Epidemiological data suggest that at two in five of us will experience at least one episode of syncope during our lifetime. There are an extensive number of ‘potential’ therapies that we might be given to reduce the likelihood of future syncope.

Midodrine is a potent α1 adrenergic agonist (a sympathomimetic agent) that has found widespread use in the treatment of low blood pressure and neurocardiogenic syncope. The active metabolite of midodrine, desglymidodrine, exerts vasopressor actions through activation of alpha-adrenergic receptors of the arteriolar and venous vasculature. The effects of midodrine are largely to raise both supine and, more particularly, standing blood pressures through a vasoconstrictor effect to increase peripheral vascular resistance.

Although it is widely used, midodrine currently ranks ninth in the Medicines and Healthcare products Regulatory Agency list of the top 10 unlicensed medicines imported into the UK in 2010. This is of particular interest because midodrine has never received a licence from the UK regulatory authorities. Concerns were recently expressed with the initiation of debates around the use of midodrine recently increased after it was threatened with a licence withdrawal in the USA. The reason cited was a failure of the manufacturing drug companies to provide previously agreed post-market studies.

The team at Niche Science & Technology Ltd. were eager to engage with physicians to report on what happens in ‘real-world’ clinical scenarios. Experience showed that the number of patients, in whom symptoms progress to the extent that requires the use of midodrine, are small. This may reflect the caution that surrounds the use of unlicensed medicines. Midodrine appears to be well tolerated with wide application for hypotensive episodes resulting from several different aetiologies. In occasional cases, as illustrated in the report, it can provide life-saving treatment for profound hypotension [1].

Our report concluded that given its features and undoubted efficacy it is possible to propose that midodrine find an expanded role in treating hypotension. However, the available data are probably still insufficient to prove the efficacy of midodrine in vasovagal syncope [1].

1. Doyle JF, Grocott-Mason R, Hardman TC, Malik O, Dubrey SW. Midodrine: use and current status in the treatment of hypotension.
   Br J Cardiol 2012;19:34–7.