FAQ

How can nephrologists cause renal failure with midodrine?

Inappropriate use midodrine of midodrine can contribute to unnecessary dialysis treatments. Midodrine, a medication typically used to treat low blood pressure (hypotension) can be misused in ways that exacerbate an existing kidney issue, leading to prolonged renal failure. In such cases, a patient may present with mild, reversible kidney impairment, which would ordinarily resolve with appropriate treatment and time (ranging from a few days to a couple of weeks). This initial renal dysfunction could stem from various causes, such as hypotension, sepsis, liver disease, or other factors. However, midodrine can provide a justification for long term dialysis treatments.
How many patients have renal failure caused by midodrine?

The true number patients who may have renal failure caused by midodrine is unknown, but estimated to include over 10,000 patients in the US. The number of patients listed in the 'Prescriber Check Up" likely underestimates the true extent of this problem, as many patients have these medications refilled by unaffiliated providers (ex. primary care providers).
Is midodrine-induced kidney failure reversible?

Yes (atleast initially). If midodrine is stopped early enough, kidney function can return to near baseline levels. However, if a patient remains on midodrine for years the damage may be irreversible.
What dose of midodrine is needed to cause kidney failure?

Generally, patients need to be receiving midodrine 3 times daily to cause renal failure (5mg+ per dose) . Higher/more frequent midodrine dosing allows the midodrine to build up in between dialysis and lead to toxic effects. Midodrine given once before dialysis is very unlikely to cause renal failure as the active metabolite will be removed during dialysis.

What would motivate nephrologists to overdose patients on midodrine?

Money. By overdosing these patients on midodrine the nephrologists are able to recruit more dialysis patients for their lucrative dialysis businesses. Doctors are paid on a fee-for-service model, meaning they get paid more for doing more. Nephrologists may use this referral scheme to drive more dialysis patients to their affiliated dialysis centers. Nephrologists can potentially earn up to $1,041,142 annually by serving as the medical director for a single dialysis facility, although the typical salary tends to be lower. Additionally, a nephrologist may hold the position of medical director at multiple facilities, thereby increasing their overall compensation. Nephrologists who maintain a steady stream of dialysis referrals are likely to be highly sought after by dialysis corporations, which view these providers as valuable assets.
The top medical director salaries (per a whistleblower lawsuit) can be found Here, Page 72.
Is overdosing patients on midodrine for profit legal?

This practice currently resides within a grey area of medicine. It is not specifically banned, but it also not specifically permitted. Additionally, there are different state and local laws in different areas, so it is extremely difficult to ensure this process is 100% legally compliant. Generally, as long as a doctor can use a scientific literature to support their decision making, their actions would be considered acceptable. Such literature exists for the use of midodrine in dialysis patients, so this practice is at least somewhat defensible.
Are these nephrologists who prescribe midodrine all evil?

No. For the most part, they are a product of a system that rewards the overutilization of healthcare resources. While their actions are despicable and lead to significant unnecessary human suffering, I am sure many of them have redeeming qualities in other aspects of their life. For example, they could be amazing husbands, wives, fathers, mothers and altruistic in other facets of their life. In that same vein, some could argue that Hitler is not evil as I am sure he also had some redeeming qualities.
When will nephrologists stop overdosing patients on midodrine?

When the risk outweighs the reward. Currently, there is very little risk for nephrologists engaging in this process and massive rewards. If the system were changed so that nephrologists did not benefit from this practice, or felt they could be punished, they would likely cease such activities.
Why are Medicaid/Medicare patients targeted?

The approval process for Medicaid/medicare claims is more streamlined and consistent. Essentially, it is highly unlikely that Medicaid/medicare would disagree with a physician's determination that dialysis is necessary. Conversely, private insurance has a much more thorough claims review process that reviews each claim with more scrutiny. While this may seem counterintuitive, given that reimbursement for Medicare/Medicaid patients is lower, anecdotal evidence seems to suggest that Medicare/Medicaid patients are targeted.
Why are alcoholics and drug addicts targeted?

Because alcoholics and drug addicts generally lack credibility. These patients would be more difficult to believe in a court of law when facing physicians. Additionally, people generally tend to believe that such patients deserve whatever complications occur to them as a result of their actions. Additionally, alcoholism/liver disease can predispose to kidney injury/hypotension and make a physicians defense for why they prescribe midodrine more believable.
Do other doctors (non-nephrologists) know about this scheme?

Generally, no. Nephrology is a highly specialized field of medicine, and, as with most specialized areas, healthcare providers typically defer to the expertise of nephrologists. While some physicians may have limited awareness through personal experience, most doctors lack in-depth expertise in this area. Additionally, many nephrologists are likely unaware of this scheme if they are not actively involved in such cases.
What is the half-life of midodrine?

Half life= Amount of time it takes for “break down”/remove 50% of a drug dose.
The half life of midodrine is reported to be 2 hours. However, in patients with kidney failure the half life can be as long as 10 hours. This is due to the fact the midodrine’s metabolite is actively removed by the kidneys, and when the kidneys are not functioning, the body cannot remove midodrine. Additionally, the half life of midodrine is complex as it can be associated with a secondary absorption period, even in healthy individuals that occurs for days after a single dose (see Evidence->Original FDA Approval Documents).
What are some unconventional ways that nephrologists could profit off of midodrine?

In theory, a nephrologist could prescribe excessive amounts of midodrine to other healthcare providers (e.g., a nurse at an assisted living facility), who might then administer the drug inappropriately to patients, potentially leading to kidney failure. However, such scenarios remain highly speculative and would be virtually impossible to substantiate. Nevertheless, there has been at least one documented case in which a nurse at an assisted living facility allegedly swapped patients’ pain medications for midodrine. That report is available here: Here.

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