When Your World Is Spinning: Is Midodrine Right for You?
Living with dysautonomia and orthostatic hypotension means that something as simple as getting out of bed requires strategy. I remember the first time I almost passed out/fainted. I jumped up to catch a ringing phone and suddenly, my vision had white blotches, my ears were ringing, and I just couldn’t tell where I was in space. Now, that dizzying dance has become a part of my daily routine.
My days are carefully choreographed. I stand up very slowly. I shower with a chair beneath me, as the heat and the standing can send my blood pressure into a nosedive. I dress myself while seated, with clothes laid out on my bed to minimize the bends and twists of my body that could rock my very unstable boat. I measure my days by the number of steps I can take without feeling faint.
I plan my routes through stores, always looking out for places where I can sit or lean if all the blood in my head suddenly decides to visit my feet. Social gatherings are navigated with the precision of a strategist, claiming a chair with my bag right away, especially one with an ottoman where I can elevate my feet, and always positioning myself near a wall or a chair, just in case.
Overcoming an Impaired Autonomic Nervous System with Midodrine
Midodrine is a sympathomimetic amine that is metabolized in the body to its active form, desglymidodrine, which activates alpha-1 adrenergic receptors and causes blood vessels to constrict (tighten). This medication is primarily prescribed to treat orthostatic hypotension (OH), a condition where blood pressure drops significantly upon standing. Usually, when we stand up, our nervous system tells the blood vessels in our legs to tighten when we stand, preventing gravity from pooling the blood in our legs and taking it away from our brain. However, when the nervous system doesn’t work properly and the blood vessels don’t tighten when we stand up, blood rushes into our legs and abdomen, depriving our brain, which can lead to symptoms of lightheadedness, dizziness, and fainting.
Midodrine's ability to stabilize blood pressure has led to its off-label use in the management of conditions like POTS and orthostatic intolerance, conditions found frequently in people with Long COVID and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), providing a potential avenue for symptom management in these complex and multifaceted conditions.
Midodrine Addresses Dysautonomia and Autonomic Dysfunction
Dysautonomia refers to a group of medical conditions that result from a malfunction of the autonomic nervous system (ANS). The ANS controls the "automatic" functions of the body, such as heart rate, blood pressure, and digestion. Midodrine is primarily used to treat orthostatic hypotension (OH), a common form of dysautonomia where blood pressure drops significantly upon standing, leading to symptoms like:
Dizziness or lightheadedness
Fainting or near-fainting spells
Blurred vision
Weakness
Fatigue
Nausea.
For those with dysautonomia as a part of their Long COVID or ME/CFS, these symptoms can be particularly pronounced and can severely impact daily functioning.
The Science Behind Midodrine
Midodrine itself is a pharmacologically inactive medication, known as a prodrug. Midodrine is converted in the body to its active form, desglymidodrine. Desglymidodrine activates alpha-1 adrenergic receptors on the smooth muscle lining of blood vessels, leading to:
Vasoconstriction (narrowing of blood vessels)
Increased vascular tone
Elevated blood pressure.
By activating alpha-1 receptors, midodrine helps counteract the blood pressure drop associated with standing, thereby alleviating the symptoms of OH.
Safety and Efficacy
Midodrine is effective in reducing the symptoms of orthostatic hypotension, thereby improving the ability of patients to engage in daily activities. Its role in managing symptoms of dysautonomia secondary to Long COVID and ME/CFS is based on its ability to stabilize blood pressure and reduce orthostatic intolerance.
Midodrine's safety profile has been well-established for its FDA-approved indication. Common side effects include:
Scalp tingling
Goosebumps
Urinary retention
Gastrointestinal discomfort
It is important to note that midodrine should be used with caution in patients with supine hypertension (blood pressure that is high while lying down), as midodrine can further increase blood pressure when lying down.
The Path Forward
Whether you have been living with dysautonomia or orthostatic hypotension for years or have only recently been diagnosed in connection with Long COVID, ME/CFS, or EDS, midodrine is a medication that can prove beneficial. Its safety and efficacy in the treatment of orthostatic hypotension and other forms of dysautonomia, like POTS, can help address many of the symptoms, such as fatigue and dizziness, that you live with every day. If you are interested in exploring midodrine as a treatment option, consult with your healthcare provider or visit RTHM Direct to learn how this treatment option can help combat autonomic dysfunction and get you back on the path to better health.
Follow the Science
Numerous papers discuss the potential benefits of midodrine, an alpha-1 adrenergic agonist drug, for conditions like Long COVID, chronic fatigue syndrome, and postural orthostatic tachycardia syndrome (POTS).
Dani, M., Dirksen, A., Taraborrelli, P., Torocastro, M., Panagopoulos, D., Sutton, R., & Lim, P. B. (2021). Autonomic dysfunction in ‘long COVID’: Rationale, physiology and management strategies. Clinical Medicine, 21(1), e63. https://doi.org/10.7861/clinmed.2020-0896
Haloot, J., Bhavaraju-Sanka, R., Pillarisetti, J., & Verduzco-Gutierrez, M. Autonomic Dysfunction Related to Postacute SARS-CoV-2 Syndrome. Physical Medicine and Rehabilitation Clinics of North America. https://doi.org/10.1016/j.pmr.2023.04.003
Fedorowski, A., & Sutton, R. (2023). Autonomic dysfunction and postural orthostatic tachycardia syndrome in post-acute COVID-19 syndrome. Nature Reviews Cardiology, 20(5), 281-282. https://doi.org/10.1038/s41569-023-00842-w
J Naschitz, D Dreyfuss, D Yeshurun, I Rosner, Midodrine treatment for chronic fatigue syndrome, Postgraduate Medical Journal, Volume 80, Issue 942, April 2004, Pages 230–232, https://doi.org/10.1136/pgmj.2003.011429
ROSS, A. J., OCON, A. J., MEDOW, M. S., & STEWART, J. M. (2014). A double-blind placebo-controlled cross-over study of the vascular effects of midodrine in neuropathic compared with hyperadrenergic postural tachycardia syndrome. Clinical Science (London, England: 1979), 126(4), 289. https://doi.org/10.1042/CS20130222
