What Is Midodrine Used For?

Midodrine is a prescription medication that raises blood pressure by tightening (constricting) blood vessels. It’s a prodrug that converts in the body to desglymidodrine, an active compound that stimulates peripheral alpha-1 adrenergic receptors. Midodrine has two main, evidence-based uses:

1. Neurogenic Orthostatic Hypotension (NOH)
2. Type 1 Hepatorenal Syndrome (HRS)

Below is a clear overview of how midodrine works, when it’s prescribed, key study findings, dosing guidelines, side effects, precautions, and when to seek medical help. You may also consider a free, online symptom check for low blood pressure symptoms.

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How Midodrine Works

• After oral ingestion, midodrine is converted by enzymes into desglymidodrine.
• Desglymidodrine binds to α₁-adrenergic receptors on small arteries and veins.
• Activation of these receptors causes blood vessels to narrow, increasing vascular tone and raising blood pressure.
• The effect typically begins within 30 minutes, peaks at about 1 hour, and lasts 3–4 hours.

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Main Uses

1. Neurogenic Orthostatic Hypotension (NOH)

• Definition: A chronic drop in blood pressure upon standing, due to malfunction of the autonomic (nervous) system.
• Symptoms: Dizziness, lightheadedness, fainting, weakness, fatigue when upright.
• Key Study:
  • Low PA et al. (1997) conducted a randomized, placebo-controlled trial in patients with NOH (Mayo Clin Proc, PMID 9289076).
  • Midodrine significantly improved standing blood pressure and reduced symptoms compared to placebo.
• Clinical Benefit: Increases systolic blood pressure by 15–20 mm Hg, reducing dizziness and fainting episodes.

2. Type 1 Hepatorenal Syndrome (HRS)

• Definition: Rapidly progressive kidney failure in patients with advanced liver disease (often cirrhosis) and portal hypertension.
• Combination Therapy: Midodrine is used with octreotide (a vasoconstrictor that reduces portal blood flow) plus intravenous albumin.
• Key Study:
  • Sanyal AJ et al. (2008) randomized patients with type 1 HRS to midodrine + octreotide + albumin vs. placebo + octreotide + albumin (J Hepatol, PMID 19185944).
  • Results showed improved renal function and higher survival at 30 days in the midodrine group.
• Guideline Endorsement:
  • The 2018 EASL Clinical Practice Guidelines (J Hepatol, PMID 30496478) recommend midodrine plus octreotide and albumin as a first-line pharmacologic approach for HRS type 1 when liver transplantation isn’t immediately available.

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Dosing and Administration

• Neurogenic Orthostatic Hypotension
  • Typical starting dose: 2.5 mg orally three times daily (before rising, midday, late afternoon).
  • May increase up to 10 mg three times daily based on response and tolerability.
• Hepatorenal Syndrome
  • Common regimen: 7.5 mg orally three times daily, titrated to effect (often up to 12.5 mg three times daily).
  • Always co-administer with octreotide (subcutaneous) and albumin infusions per protocol.
• General Tips
  • Avoid dosing within 4 hours of bedtime to reduce supine hypertension risk.
  • Take with a glass of water; can be taken with or without food.

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Common Side Effects

Most side effects stem from increased vascular tone or excess vasoconstriction:

• Supine (lying down) hypertension
• Piloerection (“goosebumps”)
• Scalp tingling or itching
• Urinary retention or difficulty urinating
• Chills
• Gastrointestinal discomfort

If any side effect is severe, persistent, or life-threatening (e.g., very high blood pressure, chest pain, severe headache), speak to a doctor immediately.

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Precautions and Interactions

• Contraindications:
  • Severe organic heart disease (e.g., ventricular tachycardia, heart block)
  • Acute kidney injury without HRS protocol
  • Supine hypertension (resting systolic BP consistently > 180 mm Hg)
• Use with Caution:
  • Elderly patients (higher supine hypertension risk)
  • Pregnancy and breastfeeding (safety not fully established)
  • Chronic kidney disease (dose adjustment may be needed)
• Drug Interactions:
  • Other vasoconstrictors (additive hypertension)
  • Alpha-blockers (antagonistic effect)
  • Cardiac glycosides (monitor for arrhythmias)
• Monitoring:
  • Regular blood pressure checks sitting, standing, and supine
  • Kidney and liver function tests, especially in HRS protocols

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When to Seek Medical Advice

• New or worsening chest pain, palpitations, severe headache, or blurred vision
• Persistent supine hypertension (systolic BP > 180 mm Hg)
• Signs of organ dysfunction (confusion, decreased urine output, swelling)
• Any allergic reaction (rash, itching, difficulty breathing)
• Recurrence of fainting or dizziness despite treatment

If you experience any serious or life-threatening symptoms, immediately speak to a doctor or visit an emergency department.

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Note: This overview is informative but not a substitute for professional medical advice. If you suspect orthostatic hypotension or hepatorenal syndrome, or if you have any questions about midodrine, always consult your healthcare provider. You may also start with a free, online symptom check for guidance on your symptoms.