How should I taper and discontinue midodrine in an adult patient?

How to Wean Midodrine

Midodrine should be tapered gradually before discontinuation to reduce the risk of an acute withdrawal syndrome characterized by adrenergic hyperactivity, though specific tapering schedules are not well-established in the literature. 1

Rationale for Tapering

• An uncommon acute withdrawal syndrome manifesting primarily as adrenergic hyperactivity has been reported following abrupt midodrine discontinuation 1
• If possible, the dose should be tapered before treatment is stopped to minimize this risk 1
• This approach parallels the discontinuation strategy used for other medications affecting the autonomic nervous system, where gradual dose reduction helps prevent rebound effects 1

Practical Tapering Approach

While no specific tapering protocol is established in guidelines, a reasonable clinical approach based on the medication's pharmacology includes:

• Reduce the dose by 2.5 mg per dose every 3-7 days 2

  • For example, if a patient is on 10 mg three times daily, reduce to 7.5 mg three times daily for one week, then to 5 mg three times daily, and so forth
  • The 2.5 mg increment is based on the standard dose escalation used when initiating therapy 3, 2

• Alternatively, eliminate one daily dose at a time 4

  • Start by discontinuing the evening dose first (which should already be given at least 4 hours before bedtime to avoid supine hypertension) 4
  • After 3-7 days, eliminate the midday dose
  • Finally, discontinue the morning dose

Monitoring During Tapering

• Monitor standing and supine blood pressure during the taper to assess for return of orthostatic hypotension symptoms 5
• Watch for recurrence of orthostatic symptoms including dizziness, lightheadedness, syncope, weakness, and fatigue 3
• Assess for withdrawal symptoms such as excessive sweating, tachycardia, or other signs of adrenergic hyperactivity 1

Special Considerations

• Hemodialysis patients: Midodrine is effectively cleared by dialysis with a reduced half-life of 1.4 hours, so withdrawal effects may be less pronounced in this population 4, 5
• Patients with urinary retention: These patients may actually experience symptom improvement as midodrine is tapered, since the drug increases vesical sphincter tone 6
• Patients with supine hypertension: Tapering may be more rapid in patients who developed this complication, as the primary reason for discontinuation is already present 5

Common Pitfalls to Avoid

• Abrupt discontinuation: Do not stop midodrine suddenly, especially in patients who have been on higher doses (10 mg three times daily) or long-term therapy 1
• Inadequate monitoring: Failure to monitor blood pressure during tapering may result in unrecognized severe orthostatic hypotension 5
• Ignoring the reason for discontinuation: If stopping due to adverse effects like supine hypertension or urinary retention, faster tapering may be appropriate while still monitoring for withdrawal 5, 6