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Midodrine
General Information
Midodrine's ability to stabilize blood pressure has led to its off-label use in the management of conditions like POTS and orthostatic intolerance, conditions found frequently in people with Long COVID and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), providing a potential avenue for symptom management in these complex and multifaceted conditions.
Dosing Instructions
Please carefully follow your dosing instructions in your RTHM patient dashboard. Midodrine has complicated blood pressure monitoring, so be sure to follow instructions precisely.
Midodrine can lower your heart rate and raise your blood pressure. We recommend checking your blood pressure and heart rate the day before and after a dose change. Your heart rate should be above 60 bpm and your blood pressure should be less than 140/90 for you to proceed with any dose increase.
If you’re on a stable dose of midodrine, check your blood pressure and heart rate at least once a month. Your heart rate should be above 60 bpm and your blood pressure should be less than 140/90.
Midodrine can cause hypertension when lying down, so this medication should not be taken within 4 hours of bedtime. It is not recommended to lie down after taking this medication. If you have to lay down within 4 hours of taking midodrine, we suggest laying with your head raised by 30 degrees, either through a recliner, several pillows, or a wedge pillow. Make sure to check your BP. If your BP is greater than 160/100, you’ll need to sit fully upright.
Please read this treatment guide in its entirety for additional important information.
Best Time to Take Midodrine
  • Midodrine should be taken as directed throughout the day, with the first dose starting when you wake up.
  • The final dose of the day should be taken at least 4 hours before you go to bed. When you lie down after taking midodrine, high blood pressure can occur.
Take With or Without Food
Midodrine can be taken with or without food. If you experience stomach upset when taking your doses, try taking it with a small snack or meal.
What To Do If I Miss a Dose
If you miss a dose, just skip that dose and take your next dose as scheduled. Do not “double-up” the dose. Doses should not be taken within 4 of each other.
Precautions When Starting Midodrine
  • Read the medication guide before you start taking midodrine. If you have any questions, log into the dashboard and message the RTHM Medical Team.
  • Take your midodrine doses at the same times each day.
  • Your mouth may get very dry when taking this medication. Chewing sugarless gum and drinking plenty of water can help.
  • Midodrine can make you drowsy or dizzy. If this occurs, do not drive or operate heavy machinery.
  • If you are having surgery, including dental surgery, let your healthcare provider know you are taking midodrine.
Potential Side Effects
Common side effects seen with midodrine include:
  • Numbness and tingling sensations
  • Goosebumps, chills, shivering or feeling cold
  • Changes in urinary habits like frequency, urgency or mild difficulty urinating
  • Feeling nervous or anxious
  • Headaches
  • Nausea or abdominal pain
  • Dry mouth
  • Difficulty sleeping
  • Cramping of the leg muscles
  • Itching (especially the scalp)
When to Seek Medical Attention
If you experience the following side effects, you should immediately go to your nearest emergency room:
  • Signs of high blood pressure like hypertension (blood pressure over 160/90), pounding in the ears, severe headaches, blurred vision, feeling your heart beat (“cardiac awareness”)
  • Signs of stroke like blurred vision, changes in vision, weakness in one side of the body, trouble speaking or thinking, drooping on one side of the face
  • Irregular or very slow heartbeat
  • New or worsening dizziness and/or fainting
  • New or worsening palpitations
  • Severe chest pain
  • Allergic symptoms like hives, skin rash or anaphylaxis
  • Significant pain with urination or difficulty urinating
Interactions with Midodrine
  • The list of contraindicated medications with midodrine is extensive so you must make sure your healthcare provider and pharmacist are aware of all the medications and supplements you are taking.
  • Do not take any OTC medications for colds, coughs, or allergies without first talking with your doctor as this can increase your blood pressure.
  • It is important to maintain a list of all medications and supplements you take to best inform your healthcare provider and pharmacist to help avoid potential drug interactions.
  • Do not start any new medications or supplements before checking with your healthcare provider and pharmacist.
