# Low blood pressure - Category: acute - Review status: reviewed (every claim checked against a document named on this page) - Sources: Bramox (midodrine) 5 mg tablets SmPC sections 4.2-4.4 (eMC product 2268) · Egyptian National Drug Formulary - Endocrine System Drugs 2024, fludrocortisone monograph (endocrine.pdf page index 157, printed p144) · SmPC sections 4.1, 4.2 and 4.4, https://www.medicines.org.uk/emc/product/2268/smpc · Chen RJ, Sharma S, Bhattacharya PT. Hypotension. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Last Update: May 3, 2025. NBK499961. - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Endocrine System Drugs 2024, fludrocortisone monograph (endocrine.pdf page index 157, printed p144) - SmPC sections 4.1, 4.2 and 4.4, https://www.medicines.org.uk/emc/product/2268/smpc - Chen RJ, Sharma S, Bhattacharya PT. Hypotension. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Last Update: May 3, 2025. NBK499961. ## Treatment metadata - Fludrocortisone — 0.1 mg — oral.solid - Midodrine — 2.5 mg — oral.solid ## Complete treatment card ```text LOW BLOOD PRESSURE Sources: Bramox (midodrine) 5 mg tablets SmPC sections 4.2-4.4 (eMC product 2268) · Egyptian National Drug Formulary - Endocrine System Drugs 2024, fludrocortisone monograph (endocrine.pdf page index 157, printed p144) · SmPC sections 4.1, 4.2 and 4.4, https://www.medicines.org.uk/emc/product/2268/smpc · Chen RJ, Sharma S, Bhattacharya PT. Hypotension. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Last Update: May 3, 2025. NBK499961. Review status: REVIEWED against 3 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Often there are no symptoms at all; when there are, lightheadedness or dizziness is the commonest, and fainting follows a bigger drop [dizziness · syncope] - If it persists, the mind is affected: reduced responsiveness, confusion, or focal signs such as weakness or trouble speaking [confusion] - Chest pain with sweating and vomiting suggests a heart attack; breathlessness with low oxygen suggests a clot in the lung; fever suggests infection [breathlessness · chest pain · fever · sweating · vomiting] - Other pointers: an irregular heartbeat, headache, neck stiffness, severe upper back pain, a productive cough, diarrhoea, vomiting, painful urination, allergy, tiredness and blurred vision [back pain · blurred vision · burning on passing urine · cough · diarrhoea · fatigue · headache · irregular pulse · neck stiffness · vomiting] SIGNS - what you find (4) - Warm skin, swelling, increased secretions and a fast pulse suggest septic or anaphylactic shock [sepsis · shock] - Cold dry limbs with a slow pulse suggest the heart is the problem [bradycardia] - Distended neck veins, swollen legs, lung crackles, muffled heart sounds and pulsus paradoxus point to obstructive shock [crackles · leg swelling · raised JVP · shock] - Slow capillary refill, dry mouth and slack skin point to loss of fluid volume [cold peripheries · dry mouth] TESTS (9) - Let the suspected cause direct the workup; the usual first bloods are a full count with differential, a metabolic panel, TSH and free thyroxine - A high white cell count, a raised lactate, or infection on urinalysis or chest film points to sepsis - A low haemoglobin suggests substantial blood loss - A very high TSH or a low free thyroxine raises myxoedema coma as the cause - ECG with troponin and BNP helps identify a cardiac cause - Bedside ultrasound, by the FAST or RUSH protocols, is valuable in shock in the emergency setting - Ultrasound picks up internal bleeding, pneumothorax, fluid in the chest or around the heart, and aortic dissection or aneurysm - Looking at the inferior vena cava tells you about fluid: a diameter that varies a lot means fluid is likely to help, while little variation supports starting vasopressors early - Go on to CT or MRI when an acute surgical condition is suspected IF NOT THIS - what else fits (7) - A low reading that is harmless or causes no symptoms - Orthostatic hypotension - Distributive shock: sepsis, a