Contraindications for Midodrine
Midodrine is absolutely contraindicated in patients with severe organic heart disease, acute renal disease, urinary retention, pheochromocytoma, thyrotoxicosis, and persistent/excessive supine hypertension. 1
Absolute Contraindications (FDA-Labeled)
The FDA drug label explicitly lists the following as contraindications 1:
- Severe organic heart disease 1
- Acute renal disease 1
- Urinary retention 1
- Pheochromocytoma 1
- Thyrotoxicosis 1
- Persistent and excessive supine hypertension 1
Clinical Context and Additional Contraindications
Cardiac Considerations
- Heart failure patients may poorly tolerate midodrine, particularly those with decompensated heart failure or significant cardiac dysfunction 2
- The American College of Cardiology notes that midodrine should be used with extreme caution in patients with cardiac amyloidosis and heart failure 2
- Patients requiring midodrine or droxidopa for orthostatic hypotension that cannot be weaned represent a contraindication to heart transplantation in cardiac amyloidosis patients 2
Urologic Complications
- Midodrine increases vesical sphincter tone through alpha-1 adrenergic effects, which can lead to progressive urinary retention, particularly in patients with spinal cord injury who void spontaneously 3
- In spinal cord injury patients, midodrine may aggravate detrusor-sphincter dyssynergia, potentially causing hydroureteronephrosis 3
- Urinary retention is both a contraindication and a potential adverse effect that requires monitoring 1, 3
Supine Hypertension Risk
- Supine hypertension occurs in up to 25% of patients and represents a contraindication when persistent and excessive 1, 4
- This risk can be minimized by avoiding doses within 4 hours of bedtime, but when supine hypertension is persistent despite timing adjustments, midodrine is contraindicated 4
- Severe hypertension during general anesthesia has been reported in patients taking midodrine 5
Important Clinical Pitfalls
Bradycardia Monitoring
- Midodrine causes reflex bradycardia through vagal stimulation in response to increased peripheral vascular resistance 6
- Cautious co-administration is required with beta-blockers, non-dihydropyridine calcium channel blockers, and other negative chronotropic agents 6
Special Populations Requiring Extreme Caution
- Hemodialysis patients require careful monitoring for bradycardia and should receive midodrine within 30 minutes of initiating dialysis 6
- Spinal cord injury patients who void spontaneously should be monitored closely for insidious urologic complications; if these develop, midodrine should be discontinued and intermittent catheterization with antimuscarinic therapy instituted 3