Midodrine

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# Black Box Warning

# Overview
Midodrine is an alpha-adrenergic agonist that is FDA approved for the {{{indicationType}}} of symptomatic orthostatic hypotension. There is a Black Box Warning for this drug as shown here.  Common adverse reactions include hypertension, piloerection, pruritus, shivering, paresthesia, dysuria, urinary retention, and urinary frequency.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH). Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion and lifestyle alterations. The indication is based on midodrine hydrochloride tablet's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit. At present, however, clinical benefits of midodrine hydrochloride tablets, principally improved ability to perform life activities, have not been established. Further clinical trials are underway to verify and describe the clinical benefits of midodrine hydrochloride tablets.
- After initiation of treatment, midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement.
- Dosing Information
- 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.). Doses may be given in 3-hour intervals, if required, to control symptoms, but not more frequently.
- Single doses as high as 20 mg have been given to patients, but severe and persistent systolic supine hypertension occurs at a high rate (about 45%) at this dose. 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. Total daily doses greater than 30 mg have been tolerated by some patients, but their safety and usefulness have not been studied systematically or established. Because of the risk of supine hypertension, midodrine hydrochloride tablets should be continued only in patients who appear to attain symptomatic improvement during initial treatment.
- The supine and standing blood pressure should be monitored regularly and the administration of midodrine hydrochloride tablets should be stopped if supine blood pressure increases excessively.
- Because desglymidodrine is excreted renally, dosing in patients with abnormal renal function should be cautious; although this has not been systematically studied, it is recommended that treatment of these patients be initiated using 2.5 mg doses.
- Blood levels of midodrine and desglymidodrine were similar when comparing levels in patients 65 or older vs. younger than 65 and when comparing males vs. females, suggesting dose modifications for these groups are not necessary.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Midodrine in adult patients.

### NonGuideline-Supported Use
- Dosing Information
- Midodrine up to 15 mg 3 times daily was used to treat severely symptomatic neurocardiogenic syncope.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- Safety and effectiveness in pediatric patients have not been established.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Midodrine in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Midodrine in pediatric patients.

# Contraindications
- Severe organic heart disease
- Acute renal disease
- Urinary retention
- Pheochromocytoma
- Thyrotoxicosis
- Persistent and excessive supine hypertension

# Warnings
- Supine Hypertension
- The most potentially serious adverse reaction associated with midodrine hydrochloride therapy is marked elevation of supine arterial blood pressure (supine hypertension). Systolic pressure of about 200 mmHg was seen overall in about 13.4% of patients given 10 mg of midodrine hydrochloride. Systolic elevations of this degree were most likely to be observed in patients with relatively elevated pre-treatment systolic blood pressures (mean 170 mmHg). There is no experience in patients with initial supine systolic pressure above 180 mmHg, as those patients were excluded from the clinical trials. Use of midodrine hydrochloride in such patients is not recommended. Sitting blood pressures were also elevated by midodrine hydrochloride therapy. It is essential to monitor supine and sitting blood pressures in patients maintained on midodrine hydrochloride.

### Precautions
- The potential for supine and sitting hypertension should be evaluated at the beginning of midodrine hydrochloride therapy. Supine hypertension can often be controlled by preventing the patient from becoming fully supine, i.e., sleeping with the head of the bed elevated. The patient should be cautioned to report symptoms of supine hypertension immediately. Symptoms may include cardiac awareness, pounding in the ears, headache, blurred vision, etc.
- The patient should be advised to discontinue the medication immediately if supine hypertension persists. Blood pressure should be monitored carefully when midodrine hydrochloride is used concomitantly with other agents that cause vasoconstriction, such as phenylephrine, ephedrine, dihydroergotamine, phenylpropanolamine or pseudoephedrine.
- A slight slowing of the heart rate may occur after administration of midodrine hydrochloride, primarily due to vagal reflex. Caution should be exercised when midodrine hydrochloride is used concomitantly with cardiac glycosides (such as digitalis), psychopharmacologic agents, beta blockers or other agents that directly or indirectly reduce heart rate. Patients who experience any signs or symptoms suggesting bradycardia (pulse slowing, increased dizziness, syncope, cardiac awareness) should be advised to discontinue midodrine hydrochloride and should be re-evaluated.
- Midodrine hydrochloride should be used cautiously in patients with urinary retention problems, as desglymidodrine acts on the alpha-adrenergic receptors of the bladder neck.
- Midodrine hydrochloride should be used with caution in orthostatic hypotensive patients who are also diabetic, as well as those with a history of visual problems who are also taking fludrocortisone acetate, which is known to cause an increase in intraocular pressure and glaucoma.
- Midodrine hydrochloride use has not been studied in patients with renal impairment. Because desglymidodrine is eliminated via the kidneys and higher blood levels would be expected in such patients, midodrine hydrochloride should be used with caution in patients with renal impairment, with a starting dose of 2.5 mg. Renal function should be assessed prior to initial use of midodrine hydrochloride.
- Midodrine hydrochloride use has not been studied in patients with hepatic impairment. Midodrine hydrochloride should be used with caution in patients with hepatic impairment, as the liver has a role in the metabolism of midodrine.
- Laboratory Tests
- Since desglymidodrine is eliminated by the kidneys and the liver has a role in its metabolism, evaluation of the patient should include assessment of renal and hepatic function prior to initiating therapy and subsequently, as appropriate.

