Alpha₁-Adrenergic Agonist (Vasopressor — Oral) Pregnancy: Not recommended during pregnancy and in women of childbearing potential not using contraception — no data in pregnant women, and animal studies showed reproductive toxicity at maternally toxic doses. Should not be used during breastfeeding (excretion in human milk unknown; risk to newborns/infants cannot be excluded).

Midodrine

Brand names: Bramox, ProAmatine

Used in: Syncope

Midodrine is an orally active alpha-1 adrenergic agonist used to treat severe orthostatic hypotension, and in hepatology it is used off-label as a vasoconstrictor in conditions such as hepatorenal syndrome.

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 the results of supine and standing blood pressure recordings, this dose may be increased weekly up to a dose of 10 mg three times a day, which is the usual maintenance dosage

Route: Oral (for oral use); 2.5 mg tablets may be taken with food

Frequency: Three times a day

Max: The SPC titration ceiling is 10 mg three times a day (stated as the usual maintenance dosage). No separate absolute maximum dose is given in the eMC SPC

A careful evaluation of the response to treatment and of the overall balance of expected benefits and risks must be undertaken before any dose increase and before advising continued therapy for long periods. The last daily dose should be taken at least 4 hours before bedtime in order to prevent supine hypertension; avoid administration in the late evening. Regular monitoring of supine and standing blood pressure is necessary (§4.4). Elderly: limited dosing data and no specific dose-reduction studies — cautious dose titration is recommended. Renal impairment: no specific dose-reduction studies; contraindicated in acute renal impairment and severe renal impairment. Hepatic impairment: no specific studies. Paediatric population: safety and efficacy in children have not been established, no data available. Cross-check only — the US label (Alembic, 2023) recommends a different regimen (10 mg three times daily, with 2.5 mg starting doses recommended in abnormal renal function); the UK SPC regimen above was used.

Dose adjustments

Renal

Contraindicated in acute renal impairment and in severe renal impairment (creatinine clearance less than 30 mL/min). There are no specific studies focused on a possible dose reduction in renal impairment.

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
Pheochromocytoma; hyperthyroidism
Narrow angle glaucoma
Hypersensitivity to the active substance or to any of the excipients

Side effects

Piloerection (goose bumps) and pruritus of the scalp — very common
Dysuria — very common; urinary retention and urinary urgency also reported
Paraesthesia (including paraesthesia of the scalp)
Supine hypertension (dose-dependent effect); reflex bradycardia
Sleep disorders / insomnia; nausea and dyspepsia

Interactions

Sympathomimetics and other vasoconstrictive substances (e.g. reserpine, guanethidine, tricyclic antidepressants, antihistamines, thyroid hormones and MAO inhibitors, including treatments available without prescription) — concomitant treatment should be avoided as a pronounced increase in blood pressure may occur
Alpha-adrenergic antagonists — block the effect of midodrine
Cardiac glycosides (such as digitalis preparations) and other agents that directly or indirectly reduce heart rate — caution with concomitant use; slowing of the heart rate may occur after midodrine due to vagal reflex, so monitor for signs or symptoms of bradycardia (§4.4)

Clinical monograph

How it works

Its active metabolite desglymidodrine stimulates peripheral alpha-1 adrenoceptors, causing arteriolar and venous vasoconstriction that raises peripheral vascular resistance and blood pressure.

Prescribing in practice

It can cause marked supine hypertension, so doses should be avoided shortly before lying down and not given late in the evening.
It is contraindicated in severe organic heart disease, acute kidney disease, phaeochromocytoma and thyrotoxicosis.
Use cautiously with other vasopressors and in urinary retention given its alpha-agonist effects on the bladder neck.

Monitoring

Monitor both supine and standing blood pressure, and review for symptoms of supine hypertension such as headache or visual disturbance.

Counselling the patient

Advise patients not to take a dose just before going to bed and to raise the head of the bed if supine hypertension occurs.
Tell patients to report scalp tingling, goosebumps or urinary difficulty, which are common alpha-agonist effects.

Evidence & guidelines

Midodrine's use in orthostatic hypotension is established, and its role in hepatorenal syndrome reflects specialist hepatology practice rather than a licensed indication.

Reference: EASL Cirrhosis Guidelines 2018; CONFIRM Trial (Wong et al, NEJM 2021); SPC Bramox; 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.

Calculators

Pathways