Orthostatic hypotension meds

I am fairly hypotensive generally (c100/50) but have been having problems with fainting on standing. I’ve had a cardio work-up with a minor arrhythmia, minor valve leak (cardiologist not bothered about either), exercise test was good, tilt table test was a very quick fail (bp fell to 52/38 and i passed out)

Anyway, cardiologist has written to GP recommending either fludrocortisone or midodrone. Hasn’t provided GP or me with any advice between the two. GP has not heard of midodrone, and was googling both as I spoke to her. They are different classes of drug with very different actions.

We’re both a bit in the dark as to which is best. At the moment the plan is to simply try midodrone for a while, which was GP’s preference simply because it’s not a steroid.

I know there are quite a few people here with low bp and orthostatic hypotension. Has anyone tried these meds? Results? side effects? Effects on riding performance, on sleep, weight, any other issues?

I realise some will want to say “go back to cardiologist” but I’ve been discharged and that seems too difficult, too slow, and unnecessary for a short conversation as to which is best between two drugs, both of which she seems to think will be suitable.

(Just as an side, GP asked about my HR – she scoffed when i said max was about 196, as “it can’t be more than 220 minus your age” (I’m 47))

Thanks.

I have low BP but not as low as yours.  IIRC fludrocortisone is the usual med used.

NICE has this to say about midodrine
<h4 id=”midodrine-hydrochloride-indication-1″>Severe orthostatic hypotension due to autonomic dysfunction when corrective factors have been ruled out and other forms of treatment are inadequate</h4>

thats the limit of my knowledge

does it need to be treated? I manage mine by slowly getting up especially from bed So from lying to sitting. Pause.  Then sit to stand and pause while over the bed / chair then walk off.

Ive fainted multiple times from postural drop

I realise some will want to say “go back to cardiologist” but I’ve been discharged and that seems too difficult, too slow, and unnecessary for a short conversation as to which is best between two drugs, both of which she seems to think will be suitable.

But surely the GP can ask for clarification – and them asking as a medical professional will result in a better understanding of the answer than you asking as a layperson and reporting your understanding back to her.

They are different classes of drug with very different actions.

From the cardiologists viewpoint they obviously both achieve the same goal even if they do it in different ways, but the GP is involved in all your health not just this one symptom so needs to consider the benefits and risk of one medication alongside your broader history and any future treatments you might need. If they understand one option and not the other then they can’t do that for you.

We have a pretty dysfunctional practice – it’s managed by a different practice following a very poor CQC review. It’s not like she’s “my” GP who has known me for years. Not sure I’ve ever seen the same doctor twice actually. I think all but one of them are locums. She was looking stuff up on google while we were speaking. She knows nothing about my history, nothing about the drugs, hadn’t read the correspondence… She has very limited time, I know that, but as a result she’s unable to give meaningful advice.

The end of the conversation was essentially “which do you want?” “I don’t know, which do you recommend?” “well i don’t like steroids so i recommend midodrone” (the one she said she had never heard of).

Was hoping someone might have tried both and could tell of their experience.

We have a pretty dysfunctional practice

So did we. Rated as one of the worst in Scotland but also was the only one available in the area (we had a choice of four vets though). In the end we just moved house rather than hope it would get better one day.

I’d still encourage them to make a phone call and if they wont then I’d just phone the clinic and explain the situation at the GPs. They should be able to give suitable advice on recommendations for treatment they’ve made whether you’ve been discharged or not – their jobs not done until you’re actually getting effective treatment.

We’re both a bit in the dark as to which is best. At the moment the plan is to simply try midodrone for a while, which was GP’s preference simply because it’s not a steroid.

Based on the NICE review, Midodrine has greater support from clinical trials. One point of note is that both drugs are agonists, which means they stimulate rather than block signalling. It’s not uncommon to either dose agonists too high, or develop resistance to them (called tachyphylaxis).

Should your hypotension need treating, if it were me, I’d want to avoid the corticosteroid, even at a low dose. Hypotension is a side effect (with many other undesirable effects) and the steroid is used off-label for that side effect. The NICE review of this steroid is here.

By contrast there are good studies on the effects of Midodrine, but no pivotal data in postural hypotension (it became generic before Shire – who acquired it – decided not to run such a trial for formal FDA approval). The main side effects, goosebumps and scalp itching, might be dose limiting, in the large trials, about 1/12 patients stopped taking the drug, but a low dose might be another option. Dose finding for old drugs was haphazard at best (I’d like to say we are a lot better now). But there is a good drug exposure response for effects on blood pressure. The FDA label makes for interesting reading reflecting the age of the drug.

Caveat: IAMNAMD but I am a Clinical Pharmacologist. Most of the above links should be accessible to your GP and all of it to your Cardiologist to help with informed decisions.