What medication can be given orally (PO) to increase blood pressure in a patient with hypotension?

From the Guidelines

Midodrine is the most effective oral medication to increase blood pressure in patients with neurogenic orthostatic hypotension, typically starting at 2.5-5mg three times daily 1. When considering medications to increase blood pressure, it's essential to weigh the benefits and risks of each option.

• Midodrine improves symptoms of OH in patients with neurogenic OH, with a dose-dependent effect, usually corresponding to an increase in standing blood pressure 1.
• Droxidopa is another option, which improves symptoms of neurogenic OH due to Parkinson disease, pure autonomic failure, and multiple system atrophy 1.
• Fludrocortisone increases plasma volume, with a resultant improvement in symptoms of OH, but its use may be limited by supine hypertension 1. These medications should be taken consistently and titrated gradually under medical supervision to achieve the desired blood pressure response while minimizing side effects.
• Lifestyle modifications, such as adequate hydration, increased salt intake (unless contraindicated), compression stockings, and avoiding rapid position changes, should accompany medication therapy 1.
• Blood pressure should be monitored regularly, both sitting and standing, to assess medication effectiveness 1. It's crucial to individualize treatment based on the underlying cause of hypotension and patient-specific factors, and to consider the potential side effects and limitations of each medication 1.

From the FDA Drug Label

The plasma levels of the prodrug peak after about half an hour, and decline with a half-life of approximately 25 minutes, while the metabolite reaches peak blood concentrations about 1 to 2 hours after a dose of midodrine and has a half-life of about 3 to 4 hours. Midodrine has been studied in 3 principal controlled trials, one of 3-weeks duration and 2 of 1 to 2 days duration. All studies were randomized, double-blind and parallel-design trials in patients with orthostatic hypotension of any etiology and supine-to-standing fall of systolic blood pressure of at least 15 mmHg accompanied by at least moderate dizziness/lightheadedness In a 3-week study in 170 patients, most previously untreated with midodrine, the midodrine-treated patients (10 mg t.i.d., with the last dose not later than 6 P.M.) had significantly higher (by about 20 mmHg) 1-minute standing systolic pressure 1 hour after dosing In a 1-day, dose-response trial, single doses of 0,2. 5,10 and 20 mg of midodrine were given to 25 patients. The 10 and 20 mg doses produced increases in standing 1-minute systolic pressure of about 30 mmHg at 1 hour; the increase was sustained in part for 2 hours after 10 mg and 4 hours after 20 mg.

Midodrine (PO) can be used to increase blood pressure in patients with orthostatic hypotension.

• The recommended dose is 10 mg t.i.d., with the last dose not later than 6 P.M.
• Increases in standing systolic blood pressure of about 20 mmHg at 1 hour after dosing have been observed in clinical trials 2.
• Dose-response trials have shown that single doses of 10 and 20 mg of midodrine produce increases in standing 1-minute systolic pressure of about 30 mmHg at 1 hour 2.

From the Research

Medications to Increase Blood Pressure

• Midodrine is a medication that has been shown to increase blood pressure in patients with orthostatic hypotension 3, 4, 5, 6, 7
• It is a prodrug that undergoes enzymatic hydrolysis to form its active metabolite, desglymidodrine, which is a selective alpha 1-adrenoceptor agonist 3, 4
• Midodrine has been found to improve standing systolic blood pressure, standing time, and energy level, and reduce symptoms of orthostatic hypotension such as dizziness, light-headedness, and syncope 3, 4, 5, 6

Efficacy of Midodrine

• Studies have shown that midodrine is effective in increasing blood pressure and improving symptoms in patients with orthostatic hypotension 3, 4, 5, 6
• A systematic review and meta-analysis found that midodrine improved standing systolic blood pressure and reduced symptoms of orthostatic hypotension, but the quality of evidence was limited by imprecision, heterogeneity, and increased risk of bias 7
• Another systematic review found that midodrine improved health-related quality of life, symptom improvement, and syncope recurrence in patients with recurrent reflex syncope and symptomatic orthostatic hypotension 6

Safety of Midodrine

• Midodrine is generally well-tolerated, but common adverse events include piloerection, pruritus, paraesthesias, urinary retention, and chills 3, 4, 5, 6, 7
• The risk of supine hypertension, which is associated with midodrine therapy, can be reduced by taking the final daily dose at least 4 hours before bedtime 3