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Treatment of orthostatic hypotension due to autonomic failure with a peripheral alpha-adrenergic agonist (midodrine)

From the Department of Neurology (Drs. Kaufmann, Brannan, and Yahr), Department of Medicine, Hypertension Division (Dr. Krakoff), and Department of Biomathematical Sciences (Dr. Mandeli), Mount Sinai School of Medicine of the City University of New York.

The therapeutic efficacy of midodrine, an alpha-adrenergic agonist that does not cross the blood-brain barrier, was investigated in a double-blind crossover trial in seven patients with orthostatic hypotension due to autonomic failure. We identified two groups of patients: those in whom upright mean arterial pressure significantly increased (group I, n = 3) and those in whom upright mean arterial pressure decreased (group II, n = 4) during midodrine treatment. Body weight changed in a parallel manner with upright blood pressure, increasing in patients of group I and decreasing in patients of group II (p < 0.05). Autonomic cardiovascular reflexes were significantly more impaired in patients of group II than in patients of group I. We conclude that midodrine is effective in the treatment of orthostatic hypotension only in those patients with significant preservation of autonomic reflexes. Conversely, in patients with markedly impaired baroreceptor mechanisms, treatment with midodrine may produce extracellular fluid volume depletion and exacerbate orthostatic hypotension.

Address correspondence and reprint requests to Dr. Kaufmann, Department of Neurology, Mount Sinai Hospital, New York, NY 10029.

Supported in part by NIH Grant # NS-11631 from NINCDS and R-R 71 from the Division of Research Resources of the NIH.

Presented in part at the thirty-eighth annual meeting of the American Academy of Neurology, New Orleans, LA, April 1986.

Received July 1, 1987. Accepted for publication in final form October 16, 1987.

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