From the Guidelines
Midodrine can be considered as a bridge therapy from intravenous pressors in treating hypotension, particularly when terlipressin and norepinephrine are not available, at a dose of 5 to 15 mg orally every 8 hours in combination with octreotide. The use of midodrine as a bridge therapy is supported by the 2021 practice guidance by the American Association for the Study of Liver Diseases 1, which suggests its use in combination with octreotide when first-line options are not available. Key points to consider when using midodrine as a bridge therapy include:
- Starting midodrine at a dose of 5 to 15 mg orally every 8 hours while the patient is still on IV pressors
- Gradually tapering the IV medications as blood pressure stabilizes
- Monitoring blood pressure closely during the overlap period
- Being aware of common side effects such as piloerection, scalp tingling, urinary retention, and supine hypertension It's essential to note that the efficacy of midodrine in this context is considered low, and its use should be carefully evaluated based on individual patient needs and responses. In comparison, other studies such as the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1 discuss the use of midodrine in the context of vasovagal syncope, but this is not directly relevant to its use as a bridge therapy from IV pressors in treating hypotension. Therefore, the recommendation to use midodrine as a bridge therapy is based on the most recent and relevant guidance available 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The role of Midodrine (Midodrine hydrochloride) as a bridge from intravenous (IV) pressors in treating hypotension is not explicitly stated in the drug label. Key points:
- The label discusses the treatment of symptomatic orthostatic hypotension (OH)
- It does not mention the use of Midodrine as a bridge from IV pressors 2
From the Research
Role of Midodrine as a Bridge from IV Pressors
- Midodrine is an oral α1-adrenergic agonist that has been studied as a potential bridge from intravenous (IV) pressors in treating hypotension 3, 4.
- The evidence suggests that midodrine may be effective in liberating patients from IV vasopressor therapy, particularly in the recovery phase of vasodilatory shock 4.
- However, a randomized controlled trial found that midodrine did not accelerate liberation from IV vasopressors in critically ill patients with hypotension 3.
Mechanism of Action and Efficacy
- Midodrine undergoes enzymatic hydrolysis to the active metabolite desglymidodrine, which is a selective alpha 1-adrenoceptor agonist 5, 6.
- Midodrine has been shown to increase standing systolic blood pressure and improve symptoms of orthostatic hypotension, including dizziness, light-headedness, and syncope 5, 7.
- The efficacy of midodrine in treating hypotension has been demonstrated in various studies, including those in patients with orthostatic hypotension and vasodilatory shock 5, 4, 6, 7.
Safety and Tolerability
- Midodrine is generally well-tolerated, with common adverse events including piloerection, pruritus, paraesthesias, urinary retention, and chills 5, 6, 7.
- The risk of supine hypertension associated with midodrine therapy can be reduced by taking the final daily dose at least 4 hours before bedtime 5.
- Midodrine has been shown to be safe and effective in patients with neurogenic orthostatic hypotension, with minimal adverse events reported 7.