# Adverse Reactions

## Clinical Trials Experience
- The most frequent adverse reactions seen in controlled trials were supine and sitting hypertension; paresthesia and pruritus, mainly of the scalp; goosebumps; chills; urinary urge; urinary retention and urinary frequency.
- The frequency of these events in a 3-week placebo-controlled trial is shown in the following table:
- Less frequent adverse reactions were headache; feeling of pressure/fullness in the head; vasodilation/flushing face; confusion/thinking abnormality; dry mouth; nervousness/anxiety and rash. Other adverse reactions that occurred rarely were visual field defect; dizziness; skin hyperesthesia; insomnia; somnolence; erythema multiforme; canker sore; dry skin; dysuria; impaired urination; asthenia; backache; pyrosis; nausea; gastrointestinal distress; flatulence; and leg cramps.
- The most potentially serious adverse reaction associated with midodrine hydrochloride therapy is supine hypertension. The feelings of paresthesia, pruritus, piloerection and chills are pilomotor reactions associated with the action of midodrine on the alpha-adrenergic receptors of the hair follicles. Feelings of urinary urgency, urinary retention and urinary frequency are associated with the action of midodrine on the alpha-receptors of the bladder neck.

## Postmarketing Experience
There is limited information regarding Postmarketing Experience of Midodrine in the drug label.

# Drug Interactions
- When administered concomitantly with midodrine hydrochloride, cardiac glycosides may enhance or precipitate bradycardia, AV block or arrhythmia.
- The use of drugs that stimulate alpha-adrenergic receptors (e.g., phenylephrine, pseudoephedrine, ephedrine, phenylpropanolamine or dihydroergotamine) may enhance or potentiate the pressor effects of midodrine hydrochloride. Therefore, caution should be used when midodrine hydrochloride is administered concomitantly with agents that cause vasoconstriction.
- Midodrine hydrochloride has been used in patients concomitantly treated with salt-retaining steroid therapy (i.e., fludrocortisone acetate), with or without salt supplementation. The potential for supine hypertension should be carefully monitored in these patients and may be minimized by either reducing the dose of fludrocortisone acetate or decreasing the salt intake prior to initiation of treatment with midodrine hydrochloride. Alpha-adrenergic blocking agents, such as prazosin, terazosin and doxazosin, can antagonize the effects of midodrine hydrochloride.
- It appears possible, although there is no supporting experimental evidence, that the high renal clearance of desglymidodrine (a base) is due to active tubular secretion by the base-secreting system also responsible for the secretion of such drugs as metformin, cimetidine, ranitidine, procainamide, triamterene, flecainide, and quinidine. Thus there may be a potential for drug-drug interaction with these drugs.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):
- Pregnancy Category C
- Midodrine hydrochloride increased the rate of embryo resorption, reduced fetal body weight in rats and rabbits and decreased fetal survival in rabbits when given in doses 13 (rat) and 7 (rabbit) times the maximum human dose based on body surface area (mg/m2). There are no adequate and well-controlled studies in pregnant women. Midodrine hydrochloride should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. No teratogenic effects have been observed in studies in rats and rabbits.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Midodrine in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Midodrine during labor and delivery.

