From the Guidelines
Midodrine is not typically used as a primary treatment for Parkinson's disease itself, but it can be used to manage orthostatic hypotension, a common non-motor symptom in Parkinson's patients, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. When using midodrine to manage orthostatic hypotension in Parkinson's patients, it's essential to consider the dosing and potential side effects. Midodrine is typically dosed at 2.5-10 mg three times daily, and it works as an alpha-1 adrenergic agonist that constricts blood vessels and raises blood pressure. Some key points to consider when using midodrine include:
- Taking the last dose at least 4 hours before bedtime to avoid supine hypertension
- Monitoring blood pressure regularly and reporting any sustained high readings to the doctor
- Using midodrine cautiously in patients with cardiovascular disease
- Being aware of common side effects, including piloerection (goosebumps), scalp tingling, and urinary retention While midodrine can help manage orthostatic symptoms, it does not address the underlying dopamine deficiency that causes primary Parkinson's symptoms. Therefore, it should be used as part of a comprehensive treatment plan that includes standard Parkinson's medications like levodopa, dopamine agonists, or MAO-B inhibitors, as supported by the 2017 ACC/AHA/HRS guideline 1.
From the Research
Midodrine for Parkinson's Disease
- Midodrine is an alpha1-adrenergic agonist that is used to treat orthostatic hypotension (OH) in patients with Parkinson's disease 2.
- The management of OH in patients with Parkinson's disease should always start with patient education and nonpharmacological treatment, and drug therapy should be reserved for symptomatic patients who do not benefit from nonpharmacological management 2.
- Midodrine is one of the most frequently used drugs for the treatment of OH in patients with Parkinson's disease, along with fludrocortisone 2.
- A study found that correcting OH in patients with Parkinson's disease or atypical Parkinsonism using a staged approach, including midodrine, improved their gross motor, balance, and cognitive functions 3.
- Another study suggested that a mean standing blood pressure below 75 mmHg appears to be a useful benchmark when deciding whether to initiate pharmacological treatment of OH, including midodrine, in patients with Parkinson's disease 4.
Efficacy and Safety of Midodrine
- There is limited evidence on the efficacy and safety of midodrine for the treatment of OH in patients with Parkinson's disease, and most studies have small sample sizes and short durations 2, 3, 4.
- A Cochrane review found very low-certainty evidence on the effects of fludrocortisone, another drug used to treat OH, and highlighted the need for standardized reporting of outcomes and measurements of blood pressure in orthostatic hypotension 5.
- Midodrine is generally well-tolerated, but its use can be limited by side effects such as supine hypertension, and its efficacy and safety in the long term are not well established 2, 3, 4.