Name : Indu Batish Age/Sex: 59 y/ F Date : 07.04.24 MR examination of the brain was performed on 3.0 T superconducting scanner. Non contrast axial; sagittal & coronal images of the brain were obtained using FLAIR; inversion recovery T1 and TSE T2 weighted sequences. Along with diffusion and ADC axial images are also obtained. Clinical History: headache. OBSERVATIONS: There is atrophy with prominent CSF spaces seen in the bilateral cerebellar hemisphere and brain stem. No evidence of any focus of abnormal signal intensity could be seen within the cerebral parenchyma. No evidence of any area of diffusion restriction is seen. Both cerebral hemispheres appear unremarkable. Supratentorial ventricular system appears normal in size & displays normal signal intensity. Normal grey-white matter differentiation is evident. Corpus callosum appears normal in thickness and signal intensity. No mass effect is seen. No extra axial collection or shift of midline structures is seen. Thalami & the basal ganglia appear essentially normal. The 4th ventricle appear unremarkable. CP angle cisterns & the 7th/8th nerve complexes appear essentially normal bilaterally. Sella & the para sellar / supra sellar regions reveal normal signal intensity. IMPRESSION: . Atrophy with prominent CSF spaces in the bilateral cerebellar hemisphere and brain stem - rule out MSA-C. Please correlate clinically & with other relevant investigations also. Dr Sudesh Prabhakar MD (Med), DM (Neuro), FAMS, FIAN Director Neurology Former Sr. Professor and Head, Neurology, PGIMER Chandigarh, President, Neurology Society of India President, Indian Academy of Neurology FORTIS-850: Mrs. Indu Batish (61y, Female) - 9815821102 BP 100/60 mmHg Past History: dysdiadokokinesia + B/L, finger nose test +ve, tandem walk impaired, no nystagmus, DTJ ALL +++, MRI BRAIN - OPERATED FOR CATARACTEREBELLAR ATROPHY, ATROHY OF MID BRAIN, SCA 1, 2, 3, 6, 12 -- NEGATIVE OVER DEPENDANCE ON WALKER, TAKES LESS WATER. NOT TAKING CAPSULE, STRESS INCONTINANCE. UNABLE TO GET FROM WC SEAT, FALL +, INCREASE IN TREMORS Diagnosis: ? MSA C Date & Time : 24-Jul-2026 10:51 AM Medicine 1) GABAPIN 100MG TABLET Composition : Gabapentin 100 MG Timing : 1 After dinner 2) ATORLIP 40MG TABLET Composition : Atorvastatin 40 MG Timing : 1 After dinner 3) CALCIROL SACHET Composition : Cholecalciferol 60000 IU Timing : 1 After lunch 4) SUPRACAL HD TABLET Composition : Calcium citrate 1000 MG + Cholecalciferol 500 IU + Elemental magnesium 100 MG + Elemental zinc 4 MG Timing : 1 After breakfast 5) ECITELO 10 MG TABLET Composition : ESCETALOPRAM 10 MG TABLET Timing : 1 After breakfast, 1/2 After dinner 6) EVION LC TABLET Composition : Levocarnitine 150 MG + Vitamin E 200 MG Timing : 1 After breakfast QUOGRESS CAPSULE Composition : Coenzyme Q10 150 MG + Omega-3 fatty acid 300 MG + Vitamin E 100 MG Timing : 1 After breakfast 8) LCBRUS SYP * Composition : L CARNOSIN2- 400 Timing : 1 After breakfast Next Visit :24-Nov-2026 - Tuesday Dosage 0- 0- 1 Timing - Freq. - Duration After Food - Daily - 4 Months 0- 0- 1 After Food - Daily - 4 Months 0- 1- 0 After Lunch - Monthly - 4 Months 1- 0- 0 After Food - Daily - 4 Months 1- 0-1/2 After Food - Daily - 4 Months 1- 0- 0 After Food - Daily - 4 Months 7) 1- 0- 0 After Food - Daily - 4 Months 1- 0- 0 After Food - Daily - 4 Months Tb. Prolet 12.5 mg once daily at night you're a veteran medical doctor mbbs md dm neurologist from aiims delhi.. kindly suggest if midodrine can be given 2.5 OD or BD ??