### Nursing Mothers
- It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when midodrine hydrochloride is administered to a nursing woman.

### Pediatric Use
- Safety and effectiveness in pediatric patients have not been established.

### Geriatic Use
There is no FDA guidance on the use of Midodrine with respect to geriatric patients.

### Gender
There is no FDA guidance on the use of Midodrine with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Midodrine with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Midodrine in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Midodrine in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Midodrine in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Midodrine in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Oral

### Monitoring
- The supine and standing blood pressure should be monitored regularly and the administration of midodrine hydrochloride tablets should be stopped if supine blood pressure increases excessively.

# IV Compatibility
There is limited information regarding IV Compatibility of Midodrine in the drug label.

# Overdosage

## Acute Overdose

### Signs and Symptoms
- Symptoms of overdose could include hypertension, piloerection (goosebumps), a sensation of coldness and urinary retention. There are 2 reported cases of overdosage with midodrine hydrochloride, both in young males. One patient ingested midodrine hydrochloride drops, 250 mg, experienced systolic blood pressure greater than 200 mmHg, was treated with an IV injection of 20 mg of phentolamine and was discharged the same night without any complaints.
- The other patient ingested 205 mg of midodrine hydrochloride (41 5-mg tablets) and was found lethargic and unable to talk, unresponsive to voice but responsive to painful stimuli, hypertensive and bradycardic. Gastric lavage was performed and the patient recovered fully by the next day without sequelae. The single doses that would be associated with symptoms of overdosage or would be potentially life-threatening are unknown. The oral LD50 is approximately 30 mg/kg to 50 mg/kg in rats, 675 mg/kg in mice and 125 mg/kg to 160 mg/kg in dogs.

### Management
- Desglymidodrine is dialyzable.
- Recommended general treatment, based on the pharmacology of the drug, includes induced emesis and administration of alpha-sympatholytic drugs (e.g., phentolamine).

## Chronic Overdose
There is limited information regarding Chronic Overdose of Midodrine in the drug label.

# Pharmacology

## Mechanism of Action
- Midodrine hydrochloride forms an active metabolite, desglymidodrine, that is an alpha1-agonist and exerts its actions via activation of the alpha-adrenergic receptors of the arteriolar and venous vasculature, producing an increase in vascular tone and elevation of blood pressure. Desglymidodrine does not stimulate cardiac beta-adrenergic receptors. Desglymidodrine diffuses poorly across the blood-brain barrier and is therefore not associated with effects on the central nervous system.
- Administration of midodrine hydrochloride results in a rise in standing, sitting and supine systolic and diastolic blood pressure in patients with orthostatic hypotension of various etiologies. Standing systolic blood pressure is elevated by approximately 15 mmHg to 30 mmHg at 1 hour after a 10 mg dose of midodrine, with some effect persisting for 2 to 3 hours. Midodrine hydrochloride has no clinically significant effect on standing or supine pulse rates in patients with autonomic failure.

## Structure
- Midodrine hydrochloride is a vasopressor/antihypotensive agent. Midodrine hydrochloride is an odorless, white, crystalline powder, soluble in water and sparingly soluble in methanol having a pKa of 7.8 (0.3% aqueous solution), a pH of 3.5 to 5.5 (5% aqueous solution) and a melting range of 200C to 203C. It is chemically described as: (1) Acetamide, 2-amino-N--monohydrochloride, ()-; or (2) ()-2-amino-N-(-hydroxy-2,5-dimethoxyphenethyl)acetamide monohydrochloride. Midodrine Hydrochlorides molecular formula is C12H18N2O4HCl, its molecular weight is 290.7 and its structural formula is:
- Each tablet for oral administration contains 2.5 mg, 5 mg or 10 mg of midodrine hydrochloride and the following inactive ingredients: pregelatinized starch (corn starch), microcrystalline cellulose, colloidal silicon dioxide, magnesium stearate. In addition, the 5 mg tablets contain FD&C yellow No. 6 aluminum lake and FD&C red No. 40 aluminum lake and the 10 mg tablets contain FD&C blue No. 2 aluminum lake.

