What are the contraindications for midodrine?

Midodrine Contraindications

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-Specific Contraindications

Heart Failure Populations

• Midodrine may be poorly tolerated in heart failure patients and should be used with extreme caution 2
• Recent evidence from 2024 demonstrates that in hospitalized patients with kidney failure and heart failure with reduced ejection fraction (HFrEF) and/or right heart failure, midodrine use was associated with significantly increased 6-month mortality (RR 1.53, HR 1.54) 3
• The American College of Cardiology notes that severe autonomic dysfunction requiring medications like midodrine that cannot be weaned represents a neurologic contraindication to heart transplantation in cardiac amyloidosis patients 2

Urologic Considerations

• Patients with spinal cord injury who void spontaneously should be considered for relative contraindication due to risk of insidious urologic complications 4
• Midodrine increases vesical sphincter tone through alpha-1 adrenergic effects, which can lead to progressive urinary retention, particularly in neurogenic bladder patients 4
• The drug may aggravate detrusor-sphincter dyssynergia, potentially causing hydroureteronephrosis 4

Important Clinical Caveats

Supine Hypertension Risk

• Supine hypertension occurs in up to 25% of patients and represents a major safety concern 5, 6
• This risk can be minimized by avoiding doses within several hours of bedtime (at least 4 hours before) 5, 6

Bradycardia Monitoring

• Patients on negative chronotropic agents (beta-blockers, non-dihydropyridine calcium channel blockers) require cautious co-administration due to reflex vagal-mediated bradycardia from increased peripheral vascular resistance 5
• Hemodialysis patients warrant particular attention for bradycardia monitoring 5

Cardiovascular Disease

• While severe organic heart disease is an absolute contraindication, even patients with less severe heart failure should be approached with caution given the potential for harm from vasoconstriction 2, 3