When should midodrine be held?

When to Hold Midodrine

Midodrine should be held if the patient is going to be supine for any length of time, with the last daily dose administered at least 4 hours before bedtime to minimize the risk of supine hypertension. 1

Key Situations to Hold Midodrine

• Supine Position:

  • Hold midodrine if the patient will be lying down for extended periods
  • The final daily dose should be taken 3-4 hours before bedtime 1
  • Recommended dosing schedule: morning upon arising, midday, and late afternoon (not later than 6 PM) 1

• Supine Hypertension:

  • Discontinue immediately if persistent supine hypertension occurs 1
  • Monitor for symptoms including cardiac awareness, pounding in ears, headache, and blurred vision 1

• Bradycardia:

  • Hold if signs of bradycardia develop (pulse slowing, increased dizziness, syncope, cardiac awareness) 1
  • Midodrine can cause vagal reflex leading to heart rate slowing 1

• Urinary Retention:

  • Consider holding in patients experiencing urinary retention problems 1
  • Desglymidodrine acts on alpha-adrenergic receptors of the bladder neck 1

Medication Interactions Requiring Dose Adjustment or Holding

• Concomitant Vasoconstrictors:

  • Use cautiously with other agents causing vasoconstriction (phenylephrine, ephedrine, dihydroergotamine, phenylpropanolamine, pseudoephedrine) 1
  • Monitor blood pressure carefully when used together 1

• Cardiac Medications:

  • Use with caution when combined with:
    • Cardiac glycosides (digitalis) - may enhance bradycardia 1
    • Beta blockers - may enhance heart rate reduction 1
    • Psychopharmacologic agents that reduce heart rate 1

• MAO Inhibitors:

  • Avoid concomitant use with MAO inhibitors or linezolid 1

Special Populations

• Renal Impairment:

  • Start with lower dose (2.5 mg) in patients with abnormal renal function 1
  • Desglymidodrine is eliminated via the kidneys 1

• Hepatic Impairment:

  • Use with caution as the liver has a role in midodrine metabolism 1

• Diabetic Patients:

  • Use with caution in orthostatic hypotensive patients who are diabetic 1

• Patients Using Fludrocortisone:

  • Monitor closely, especially those with visual problems 1
  • Consider reducing fludrocortisone dose or decreasing salt intake before starting midodrine 1

Monitoring Parameters

• Regular monitoring of supine and standing blood pressure 1
• Heart rate monitoring for bradycardia 2
• Assessment of symptom improvement versus side effects 3

Common Pitfalls to Avoid

• Administering the last dose too close to bedtime (increases risk of supine hypertension) 1
• Failing to recognize signs of supine hypertension which occurs in up to 25% of patients 4
• Overlooking drug interactions that may potentiate midodrine's effects 1
• Not adjusting dosage in patients with renal impairment 1
• Continuing treatment without documented symptomatic improvement 1

By following these guidelines for when to hold midodrine, clinicians can maximize the benefits of this medication while minimizing the risk of adverse effects, particularly supine hypertension, which is the most concerning side effect of midodrine therapy.