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Dr. Andrew Rynne
MD
Dr. Andrew Rynne

Family Physician

Exp 50 years

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Should Midodrine Be Replaced With Northera For The Treatment Of Neurocardiogenic Syncope?

I have a complicated patient who has multiple medical problems. She is a 39-year-old female with neurocardiogenic syncope (Abnormal tilt table study), sarcoidosis, including the myocardium by cardiac MRI, symptomatic PVCs that were improved with Prednisone, mitral valve prolapse with mild MR and migraine. She had unsuccessful ablation for PVCs. She has been treated with Midodrine 10 mg po tid and Metoprolol succ 25 mg, 1 1/2 tablet po bid She weas compression stockings. She had a normal nuclear stress test. She has been on multiple medications including the above , in addition Plaquenil, Pepcid, Methotrexate. Mg oxide, Carafate. She recently presented with presyncopal episode while standing at work. Her office BP was 119/69 with no orthostatis in one minute. Is it the time to change Midodrine to Northera in this complicated patient? Thanks.
Sat, 19 Sep 2020
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Internal Medicine Specialist 's  Response
Hello,

With the Midodrine being at its highest dose and your patient still having symptoms I have usually considered adding Fludrocortisone 0.1mg/day to their regimen prior to changing to Northera. The mechanisms are certainly different between the Midodrine and Northera and I have found that the addition of the Fludrocortisone works synergistically better with the Midodrine to a greater degree than the Northera. I have started at 0.1mg/day and increased to 0.1 mg/day if needed. Usually I have been about to reduce the Midodrine dose after the Fludrocortisone was started. I would consider this as an additional strategy or alternative as needed.

Take care. Hope I have answered your question. Let me know if I can assist you further.

Regards,
Dr. David Girardi, Internal Medicine Specialist
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Should Midodrine Be Replaced With Northera For The Treatment Of Neurocardiogenic Syncope?

Hello, With the Midodrine being at its highest dose and your patient still having symptoms I have usually considered adding Fludrocortisone 0.1mg/day to their regimen prior to changing to Northera. The mechanisms are certainly different between the Midodrine and Northera and I have found that the addition of the Fludrocortisone works synergistically better with the Midodrine to a greater degree than the Northera. I have started at 0.1mg/day and increased to 0.1 mg/day if needed. Usually I have been about to reduce the Midodrine dose after the Fludrocortisone was started. I would consider this as an additional strategy or alternative as needed. Take care. Hope I have answered your question. Let me know if I can assist you further. Regards, Dr. David Girardi, Internal Medicine Specialist