When should midodrine be held?

When to Hold Midodrine

Midodrine should be held if the patient develops supine hypertension, bradycardia, or if the dose would be taken less than 4 hours before bedtime. 1, 2

Primary Withhold Criteria

• Hold midodrine if supine systolic hypertension develops, which occurs in approximately 10% of patients on long-term therapy 1, 2
• Discontinue immediately if supine hypertension persists, as this is a significant safety concern 2
• Hold midodrine if bradycardia develops due to reflex parasympathetic stimulation 1, 2
• Do not administer midodrine in the evening (not later than 6 PM) or less than 4 hours before bedtime to minimize the risk of nighttime supine hypertension 2

Monitoring Parameters

• Blood pressure should be monitored regularly in both supine and standing positions to assess efficacy and detect supine hypertension 1, 2
• Monitor heart rate for bradycardia, especially when initiating therapy 1
• Assess for symptoms of supine hypertension including cardiac awareness, pounding in the ears, headache, and blurred vision 2

Drug Interactions Requiring Withholding

• Hold midodrine when used concomitantly with other agents that cause vasoconstriction, such as phenylephrine, ephedrine, dihydroergotamine, phenylpropanolamine, or pseudoephedrine 1, 2
• Use caution or consider holding when used with cardiac glycosides (digitalis), beta blockers, or other agents that directly or indirectly reduce heart rate 2
• Avoid concomitant use with MAO inhibitors or linezolid 2

Special Populations Considerations

• In patients with renal impairment, consider dose reduction (starting with 2.5 mg) and more careful monitoring as desglymidodrine is eliminated via the kidneys 2
• Use with caution in patients with urinary retention problems, as desglymidodrine acts on the alpha-adrenergic receptors of the bladder neck 2
• In patients with congestive heart failure, midodrine should be used cautiously and may need to be held if poorly tolerated 1, 2
• For patients with cirrhosis and refractory ascites, midodrine may be used on a case-by-case basis but should be monitored closely for adverse effects 3

Dosing Schedule Considerations

• Midodrine should be administered during daytime hours when the patient needs to be upright 2
• The recommended dosing schedule is approximately every 4 hours (or 3 hours if required): upon arising in the morning, midday, and late afternoon (not later than 6 PM) 2
• The maximum recommended dose is 10 mg three times daily, with total daily doses greater than 30 mg not well studied 2

Common Side Effects Requiring Monitoring

• Piloerection, scalp itching or tingling 1, 4
• Urinary urgency or retention 1, 2
• Nausea and heartburn 1
• Headache, nervousness, and sleep disturbance 1

Clinical Pearls

• Midodrine should be continued only in patients who demonstrate symptomatic improvement during initial treatment 2
• The risk of supine hypertension can be reduced by having the patient sleep with the head of the bed elevated 2
• Patients should be instructed to report symptoms of supine hypertension immediately 2
• In dialysis patients, midodrine can be used to prevent intradialytic hypotension 5, 6