Usual Adult Dose for Hypotension

10 mg orally 3 times a day during daytime hours when the patient needs to be upright

Comments:

• The three daily doses may be given at 3-hour intervals, if needed, but not more frequently.
• This drug should not be given after the evening meal or less than 4 hours before bedtime.
• This drug should only be continued in patients who appear to attain symptomatic improvement during initial treatment.

Renal Dose Adjustments

CrCl less than 90 mL/min: Initiate treatment using 2.5 mg doses

Acute renal disease: Contraindicated

Liver Dose Adjustments

Use with caution

Precautions

US BOXED WARNING:

• SUPINE HYPERTENSION: Because this drug can cause marked elevation of supine blood pressure, it should be used in patients whose lives are considerably impaired despite standard clinical care. The indication for this drug in the treatment of symptomatic orthostatic hypotension is based primarily on a change in a surrogate marker of effectiveness, an increase in systolic blood pressure measured one minute after standing, a surrogate marker considered likely to correspond to a clinical benefit. At present, however, clinical benefits of this drug, principally improved ability to carry out activities of daily living, have not been verified.

Dialysis

This drug is dialyzable; however, no dose adjustment guidelines have been reported.

Other Comments

Monitoring:

• Cardiovascular: Supine, standing, and sitting blood pressure; signs or symptoms suggestive of bradycardia (e.g., pulse slowing, increased dizziness, syncope, cardiac awareness).
• Hepatic: Liver function prior to initial use and thereafter as needed.
• Renal: Kidney function prior to initial use and thereafter as needed.

• Advise patients to immediately report supine hypertension symptoms (e.g., cardiac awareness, pounding in the ears, headache, blurred vision, etc.).
• Advise patients to discontinue this drug if supine hypertension persists.
• Inform patients to discontinue this drug if they experience any signs or symptoms suggestive of bradycardia (e.g., pulse slowing, increased dizziness, syncope, cardiac awareness).
• Advise patients to administer the final dose of the day 4 hours or more before bedtime to minimize nighttime supine hypertension. Nighttime supine hypertension may be further minimized by elevation of the patient's head.
• Inform patients that certain components in over-the-counter products (e.g., cold remedies, diet aids) should be used cautiously with this drug as they can also increase blood pressure.