What are the indications for midodrine (Alpha-1 adrenergic receptor agonist)?

From the Guidelines

Midodrine is primarily indicated for the treatment of symptomatic orthostatic hypotension in patients who have not responded to non-pharmacological interventions, with a typical dosing regimen of 2.5-10 mg three times daily. The use of midodrine is supported by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope, which recommends midodrine as a reasonable treatment option for patients with recurrent vasovagal syncope (VVS) with no history of hypertension, heart failure, or urinary retention 1. Midodrine works as an alpha-1 adrenergic agonist, causing peripheral vasoconstriction and increasing blood pressure, thereby improving cerebral perfusion upon standing.

Key Considerations

• The dosing of midodrine should be individually tailored, with the first dose taken before arising and use avoided several hours before planned recumbency, particularly in patients with documented supine hypertension 1.
• Patients should be monitored for potential side effects, including supine hypertension, piloerection, paresthesias, urinary retention, and bradycardia.
• Midodrine is contraindicated in patients with severe heart disease, acute renal failure, urinary retention, pheochromocytoma, and thyrotoxicosis.

Off-Label Uses

• Midodrine may be used off-label for the management of dialysis-induced hypotension, hepatorenal syndrome, and vasovagal syncope, although the evidence for these uses is limited 1.
• The 2009 European Heart Journal guidelines recommend midodrine as an adjunctive therapy for the treatment of orthostatic hypotension, in addition to adequate hydration and salt intake 1.

Clinical Decision-Making

• The decision to use midodrine should be based on a careful assessment of the patient's symptoms, medical history, and potential risks and benefits.
• Patients should be educated on the potential side effects of midodrine and the importance of monitoring their blood pressure and adjusting their dosage as needed.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The indications for midodrine are:

• Treatment of symptomatic orthostatic hypotension (OH) Midodrine should be used in patients whose lives are considerably impaired despite standard clinical care. The treatment should be continued only for patients who report significant symptomatic improvement 2

From the Research

Indications for Midodrine

Midodrine, an alpha-1 adrenergic receptor agonist, is indicated for the treatment of various forms of orthostatic hypotension, including:

• Orthostatic hypotension due to autonomic dysfunction 3, 4, 5, 6
• Neurogenic orthostatic hypotension 5
• Secondary hypotensive disorders 3
• Severe orthostatic hypotension due to autonomic dysfunction in adults when corrective factors have been ruled out and other forms of treatment are inadequate 6

Specific Conditions

Midodrine has been shown to be effective in patients with:

• Shy Drager syndrome 5
• Bradbury Eggleston syndrome (idiopathic orthostatic hypotension) 5
• Diabetic autonomic neuropathy 5
• Parkinson's disease 5, 7

Key Benefits

The use of midodrine has been associated with:

• Increased standing blood pressure 3, 4, 5
• Improved symptoms of orthostatic hypotension, such as dizziness, lightheadedness, and syncope 3, 4, 5
• Improved energy level and standing time 4, 5
• Mild and controllable adverse effects 3, 4, 5