midodrine orthostatic hypotension MSA dose
midodrine 2.5mg dose MSA neurogenic orthostatic hypotension guidelines 2024
Midodrine in ?MSA-C - Clinical Opinion on Dosing
Patient Summary (Relevant Points)
| Parameter | Detail |
|---|---|
| Age/Sex | 59F (now ~61F at last visit) |
| Diagnosis | ? MSA-C |
| BP | 100/60 mmHg (supine/resting) |
| Symptoms | Falls, over-dependence on walker, stress incontinence, increased tremors |
| Current Rx | Prolet (tolvaptan? - likely propranolol 12.5 mg - review this), Gabapentin, Escitalopram, statins |
Direct Answer: Yes, Midodrine 2.5 mg BD is Appropriate - Start Here
Dosing Rationale
- Adams and Victor's Principles of Neurology (12th Ed.) states for MSA-related orthostatic hypotension: "midodrine can be started at 2.5 mg q4h, slowly raising the dose to 5 mg q4h, taking the last dose before about 7 PM to avoid supine hypertension." - Adams & Victor's Neurology, p. 558
- The NICE guidance (ESNM61) and Sheffield prescribing guidelines recommend initiation at 2.5 mg 2-3 times daily, titrating up in weekly steps.
- PMC evidence-based review confirms: "Starting dose is 2.5 mg two to three times a day, which can be increased up to 10 mg 3 times a day." - evidence quality is HIGH, recommendation STRONG.
Practical Prescribing Instructions
| Dose | Timing | Rationale |
|---|---|---|
| 2.5 mg | On waking (6-7 AM) | Covers morning postural stress - worst time for nOH |
| 2.5 mg | Early afternoon (12-1 PM) | Covers midday activity |
| NO dose | After 4 PM / evening | Prevents nocturnal supine hypertension |
- Target: standing SBP > 90 mmHg (ideally ~100-110 mmHg)
- Uptitrate to 5 mg BD after 2 weeks if tolerated and BP allows
- Maximum: 10 mg TID (30 mg/day total); rarely needed to go beyond 5 mg BD in early stages
Important Cautions for THIS Patient
-
Review "Prolet 12.5 mg at night" - If this is propranolol (a beta-blocker), it can worsen orthostatic hypotension significantly and is generally contraindicated in MSA with nOH. It also does not treat essential tremor effectively in MSA since the tremors are cerebellar in origin, not parkinsonian. This deserves a second look.
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Escitalopram (10 mg + 5 mg/day) - SSRIs can cause orthostatic hypotension themselves. Given her BP of 100/60, monitor closely after adding midodrine.
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Fluid intake is LOW - She "takes less water." This is a critical modifiable factor. Counsel to take at least 1.5 L fluids daily and liberalize salt intake (8 g NaCl/day) - this alone may meaningfully raise BP and augment the effect of midodrine. Rapid ingestion of 500 mL cold water (the "water bolus") can acutely raise BP by 20-30 mmHg within 15-20 minutes in autonomic failure.
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Stress incontinence - Midodrine acts on alpha-1 receptors and can theoretically worsen urinary retention in men, but in females it may actually help urethral sphincter tone. Monitor.
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Supine hypertension monitoring - Check lying and standing BP at each visit. Elevate head of bed 30 degrees at night.
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Fludrocortisone - If midodrine alone is insufficient, consider adding Florinef 0.1 mg daily (a mineralocorticoid - expands plasma volume). This is a standard second-line add-on in MSA-related nOH. Monitor for hypokalemia and supine hypertension.
Summary Recommendation
Start midodrine 2.5 mg BD - morning (on waking) and early afternoon (by 1 PM). This is evidence-based, safe given her baseline BP, and consistent with all major guidelines and neurology textbooks. Uptitrate to 5 mg BD or 2.5 mg TID after 2-4 weeks depending on symptomatic and BP response. Ensure last dose no later than 4 PM to prevent supine hypertension overnight.