Clinical trial of home blood pressure monitoring following midodrine administration in hypotensive individuals with spinal cord injury

J Spinal Cord Med. 2023 Jul;46(4):531-539. doi: 10.1080/10790268.2021.1977904. Epub 2023 Mar 27.

Abstract

Background: Individuals with spinal cord injury (SCI) above thoracic level-6 (T6) experience impaired descending cortical control of the autonomic nervous system which predisposes them to blood pressure (BP) instability, including includes hypotension, orthostatic hypotension (OH), and autonomic dysreflexia (AD). However, many individuals do not report symptoms of these BP disorders, and because there are few treatment options that have been proven safe and effective for use in the SCI population, most individuals remain untreated.

Objective: The primary aim of this investigation was to determine the effects of midodrine (10 mg) prescribed TID or BID in the home environment, compared to placebo, on 30-day BP, study withdrawals, and symptom reporting associated with OH and AD in hypotensive individuals with SCI.

Design/methods: Participants were randomly assigned to received midodrine/placebo or placebo/midodrine, with a 2-weeks washout period in between, and both the participants and investigators were blinded to randomization order. Study medication was taken 2 or 3 times/day, depending on their sleep/wake schedule, BP, and any related symptoms were recorded before and 1 h after each dosage and periodically throughout the day.

Results: Nineteen individuals with SCI were recruited; however, 9 withdrew prior to completion of the full protocol. A total of 1892 BP recordings (75 ± 48 recordings/participant/30-day period) were collected in the 19 participants over the two 30-day monitoring periods. Average 30-day systolic BP was significantly increased with midodrine compared to placebo (114 ± 14 vs. 96 ± 11 mmHg, respectively; P = 0.004), and midodrine significantly reduced the number of hypotensive BP recordings compared to placebo (38.7 ± 41.9 vs. 73.3 ± 40.6, respectively; P = 0.01). However, compared to placebo, midodrine increased fluctuations in BP, did not improve symptoms of OH, but did significantly worsen the intensity of symptoms associated with AD (P = 0.03).

Conclusion: Midodrine (10 mg) administered in the home environment effectively increases BP and reduces the incidence of hypotension; however these beneficial effects come at the expense of worsened BP instability and AD symptom intensity.

Keywords: Autonomic dysreflexia; Hemodynamic instability; Hypotension; Orthostatic hypotension; Paraplegia; Spinal cord injuries; Tetraplegia.

Publication types

  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Autonomic Dysreflexia* / drug therapy
  • Autonomic Dysreflexia* / etiology
  • Blood Pressure Monitoring, Ambulatory / adverse effects
  • Humans
  • Hypotension* / complications
  • Hypotension* / etiology
  • Hypotension, Orthostatic* / drug therapy
  • Hypotension, Orthostatic* / etiology
  • Midodrine* / therapeutic use
  • Spinal Cord Injuries* / complications
  • Spinal Cord Injuries* / drug therapy

Substances

  • Midodrine

Grants and funding

This work was funded by the Craig H. Neilsen Foundation grant #284196; U.S. Department of Veterans Affairs, Veterans Health Administration, Rehabilitation Research & Development Service SPiRE award grant #D1382-P.