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Alpha₁-Adrenergic Agonist (Vasopressor — Oral) Pregnancy: Contraindicated — vasoconstriction may cause placental ischaemia.

Midodrine

Brand names: Bramox, ProAmatine

Adult dose

Dose: Hepatorenal syndrome type 1 (with albumin, when terlipressin not available): 7.5mg three times daily (titrate to 12.5mg TDS if needed). Orthostatic hypotension: 2.5–10mg three times daily (morning, midday, late afternoon — last dose at least 4 hours before bedtime).
Route: Oral
Frequency: Three times daily
Max: 40mg/day
For hepatorenal syndrome (HRS-1): used in combination with octreotide (200 micrograms SC TDS) and albumin (20–40g/day IV) as an alternative when terlipressin unavailable. For orthostatic hypotension: take final dose ≥4 hours before bedtime — supine hypertension risk when lying down.

Paediatric dose

Route: N/A
Frequency: N/A
Max: Seek specialist opinion
Not licensed in children. Limited evidence. Seek specialist opinion.

Dose adjustments

Renal

Use with caution in renal impairment — increased risk of supine hypertension and urinary retention. Avoid if eGFR <30.

Hepatic

Primary use is in hepatic disease. No specific dose reduction; titrate carefully.

Clinical pearls

  • HRS treatment combination: midodrine 7.5–12.5mg TDS + octreotide 200 micrograms SC TDS + albumin 20–40g/day IV — used when terlipressin is unavailable or contraindicated.
  • Terlipressin is superior to midodrine/octreotide for HRS-1 reversal — use terlipressin first-line when available (CONFIRM trial: terlipressin + albumin achieved HRS reversal in 32% vs 17% with placebo).
  • Supine hypertension: a key safety concern — patients must take the last dose at least 4 hours before lying down. Monitor lying and standing BP.
  • Orthostatic hypotension: effective for autonomic failure and dialysis-associated hypotension — different from HRS use.

Contraindications

  • Severe organic heart disease
  • Urinary retention
  • Phaeochromocytoma
  • Thyrotoxicosis
  • Supine hypertension (systolic >180mmHg)
  • Acute renal failure not caused by circulatory dysfunction

Side effects

  • Supine hypertension (most important — do not take within 4 hours of bedtime)
  • Paraesthesia (scalp tingling — common alpha₁ agonist effect)
  • Urinary retention (especially in men with BPH)
  • Pilomotor reactions (goosebumps)
  • Nausea, headache

Interactions

  • Cardiac glycosides (digoxin): additive bradycardia risk (reflex bradycardia from hypertension)
  • Alpha-blockers (doxazosin, tamsulosin): antagonise vasopressor effect
  • Fludrocortisone: additive pressor effect — monitor blood pressure closely
  • MAOIs: severe hypertensive crisis — contraindicated combination

Monitoring

  • Blood pressure (lying and standing — supine hypertension and postural effect)
  • Renal function (creatinine — monitor HRS reversal)
  • Urinary output
  • Heart rate

Reference: BNFc; BNF 90; EASL Cirrhosis Guidelines 2018; CONFIRM Trial (Wong et al, NEJM 2021); SPC Bramox. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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