  • These medications and medication classes should be avoided in those taking midodrine:
    • Mineralocorticoids or corticosteroids
      • Fludrocortisone
      • Prednisone
      • Solumedrol
      • Dexamethasone
    • Digoxin/Digitoxin
    • Inotropics
      • Epinephrine
      • Norepinephrine
      • Dopamine
      • Dobutamine
      • Amiodarone
    • Alpha adrenergic receptor blockers
      • Prazozin (Minipress)
      • Phentolamine (Regitine, OraVerse)
      • Terazosin (Hytrin)
      • Alfuzosin (Uroxatral)
      • Doxazosin (Cardura)
      • Tamsulosin (Flomax)
      • Phenoxybenzamine (Dibenzyline, Dibenyline)
    • Amphetamines or amphetamine like medications
      • Amphetamine salts (Adderall/Adderall XR)
      • Pseudophedrine (Sudafed)
      • Methamphetamine (Desoxyn)
      • Dextroamphetamine (Dexedrine, ProCentra, Zenzedi)
      • Amphetamine (Dynavel, Evekeo)
      • Lisdexamfetamine (Vyvanse)
    • Recreational drugs
      • Methamphetamine (meth, crank, glass, etc)
      • Cocaine (blow, crack, etc)
      • Bath salts
      • MDMA (ecstasy, etc)
    • Monoamine oxidase inhibitors (MAOIs)
      • Methylene blue (Provayblue)
      • Linezolid (Zyvox)
      • Iproniazid (Marsilid, Rivivol, Euphozid, Iprazid)
      • Isocarboxazid (Marplan)
      • Furazolidone (Depandal-M)
      • Moclobemide (Aurorix, Manerix)
      • Phenelzine (Nardil)
      • Pheniprazine (Catron, Cavodil)
      • Procarbazine (Matulane, Natulan, Indicarb)
      • Rasagiline (Azilect)
      • Safinamide (Xadago)
      • Selegiline (Eldepryl, Zelapar, Emsam)
      • Tranylcypromine (Parnate)
    • Tricyclic antidepressants (TCAs)
      • Amitriptyline (Elavil, Vanatrip)
      • Nortriptyline (Aventyl, Pamelor)
      • Imipramine (Tofranil)
      • Doxepin (Sinequan)
      • Amoxapine (Asendin)
      • Trimipramine (Surmontil)
    • Dihydroergotamine (Migranal, DHE 45, Trudhesa)
    • Deslanoside (Cedilanid-D)
    • Ergonovine (Ergomar)
    • Iobenguane I-123 or I-131 (used in imaging and therapy of neuroendocrine tumors)
Who Should Not Take Midodrine
Contraindications associated with the use of midodrine include:
  • Liver disease - may interfere with the metabolism of midodrine
  • Kidney disease - may worsen urinary retention, or worsen kidney function
  • Heart disease, arrhythmias or heart failure
  • High blood pressure, hyperadrenergic POTS, hyperthyroidism, thyrotoxicosis or pheochromocytoma (or otherwise excessive adrenaline, noradrenaline or dopamine) - these disorders put you at risk for severe hypertension, and midodrine can worsen this hypertension
  • Obliterative or spastic vessel disease like Prinzmetal's angina, Buerger's disease, coronary artery spasms - these disorders put you at risk for ischemia or heart attack and midodrine can worsen this by further narrowing blood vessels
  • Urinary retention or serious prostate disorder - midodrine can increase urinary retention and worsen these symptoms
  • Proliferative diabetic retinopathy or narrow angle glaucoma - midodrine can increase intraocular pressure (pressure in the eye), worsening these conditions
  • Allergy to midodrine or other alpha-1 receptor agonists like apraclonidine, epinephrine, methoxamine, norepinephrine, oxymetazoline, phenylephrine, pseudoephedrine, tetryzoline or xylometazoline.
What If I Become Pregnant While Taking This Medication?
Midodrine is marked as an FDA pregnancy category C, meaning that a risk to the fetus cannot be ruled out. Inform your OB/GYN and primary care provider if you become pregnant while on midodrine.
Medication Storage
  • Keep this medication in the container provided by the pharmacy. Ensure it is properly closed and out of the reach of children. Store at room temperature and away from excess heat, direct light, and moisture (not in the bathroom).
  • Do not share this medication with anyone else.
  • Do not throw away unwanted or expired medications. Do not flush down the toilet or pour down the drain. Ask your local pharmacist about local drug take back programs to discard your medication
Questions?
If you have questions about this medication, please contact us by using our support form. We generally respond within 2 business days. If you have a more urgent issue, please seek care from your local primary care provider, urgent care or emergency services.
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