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
Primary Contraindications
Midodrine, a peripheral alpha-1 adrenergic agonist used primarily for orthostatic hypotension, has several absolute contraindications according to FDA labeling:
- Severe organic heart disease: Due to its vasopressor effects that could worsen cardiac conditions
- Acute renal disease: May lead to drug accumulation and increased adverse effects
- Urinary retention: Midodrine can worsen urinary retention through increased sphincter tone
- Pheochromocytoma: Could precipitate hypertensive crisis
- Thyrotoxicosis: May exacerbate hypertension in this condition
- Persistent and excessive supine hypertension: Midodrine can significantly worsen supine hypertension 1
Relative Contraindications and Precautions
Several conditions require caution when considering midodrine:
- Congestive heart failure: May be poorly tolerated in heart failure patients 2
- Patients requiring heart transplantation: Severe autonomic dysfunction requiring midodrine that cannot be weaned is considered a contraindication to heart transplantation 2
- Spinal cord injury patients who void spontaneously: May develop insidious urologic adverse effects including progressive urinary retention and worsening of detrusor-sphincter dyssynergia 3
- Patients with significantly impaired autonomic reflexes: May experience worsening of orthostatic hypotension due to extracellular fluid volume depletion 4
Drug Interactions to Avoid
- MAO inhibitors or linezolid: Avoid concurrent use due to potential for hypertensive crisis 5
- Alpha-adrenergic blocking agents: Antagonistic effects may occur 5
- Cardiac glycosides, beta blockers, and salt-retaining steroids like fludrocortisone: Require close monitoring when used with midodrine 5
- Other alpha-adrenergic agents: Avoid concomitant use due to additive effects 5
Monitoring Considerations
When midodrine is prescribed despite relative contraindications:
- Regular blood pressure monitoring in both supine and standing positions is essential to detect supine hypertension, which occurs in up to 25% of patients 5, 6
- Monitor for urinary symptoms: Particularly in patients with pre-existing urinary issues 5
- Last dose timing: Should be administered no later than 6 PM and at least 4 hours before bedtime to avoid supine hypertension during sleep 5
Common Adverse Effects to Monitor
- Piloerection and scalp itching/tingling (most common)
- Urinary urgency or retention
- Supine hypertension
- Headache
- Nausea and gastrointestinal disorders 7, 8
Special Populations
In patients with end-stage renal disease, observational data suggests potential increased risks of cardiovascular events, hospitalization, and mortality despite short-term symptomatic benefits 5. Additionally, midodrine should not be used in patients with acute kidney injury with serum creatinine ≥5 mg/dL 5.