Alternatives to Droxidopa: What to Know

If you can't fill your Droxidopa (Northera) prescription — whether due to a shortage, pharmacy availability issues, insurance problems, or cost — you may be wondering what alternatives exist. The good news is that there are other medications that can help manage neurogenic orthostatic hypotension (nOH).

This guide covers the most commonly used alternatives, how they compare to Droxidopa, and what to discuss with your doctor.

Important: Never stop or switch medications without talking to your doctor first. This article is for informational purposes only.

Why You Might Need an Alternative

There are several reasons patients look for Droxidopa alternatives:

• Pharmacy availability — Droxidopa can be hard to find due to specialty distribution
• Cost — Brand-name Northera retails at around $2,721 for 90 capsules (though generic versions are cheaper)
• Insurance denial — Some plans may not cover Droxidopa or require step therapy with another medication first
• Side effects — Some patients experience side effects that make Droxidopa intolerable
• Supply shortages — Manufacturing disruptions can temporarily limit availability

Alternative #1: Midodrine

Midodrine (brand name ProAmatine) is the most commonly used alternative to Droxidopa for orthostatic hypotension. It's an alpha-1 adrenergic agonist that works by constricting blood vessels to raise blood pressure.

Key Facts About Midodrine

• FDA-approved for orthostatic hypotension
• Widely available at most retail pharmacies
• Much cheaper — generic Midodrine costs $10-$30 per month with a coupon
• Taken 3 times daily (similar to Droxidopa)
• Common side effects: tingling, goosebumps, urinary urgency, supine hypertension

How It Compares to Droxidopa

Midodrine raises blood pressure through a different mechanism than Droxidopa. While Droxidopa is converted to norepinephrine in the body (replacing what's missing in nOH), Midodrine directly stimulates blood vessel receptors. Both are effective, but some patients respond better to one than the other.

Midodrine is often tried first because it's cheaper and more widely available. Many insurance plans require a trial of Midodrine before approving Droxidopa.

Alternative #2: Fludrocortisone

Fludrocortisone is a synthetic mineralocorticoid (a type of steroid) that helps your body retain sodium and water, increasing blood volume and raising blood pressure.

Key Facts About Fludrocortisone

• Used off-label for orthostatic hypotension (not FDA-approved for this specific use)
• Very affordable — typically $10-$20 per month
• Taken once daily
• Widely available at retail pharmacies
• Common side effects: swelling, low potassium, headache, weight gain

How It Compares to Droxidopa

Fludrocortisone works very differently from Droxidopa. It increases blood volume rather than directly affecting norepinephrine levels. It's often used in combination with other medications. Your doctor may prescribe it alongside Midodrine or as a standalone option for milder cases.

Alternative #3: Pyridostigmine

Pyridostigmine (brand name Mestinon) is a cholinesterase inhibitor that may help with mild to moderate orthostatic hypotension by improving the body's ability to regulate blood pressure during standing.

Key Facts About Pyridostigmine

• Used off-label for orthostatic hypotension
• Affordable — typically $15-$40 per month
• May be better tolerated in terms of supine hypertension risk
• Common side effects: stomach cramps, diarrhea, increased salivation

How It Compares to Droxidopa

Pyridostigmine is generally considered less potent than Droxidopa for severe nOH but may be a good option for patients with milder symptoms or those who can't tolerate other medications. It has a lower risk of causing supine hypertension.

Non-Medication Approaches

In addition to medications, several non-drug strategies can help manage orthostatic hypotension:

• Compression garments — Abdominal binders and compression stockings help prevent blood pooling
• Increased salt and fluid intake — Your doctor may recommend 2-3 liters of fluid and 6-10 grams of salt daily
• Elevating the head of your bed — Sleeping at a slight incline can help regulate blood pressure
• Standing up slowly — Taking your time when changing positions reduces symptoms
• Small, frequent meals — Large meals can worsen blood pressure drops

Comparison Table

Here's a quick comparison of Droxidopa and its main alternatives:

• Droxidopa: FDA-approved for nOH, ~$37-$2,721/month depending on generic vs. brand, specialty distribution, norepinephrine precursor
• Midodrine: FDA-approved for OH, ~$10-$30/month, widely available, alpha-1 agonist
• Fludrocortisone: Off-label for OH, ~$10-$20/month, widely available, mineralocorticoid
• Pyridostigmine: Off-label for OH, ~$15-$40/month, widely available, cholinesterase inhibitor

What to Ask Your Doctor

If you're considering switching from Droxidopa, here are questions to ask your healthcare provider:

1. Which alternative is best for my specific type of nOH?
2. Can I try Midodrine while waiting for Droxidopa to become available?
3. Would a combination approach work for me?
4. Are there any drug interactions I should be aware of with the new medication?
5. How will we monitor my response to the new medication?

Before You Switch: Try Finding Droxidopa First

If Droxidopa works well for you, it's worth trying to find it before switching. Use MedFinder to check pharmacy availability in real time. Generic Droxidopa is increasingly available and much more affordable than brand-name Northera.

You can also explore ways to save money on Droxidopa if cost is the main barrier.

The Bottom Line

While Droxidopa is the only medication specifically designed to replace norepinephrine in patients with nOH, alternatives like Midodrine, Fludrocortisone, and Pyridostigmine can effectively manage symptoms for many patients. Talk to your doctor about which option is best for your situation, and use MedFinder to stay on top of Droxidopa availability if you want to return to it.