From the FDA Drug Label
The recommended dose of midodrine hydrochloride tablets is 10 mg, 3 times daily. Dosing should take place during the daytime hours when the patient needs to be upright, pursuing the activities of daily living A suggested dosing schedule of approximately 4-hour intervals is as follows: shortly before, or upon arising in the morning, midday and late afternoon (not later than 6 P.M.) In order to reduce the potential for supine hypertension during sleep, midodrine hydrochloride tablets should not be given after the evening meal or less than 4 hours before bedtime.
The optimal timing of midodrine tid for treating orthostatic hypotension in elderly is:
- 10 mg, 3 times daily
- Dosing should occur during daytime hours
- A suggested schedule is:
- Shortly before, or upon arising in the morning
- Midday
- Late afternoon (not later than 6 P.M.)
- Not after the evening meal or less than 4 hours before bedtime 1
From the Research
The optimal timing for midodrine administration in elderly patients with orthostatic hypotension is typically three times daily at approximately 8 AM, noon, and 4 PM, with the last dose taken at least 3-4 hours before bedtime. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of maximizing the drug's effect during daytime hours while minimizing the risk of supine hypertension at night 2.
Key Considerations
- Midodrine is an alpha-1 adrenergic agonist that increases peripheral vascular resistance and raises blood pressure, with effects beginning within 30-60 minutes and lasting about 2-3 hours 2.
- Starting doses usually range from 2.5 to 5 mg per dose, which can be titrated up to 10 mg per dose based on blood pressure response and tolerability 3.
- The medication should be taken with the patient seated or standing to minimize supine hypertension risk.
- Patients should be monitored for common side effects including piloerection (goosebumps), scalp tingling, urinary retention, and supine hypertension 2.
- Blood pressure should be checked regularly in both standing and supine positions to ensure effectiveness while avoiding excessive pressure when lying down.
Management Strategies
- Nonpharmacological strategies are the primary treatment, such as discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, adding salt to diet, and so on 3.
- If these fail, pharmacotherapy can help ameliorate symptoms, including midodrine, droxidopa, fludrocortisone, pyridostigmine, atomoxetine, sympathomimetic agents, and octreotide 3.
- Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms 3.
Special Considerations
- Midodrine is contraindicated in patients with severe cardiac disease, acute renal failure, urinary retention, pheochromocytoma, or thyrotoxicosis 2.
- Medication management of primary OH should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions 3.