Preliminary experience with midodrine in kidney/pancreas transplant patients with orthostatic hypotension

In an effort to ameliorate the problem of orthostatic hypotension in pancre as transplant patients, current medical management consists of maximizing t he patient's hydration, altering antihypertensives, increasing sodium intak e, initiation of fludrocortisone, compression stockings, and behavioral mod ifications. Despite these medical interventions, a subset of patients remai ns symptomatic. Midodrine (ProAmatine(R)), an alpha-adrenergic agonist, was approved for the treatment of symptomatic orthostatic hypotension in the U S. This preliminary report attempts to assess the safety and efficacy of mi dodrine use in kidney/pancreas (KP) or pancreas alone (PA) transplant recip ients. A retrospective review was performed of 7 KP and 1 PA recipient expe riencing symptomatic postural hypotension after maximizing other medical tr eatments. Blood pressure, serum creatinine (SrCr), and objective responses to postural hypotension were assessed at routine intervals. Pre-midodrine m onitoring revealed a mean orthostatic change in systolic blood pressure fro m sitting to standing of 43 mmHg (range 20-100 mmHg). Patients received a m ean starting midodrine dose of 18 mg/d, which was titrated to a maximum dos e of 30 mg/d. Systolic blood pressure monitoring revealed a mean orthostati c change of 27 mmHg (range 0-81 mmHg) after initiation of treatment with mi dodrine and a mean follow-up of 3.2 months. All study patients reported imp rovement in symptoms of orthostatic hypotension. SrCr was not affected base d upon comparison of pre-treatment and current SrCr values of 1.4 and 1.3 m g/dL, respectively, The most common side effect experienced was supine hype rtension. These preliminary results suggest that midodrine is safe and effe ctive in transplant recipients; however, the dosage should be titrated to s ymptomatic relief or a maximum dose of 30 mg. Careful monitoring for supine hypertension is necessary.