Midodrine for Liver Cirrhosis and Intradylatic Hypotension: 7 things you should know

1. What is midodrine?
Midodrine is a pro-drug that classes in adrenergic and dopaminergic cardiac stimulants
excluding glycoside that widely used in the therapy of intradylatic hypotension and
recently been show can be used for liver cirrhosis patient with ascites.1
2. How it works for for liver cirrhosis and intradylatic hypotension

Cirrhosis is the end result for most chronic liver diseases and ascites is the most
common complication of cirrhosis.2 The therapeutic options available for patients with
ascites are serial therapeutic paracentesis, liver transplantation, transjagular intrahepatic
portosystemic shunts (TIPS), and peritoneovenous shunt.2

Intradylatic hypotension (IDH) is a clinical problem encountered in renal dialysis units

and is observed in patients with end stage renal failure (ESRF) on maintenance
hemodialysis.3 The general consensus is though, that it is best defined as a systolic
blood pressure of <100 mmHg, or a blood pressure drop of more than 20 mmHg with
symptoms.3

IDH also associated with increasing mortality rate, decreased quality of life, loss of
vascular access and also myocardial infarction. Finally, it can lead to dialysis
inadequacy because of unavoidable condition during that process like symptoms of
dizziness, fatigue cramps and blurred vision which can be debilitating.3

So here is the role of midodrine which can help for this condition and can been used in
the treatment of ascites and IDH. Studies showed systolic and diastolic blood pressures
to be higher during midodrine treatment post-dialysis and therapeutic paracentesis.4
 Midodrine also help to reduce fluid drained in ascites patient. So this can help dialysis
can be done smoothly and frequency of paracentesis procedures can be reduced.4

3. Upsides
 Orally administered.5
 Does not cross the blood brain barrier thereby minimizing neurological and
cardiovascular effects.2
4. Downsides
 Special precaution to patient with severe organic heart disease (e.g. bradycardia,
ischaemic heart disease, CHF), acute renal failure, urinary retention,
phaeochromocytoma, thyrotoxicosis, persistent and excessive supine HTN.5

This is one of the Midodrine HCL that

is available by brand named Jolavi and
manufactured by Jolly Healthcare and
its USFDA Compliant.

5. Tips
 Should be taken with food.5
6. Response and Effectiveness
 Peak levels of the active metabolite in serum are achieved in 1 hour and its half-
life is 3 hours.2
7. Interactions
Other medicines that possibly interact with midodrine may either decrease its effect,
affect how long it works for, increase side effects, or have less of an effect when taken
with midodrine. If there is any interaction between two or more medication you take, it
does not mean you must stop taking one of them, however, sometimes it does. You can
speak and discuss with your doctor about how it should be managed.

Common medications that may interact with midodrine include:5

 Enhanced pressor effects with α-adrenergic agonists (e.g. phenylephrine,
ephedrine, dihydroergotamine, phenylpropanolamine, pseudoephedrine).
 Reduced effect with α-adrenergic blockers (e.g. prazosin, terazosin, doxazosin).
 May precipitate bradycardia, AV block, or arrhythmia w/ cardiac glycosides.
FAQ

1. What is midodrine?
 Midodrine works by constricting (narrowing) the blood vessels and increasing
blood pressure.
2. How should I take midodrine?
 Follow all directions on your prescription label.
 Do not take this medicine in larger or smaller amounts or for longer than
recommended.
3. What happayens if I miss a dose?
 Take the missed dose as soon as you remember. Skip the missed dose if it is almost
time for your next scheduled dose. Do not take extra medicine to make up the
missed dose.
4. What happens if I overdose?
 Seek emergency medical attention
 Symptoms of a midodrine overdose may include increased blood pressure (flushing,
headache, pounding heartbeat, blurred vision), goosebumps, feeling cold, or trouble
urinating.
5. What should I avoid while taking midodrine?
 Avoid taking a dose within less than 3 hours before your normal bedtime.
 Ask your doctor or pharmacist before using any over-the-counter diet pills, or
cough/cold medicine that contains phenylephrine or pseudoephedrine. These
medicines may raise your blood pressure.
6. Midodrine side effects?

More common Rare

Blurred vision Fainting
Cardiac awareness Increased dizziness
Headache
Slow pulse
Pounding in the ears

7. What other drugs will affect midodrine?

Taking midodrine with other drugs that constrict blood vessels can further increase your
blood pressure. Tell your doctor about all your current medicines and any you start or
stop using, especially:
 digoxin, digitalis, droxidopa, fludrocortisone
 an antidepressant
 asthma medicine
 heart or blood pressure medicine
 migraine headache medicine
 thyroid medicine such as levothyroid or Synthroid
 drugs to treat high blood pressure or a prostate disorde-prazosin, terazosin, or
doxazosin
 an MAO inhibitor-isocarboxazid, linezolid, methylene blue injection,
phenelzine, rasagiline, selegiline, tranylcypromine.
Refference

1. Wells BG, Dipiro JT, Schwinghammer TL, Dipiro CV. Pharmacoterapy handbook. 7th ed. New
York: McGraw-Hill; 2009. p. 72-73
2. Obiedallah AA, Abdelmohsen E, Kelani AI, Mousa M. Effect of midodrine in patients
with liver cirrhosis and refractory ascites. American Journal of Internal Medicine. 2017;
5(1): 12-17. Available from
http://www.sciencepublishinggroup.com/journal/paperinfo?journalid=252&doi=10.11
648/j.ajim.20170501.13
3. Srinivasa V. A review of midodrine for the treatment of intradialytic hypotension.
International Journal of Nephrology and Kidney Failure. 2019; 5(1): 1-3. Available
from https://www.sciforschenonline.org/journals/nephrology-kidney/article-
data/IJNKF169/IJNKF169.pdf
4. Beneficial effect of midodrine in hypotensive cirrhotic patients with refractory ascites.
Gastroenterology & Hepatology. 2011; 7(2) 132-134. Available from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3061020/pdf/GH-07-
132.pdf/?tool=EBI
5. MIMS. Midodrine. Available from
https://mims.com/india/drug/info/midodrine?mtype=generic