drug effect or overdose, anaphylaxis, and neurogenic shock such as an acute cord injury - Cardiogenic shock: decompensated heart failure, drug effect or overdose, myocarditis, a heart attack, high-degree AV block, fast atrial fibrillation, or ventricular arrhythmia - Hypovolaemic shock: bleeding from trauma, the gut or a ruptured aorta, plus dehydration, diabetic ketoacidosis and the hyperosmolar hyperglycaemic state - Obstructive shock: a massive clot in the lung or heart, tension pneumothorax, cardiac tamponade, or decompensated pulmonary hypertension - A mixed picture with more than one mechanism at once Source StatPearls "Hypotension" - disease-level clinical article Status traced to the source above 1. FLUDROCORTISONE [1st line] Adult 0.05 mg to 0.2 mg (50-200 micrograms) by mouth once daily, up to a maximum of 0.3 mg daily, titrated to response; reduce to 0.05 mg if hypertension develops. Usually given together with oral hydrocortisone or cortisone. Formulary indications are primary adrenal insufficiency (Addison disease) and classic congenital adrenal hyperplasia. - Long-term replacement therapy; the formulary sets no fixed duration and states that dosage depends on disease severity and patient response Peds The formulary says to refer to adult dosing and adjust according to age, weight and severity. No mg/kg figure is given, so no weight-based calculation can be made from this source. Tablets may be crushed and mixed with about a teaspoon of water or soft food. Monitor growth on prolonged therapy. Source Egyptian National Drug Formulary - Endocrine System Drugs 2024, fludrocortisone monograph (endocrine.pdf page index 157, printed p144) Why Standard first-line mineralocorticoid used to expand blood volume and raise pressure in troublesome postural/chronic hypotension once secondary causes are excluded. Caution Do not stop abruptly after long-term use; taper - abrupt withdrawal can cause hypotension, vomiting, fever and myalgia. Monitor blood pressure, serum potassium, electrolytes and blood glucose. Formulary indications are primary adrenal insufficiency (Addison disease) and classic congenital adrenal hyperplasia only; it is not listed for low blood pressure of other causes. Syncope with injury, signs of shock, dehydration, sepsis, gastrointestinal bleeding, suspected adrenal insufficiency. Confirm the cause first - dehydration, sepsis, GI bleeding, adrenal insufficiency, and drug causes (antihypertensives, diuretics) must be excluded or corrected before starting a pressor agent. Contraindicated in heart failure, significant fluid overload, or uncontrolled severe hypertension. Monitor supine and standing blood pressure and serum potassium regularly - risk of hypokalaemia and supine hypertension. Causes dose-dependent fluid retention/oedema; use the lowest effective dose, especially in the elderly. Egypt ASTONIN-H 0.1MG 30 TAB. AMOUN > MERCK... 18.00 EGP (0.60/unit) CORTILON 0.1 MG 20 TAB. AMOUN 16.00 EGP (0.80/unit) 2. MIDODRINE [2nd line] Adult Start 2.5 mg PO TID; titrate weekly based on supine/standing BP to usual maintenance 10 mg TID (take last dose >=4h before bedtime). - long-term Peds Safety and efficacy in children have not been established. Source SmPC sections 4.1, 4.2 and 4.4, https://www.medicines.org.uk/emc/product/2268/smpc Why Alternative or add-on vasopressor for postural hypotension when lifestyle measures and/or fludrocortisone are insufficient. Caution Try non-drug measures first: 2-2.5 L/day fluid intake, adequate salt, waist-high compression stockings, and stopping any contributing antihypertensive/diuretic. Contraindicated in severe organic heart disease, acute renal disease, urinary retention, thyrotoxicosis, and phaeochromocytoma. Take the last dose at least 4 hours before bedtime - taken late it causes supine hypertension at night, which is the real harm from this drug. Egypt MIDODRINE 2.5MG 20 TAB. EL NILE. 50.00 EGP (2.50/unit) MIDODRINE 1% ORAL DROPS 10ML EL NILE. 67.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)