From the Guidelines
Midodrine is primarily indicated for the treatment of symptomatic orthostatic hypotension in patients who have not responded adequately to lifestyle modifications. The typical dosing regimen starts at 2.5 mg three times daily, with doses taken upon waking, at midday, and in the mid-afternoon (no later than 6 PM to avoid supine hypertension while sleeping) 1. It is particularly useful for patients with neurogenic orthostatic hypotension from conditions like autonomic failure, multiple system atrophy, or diabetic neuropathy. The dose may be titrated up to 10 mg three times daily based on standing blood pressure response. Midodrine works as an alpha-1 adrenergic agonist that causes peripheral vasoconstriction, thereby increasing blood pressure and reducing symptoms of dizziness, lightheadedness, and syncope upon standing. Important precautions include avoiding use in patients with severe cardiac disease, acute kidney injury, urinary retention, pheochromocytoma, or thyrotoxicosis. Blood pressure should be monitored regularly, especially when initiating therapy or adjusting doses, to prevent supine hypertension, which is the most significant adverse effect. According to the 2017 ACC/AHA/HRS guideline, midodrine is reasonable in patients with recurrent vasovagal syncope with no history of hypertension, heart failure, or urinary retention 1. Additionally, the European Heart Journal guidelines suggest that midodrine should be administered as adjunctive therapy if needed for the treatment of orthostatic hypotension 1. Some key points to consider when prescribing midodrine include:
- Monitoring blood pressure regularly to prevent supine hypertension
- Avoiding use in patients with certain medical conditions, such as severe cardiac disease or urinary retention
- Titration of the dose based on standing blood pressure response
- Education of patients on the importance of gradual staged movements with postural change, mild isotonic exercise, and physical counter-manoeuvres to minimize postural symptoms.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The primary indication for midodrine is the treatment of symptomatic orthostatic hypotension (OH).
- The use of midodrine is recommended for patients whose lives are considerably impaired despite standard clinical care.
- Midodrine should be continued only for patients who report significant symptomatic improvement 2
From the Research
Indication for Midodrine
- Midodrine is indicated for the treatment of orthostatic hypotension, a condition characterized by a significant drop in blood pressure when standing up from a sitting or lying down position 3, 4, 5, 6.
- The drug is effective in increasing standing blood pressure and improving symptoms of orthostatic hypotension, such as dizziness, lightheadedness, and syncope 3, 4, 5.
- Midodrine is also useful in the management of orthostatic hypotension due to autonomic failure, but its effectiveness may vary depending on the preservation of autonomic reflexes 6.
Clinical Benefits
- Midodrine has been shown to be clinically effective in reducing the time to syncopal symptoms or near-syncope in patients with severe symptomatic orthostatic hypotension 5.
- The drug is well-tolerated, with common adverse events including piloerection, pruritus, paraesthesias, urinary retention, and chills 3, 4.
- Midodrine is considered a useful therapeutic option for the management of orthostatic hypotension, particularly in conjunction with standard nonpharmacological care 3.
Comparison with Other Treatments
- Midodrine has been compared to other treatments for orthostatic hypotension, including dihydroergotamine mesylate, norfenefrine, fludrocortisone, and etilefrine, and has been shown to be at least as effective as these agents 3, 4.
- However, the choice of treatment may depend on individual patient factors and the underlying cause of orthostatic hypotension 7.