α1 adrenergic agonist Pregnancy: No data from use in pregnant women; animal studies have shown reproductive toxicity at maternally toxic doses. Not recommended during pregnancy or in women of childbearing potential not using contraception. Should not be used during breastfeeding (excretion in human milk unknown; risk to newborns/infants cannot be excluded).

Midodrine hydrochloride

Brand names: Bramox

Used in: Syncope

Midodrine hydrochloride is an orally active alpha-1 adrenoceptor agonist used to treat severe orthostatic hypotension when non-pharmacological measures and other treatments are insufficient.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Initial dose 2.5 mg three times a day; depending on supine and standing blood pressure recordings this may be increased weekly up to 10 mg three times a day, which is the usual maintenance dosage.

Route: Oral

Frequency: Three times a day; the last daily dose should be taken at least 4 hours before bedtime to prevent supine hypertension

Source: Bramox 10 mg tablets SPC §4.2. A careful evaluation of the response to treatment and of the overall balance of expected benefits and risks is needed before any dose increase and before advising continuation for long periods. 10 mg tablets may be taken with food. Regular monitoring of supine and standing blood pressure is necessary; if supine hypertension is not overcome by reducing the dose, treatment must be stopped. Elderly: limited dosing data and no specific dose-reduction studies — cautious dose titration is recommended. Hepatic impairment: no specific studies in this population. Paediatric population: safety and efficacy of midodrine in children have not been established; no data are available (SPC §4.2; US label agrees — 'Dosing in children has not been adequately studied').

Dose adjustments

Renal

No specific studies on dose reduction in renal impairment; midodrine is contraindicated in acute renal impairment and severe renal impairment (creatinine clearance less than 30 ml/min) (SPC §4.2/§4.3).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Severe organic heart disease (e.g. bradycardia, heart attack, congestive heart failure, cardiac conduction disturbances or aortic aneurysm)
Hypertension
Serious obliterative blood vessel disease, cerebrovascular occlusions and vessel spasms
Acute kidney disease; severe renal impairment (creatinine clearance less than 30 ml/min)
Serious prostate disorder; urinary retention
Proliferative diabetic retinopathy
Phaeochromocytoma; hyperthyroidism
Narrow angle glaucoma
Hypersensitivity to the active substance or to any of the excipients

Side effects

Very common: piloerection (goosebumps), pruritus of the scalp, dysuria
Paraesthesia, paraesthesia of the scalp, headache
Supine hypertension (dose-dependent effect)
Reflex bradycardia; tachycardia, palpitations
Nausea, dyspepsia, stomatitis; urinary retention, urinary urgency

Interactions

Sympathomimetics and other vasoconstrictive substances (reserpine, guanethidine, tricyclic antidepressants, antihistamines, thyroid hormones, MAO inhibitors, including non-prescription products) — avoid; a pronounced increase in blood pressure may occur (SPC §4.5)
Alpha-adrenergic antagonists such as prazosin and phentolamine — block the effect of midodrine (SPC §4.5)
Heart-rate-reducing drugs, including cardiac glycosides (e.g. digitalis preparations) — monitoring recommended; slowing of heart rate may occur via vagal reflex (SPC §4.4/§4.5)

Clinical monograph

How it works

Its active metabolite desglymidodrine stimulates peripheral alpha-1 adrenoceptors, causing arterial and venous constriction that raises standing blood pressure.

Prescribing in practice

Supine (lying) hypertension is the key hazard, so the last dose of the day should be taken several hours before lying down and patients should avoid dosing before bed.
It is contraindicated in severe organic heart disease, urinary retention, phaeochromocytoma and significant hypertension.
Doses are timed to periods of upright activity, and it should be avoided close to bedtime.

Monitoring

Monitor both standing and supine blood pressure regularly, and reduce or stop treatment if supine hypertension develops.

Counselling the patient

Take your doses when you will be up and about, and not within a few hours of lying down or going to bed.
Raise the head of your bed and report headache, pounding in the head or blurred vision when lying down.
Tingling or goose bumps of the scalp and skin are common and harmless.

Evidence & guidelines

Midodrine is an established option in specialist management of symptomatic orthostatic hypotension where conservative measures and fludrocortisone are inadequate, as reflected in current prescribing references.

Reference: NICE; SmPC; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Pathways