Midodrine

PROAMATINE

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What it isAlpha-1 agonist prodrug causing peripheral vasoconstriction; symptomatic orthostatic hypotension.

Why this oneOne of the few agents that reliably raises standing blood pressure, and it does not cross into the CNS.

What limits itSupine hypertension is the limiting problem — never dose within four hours of lying down. Scalp tingling and urinary retention.

FDA-approved for

orthostatic hypotension (1996)

Off-label

hepatorenal syndrome and cirrhotic ascites
vasovagal syncope
intradialytic hypotension

FDA label

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BOXED WARNING Can cause marked elevation of supine BP; reserve for symptomatic orthostatic hypotension considerably impairing daily life; clinical benefit (activities of daily living) not verified (approved on surrogate marker)

FDA dosing	Population	Start	Target	Max
Symptomatic orthostatic hypotension	Adult	10 mg TID (daytime, ~4 h apart)	10 mg TID	single doses ≤20 mg studied; >30 mg/day not established
Orthostatic hypotension	Renal impairment	2.5 mg TID

Renal Initiate at 2.5 mg; dose cautiously (desglymidodrine excreted renally)

Hepatic Undefined

Doses may be spaced at 3-h intervals if needed to control symptoms, but not more frequently

Instructions

Dose during daytime upright hours: on arising, midday, and late afternoon (not later than 6 PM)
Do not give after the evening meal or <4 h before bedtime (supine hypertension risk)
Monitor supine and standing BP; stop if supine BP rises excessively; continue only if symptomatic improvement

Contraindications

Severe organic heart disease
Acute renal disease
Urinary retention
Pheochromocytoma
Thyrotoxicosis
Persistent and excessive supine hypertension

Cautions

Supine hypertension (most serious) — monitor supine/standing BP
Use cautiously in renal impairment

Adverse reactions

Supine/sitting hypertension
Paresthesia (incl. scalp)
Pruritus (mainly scalp)
Piloerection (goosebumps)
Chills
Urinary urgency/retention/frequency, dysuria
Headache

Pregnancy Undefined

Lactation Undefined

⚠ BOXED WARNING

Supine hypertension

Cost, est. cash$5–$150/month

Generic entry2003

Classes and tags

Clinical profile

Therapeutic safety burden1 / 4

Overdose danger1 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk1 / 4

Legacy pregnancy categoryUnknown / historical label unavailable

Defining liabilityGenerally tolerated at therapeutic doses; clinically important risks are agent-specific and increase with interactions or organ impairment.