Midodrine (gutron) is an alpha-1 receptor agonist. It causes vasoconstriction resulting in the elevation of blood pressure.

Midodrine (gutron) Uses:

• Hypotension, symptomatic orthostatic:

  • Treatment of symptomatic orthostatic hypotension.

• Off Label Use of Midodrine in Adults:

  • Refractory Ascites
  • Hepatorenal Syndrome
  • As a vasopressor-sparing drug to treat Hypotension in the ICU
  • For the prevention of hemodialysis-induced Hypotension
  • Vasovagal syncope

Midodrine Dose in Adults:

Note:

• One hour after taking a 10 mg dosage, it may result in a 15–30 mmHg increase in systolic blood pressure.
• The effects may persist for 2 - 3 hours.

Midodrine (gutron) Dose in the treatment of refractory ascites (off-label):

• 5 to 7.5 mg orally, three times a day.

Treatment of hepatorenal syndrome with midodrine (gutron) (off-label):

• At first, it must be given 3 times per day with a dose of 5 to 10 mg, orally 
• To increase the MAP (mean arterial pressure) by a minimum of 15 mm Hg from the baseline, the dosage must be increased to 12.5 mg or 15 mg 3 times per

Treatment of hypotension with midodrine (gutron) dose in the intensive care unit using vasopressor sparing agents:

• At first, it must be given 3 times per day with a dose of 5 to 20 mg, orally 
• Before stopping the intravenous vasopressors, the dosage may be raised incrementally.

Doses of midodrine (gutron) used off-label to counteract hypotension brought on by hemodialysis

• 2.5 to 10 mg orally given 15 - 30 minutes before the start of the dialysis session.

Midodrine (gutron) Dose in the treatment of Hypotension, symptomatic orthostatic:

• 2.5 to 10 milligrams are taken orally three times daily, every three to four hours, while the patient is upright.
• The daily dosage cap is 40 mg.
• Note:
  • To prevent supine hypertension, avoid it at bedtime (at least four hours before bedtime).
  • Patients who develop supine hypertension should discontinue the treatment.

Midodrine (gutron) Dose in the treatment of Vasovagal syncope (off-label):

• If necessary, the dosage can be raised to 15 mg each dose.
• Initially, 2.5 to 10 mg orally thrice per day during morning hours, administered 6hrs apart.

Use in Children:

The drug's effectiveness and safety in children have not been shown.

Pregnancy Risk Factor C

• Its use in pregnancy is not known.
• In animal reproduction studies, however, negative fetal outcomes were found.

Use of midodrine during lactation

• Whether the drug gets released into the breastmilk or not, is not known yet.
• It is recommended that you use it with caution if you are lactating.

Midodrine (gutron) Dose in Kidney Disease:

• Be careful when using it for patients with renal disease.
• Depending on the clinical response, the dose can be increased
• A typical dose is 5mg which is given 3 times per day
• Hemodialysis:
  • Dialyzable

Midodrine (gutron) Dose in Liver disease:

In the manufacturer's labeling dose adjustment has not been provided. Precautions must be taken when using the drug for patients with hepatic disease.

Common Side Effects of Midodrine (gutron):

• Genitourinary:

  • Dysuria
  • Urinary retention
  • Urinary urgency

• Central nervous system:

  • Paresthesia

• Dermatologic:

  • Piloerection
  • Pruritus

• Renal:

  • Polyuria

• Cardiovascular:

  • Supine hypertension

Less Common Side Effects of Midodrine (gutron):

• Central nervous system:

  • Chills
  • Pain

• Gastrointestinal:

  • Abdominal pain

• Dermatologic:

  • Skin rash

Contraindications to Midodrine (gutron):

• Pheochromocytoma
• Urinary retention
• Thyrotoxicosis
• Grave organic heart disease
• Supine hypertension patients
• Hypertension that is not well controlled.
• Acute renal failure

Warnings and precautions

• Bradycardia

  • A vagal reflex may cause Bradycardia. Avoid concurrent administration of beta-blockers or digoxin.
  • Bradycardia must be treated immediately.

• Hypertension:

  • It can cause an increase in both systolic as well as diastolic blood pressure.
  • Supine hypertension is a condition that can be fatal. Patients with a baseline blood pressure of 180 mmHg or more must stop taking the treatment.
  • These patients can benefit from non-pharmacologic treatments, fluid expansion, and compression stockings to avoid hypotension.
  • Concomitant administration with other drugs that cause vasoconstriction such as phenylephrine, ephedrine, phenylpropanolamine, dihydroergotamine, and pseudoephedrine should be avoided.

• Diabetes:

  • Precautions must be taken when used by patients with DM

• Hepatic impairment

  • It should not be used in patients suffering from liver disease.

• Renal impairment

  • The active metabolite, desglymidodrine, is primarily eliminated through the kidneys.
  • Assessing renal function is crucial before beginning therapy.
  • It has not been used to treat renal disease patients.
  • These people ought to start out with a lesser dosage.
  • It should not be used by those with severe renal impairment.

• Visual problems

  • Patients with visual issues, especially those on fludrocortisone, should use it with care.

Midodrine: Drug Interaction

Monitoring parameters:

• Renal function tests.
• Blood pressure while sitting, standing, and supine.
• Liver function tests.

How to administer Midodrine (gutron)?

• It is administered orally. The drug can be administered at three to four-hour intervals.
• It can be administered upon rising in the morning or just shortly before getting out of bed, and at midday.
• To avoid supine hypertension, the medication shouldn't be given after 6 o'clock or within four hours of going to bed.

Mechanism of action of Midodrine (gutron):

• The body creates desglymidodrine, an alpha-1 agonist and active metabolite of midodrine. Alpha-1 receptors are found primarily in vessel walls. It activates the alpha-1 receptors in vessel walls, increasing arteriolar tone and venous tone, which results in an increase in blood pressure.
• Orthostatic hypotension patients may experience an increase in their diastolic and systolic blood pressures when they sit, stand, or supine.

The onset of action:

• About 1 hour

Protein binding:

• It is minimally bound to proteins.

Absorption:

• It is rapidly absorbed.

Distribution:

• It does not cross the blood-brain barrier.

Duration of action:

• 2 to 3 hours

Metabolism:

• The liver and other tissues metabolize it.
• It starts out as a prodrug and quickly deglycinates to desglymidodrine to create the active metabolite.

Bioavailability:

• Desglymidodrine: 93%

Half-life elimination:

• Desglymidodrine: About 3 to 4 hours;
• Midodrine: 25 minutes

Excretion:

• 80% of the metabolite, Desglymidodrine, is actively secreted in the urine.

International Brands of Midodrine:

• Amatine
• APO-Midodrine
• MAR-Midodrine
• Bramox
• Gutron
• Metligine
• Midodrine Hydrochloride
• Midon
• Midorine
• Midron
• Morepress

Midodrine Brand Names in Pakistan:

Midodrine is available in some hospitals. It is not freely available in the market.

For availability, kindly call or text via WhatsApp @ 03455109348