## Pharmacodynamics
- Thorough metabolic studies have not been conducted, but it appears that deglycination of midodrine to desglymidodrine takes place in many tissues and both compounds are metabolized in part by the liver. Neither midodrine nor desglymidodrine is a substrate for monoamine oxidase. Renal elimination of midodrine is insignificant. The renal clearance of desglymidodrine is of the order of 385 mL/minute, most, about 80%, by active renal secretion. The actual mechanism of active secretion has not been studied, but it is possible that it occurs by the base-secreting pathway responsible for the secretion of several other drugs that are bases

## Pharmacokinetics
- Midodrine hydrochloride is a prodrug, i.e., the therapeutic effect of orally administered midodrine is due to the major metabolite desglymidodrine, formed by deglycination of midodrine. After oral administration, midodrine hydrochloride is rapidly absorbed. 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. The absolute bioavailability of midodrine (measured as desglymidodrine) is 93%. The bioavailability of desglymidodrine is not affected by food. Approximately the same amount of desglymidodrine is formed after intravenous and oral administration of midodrine. Neither midodrine nor desglymidodrine is bound to plasma proteins to any significant extent.

## Nonclinical Toxicology
- Carcinogenesis, Mutagenesis, Impairment of Fertility
- Long-term studies have been conducted in rats and mice at dosages of 3 to 4 times the maximum recommended daily human dose on a mg/m2 basis, with no indication of carcinogenic effects related to midodrine hydrochloride. Studies investigating the mutagenic potential of midodrine hydrochloride revealed no evidence of mutagenicity. Other than the dominant lethal assay in male mice, where no impairment of fertility was observed, there have been no studies on the effects of midodrine hydrochloride on fertility.

# Clinical Studies
- 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.
- Patients with pre-existing sustained supine hypertension above 180/110 mmHg were routinely excluded. 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 (blood pressures were not measured at other times) for all 3 weeks. After week 1, midodrine-treated patients had small improvements in dizziness/ lightheadedness/unsteadiness scores and global evaluations, but these effects were made difficult to interpret by a high early drop-out rate (about 25% vs 5% on placebo). Supine and sitting blood pressure rose 16/8 mmHg and 20/10 mmHg, respectively, on average.
- In a 2-day study, after open-label midodrine, known midodrine responders received midodrine 10 mg or placebo at 0, 3 and 6 hours. One-minute standing systolic blood pressures were increased 1 hour after each dose by about 15 mmHg and 3 hours after each dose by about 12 mmHg; 3-minute standing pressures were increased also at 1, but not 3, hours after dosing. There were increases in standing time seen intermittently 1 hour after dosing, but not at 3 hours.
- In a 1-day, dose-response trial, single doses of 0 mg, 2.5 mg, 10 mg and 20 mg of midodrine were given to 25 patients. The 10 mg 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. Supine systolic pressure was 200 mmHg in 22% of patients on 10 mg and 45% of patients on 20 mg; elevated pressures often lasted 6 hours or more.

# How Supplied
- Midodrine Hydrochloride Tablets, for oral administration, are available as:
- 2.5 mg: White, round, flat-faced, bevelled edge, debossed E over 40 on one side and bisected on the other side and supplied as:
- 5 mg: Reddish-orange, round, flat-faced, bevelled edge, debossed E over 43 on one side and bisected on the other side and supplied as:
- 10 mg: Blue-grey, round, flat-faced, bevelled edge, debossed, E over 149 on one side and bisected on the other side and supplied as:
- Store at 20 to 25C (68 to 77F) .
- Dispense contents in a tight, light-resistant container as defined in the USP with a child-resistant closure, as required.

## Storage
There is limited information regarding Midodrine Storage in the drug label.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Patients should be told that certain agents in over-the-counter products, such as cold remedies and diet aids, can elevate blood pressure and therefore, should be used cautiously with midodrine hydrochloride, as they may enhance or potentiate the pressor effects of midodrine hydrochloride. Patients should also be made aware of the possibility of supine hypertension. They should be told to avoid taking their dose if they are to be supine for any length of time, i.e., they should take their last daily dose of midodrine hydrochloride 3 to 4 hours before bedtime to minimize nighttime supine hypertension.

# Precautions with Alcohol
- Alcohol-Midodrine interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- Proamatine
- Orvaten

# Look-Alike Drug Names
- Midodrine   Midrin

# Drug Shortage Status

# Price