Maximum Daily Dose of Midodrine
The maximum daily dose of midodrine is 30 mg per day, typically administered as 10 mg three times daily, with doses spaced approximately 4 hours apart during daytime hours when the patient is upright. 1
FDA-Approved Dosing Parameters
- The standard recommended dose is 10 mg three times daily during waking hours 1
- Total daily doses greater than 30 mg have been tolerated by some patients, but their safety and usefulness have not been systematically studied or established 1
- Single doses as high as 20 mg have been administered, but severe and persistent systolic supine hypertension occurs at a high rate (approximately 45%) at this dose level 1
Timing and Administration Constraints
- Doses should be given during daytime hours when upright activity is needed, with a suggested schedule of morning (upon arising), midday, and late afternoon 1
- The last dose must not be taken later than 6 PM or within 4 hours of bedtime to reduce the risk of supine hypertension during sleep 1, 2
- Doses may be given at 3-hour intervals if required to control symptoms, but not more frequently 1
Clinical Context from Guidelines
Multiple guidelines consistently support the 30 mg/day maximum across different conditions:
- For orthostatic hypotension in diabetes, dosing is individualized up to 10 mg two to four times daily (maximum 40 mg mentioned in older literature, but FDA label supersedes this) 2
- For cardiac amyloidosis-related orthostatic hypotension, the maximum is specified as 10 mg three times daily 2
- For hepatorenal syndrome, higher initial dosing of 7.5-12.5 mg three times daily is used in combination with octreotide, but still within the 30-40 mg daily range 2, 3
Special Population Adjustments
- Renal impairment: Initiate at 2.5 mg doses due to renal excretion of the active metabolite desglymidodrine 1
- Hemodialysis patients: Use 5-10 mg administered 30 minutes before dialysis, as midodrine is removed by dialysis 3
Critical Safety Consideration
The primary dose-limiting adverse effect is supine hypertension, which necessitates regular monitoring of both supine and standing blood pressure 1, 2. Treatment should be discontinued if supine blood pressure increases excessively 1.