely prescribe midodrine for appropriate indications such as orthostatic hypotension, intradialytic hypotension, or as part of management for hepatorenal syndrome.