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©The Author(s) 2024.
World J Clin Cases. Dec 26, 2024; 12(36): 6892-6904
Published online Dec 26, 2024. doi: 10.12998/wjcc.v12.i36.6892
Published online Dec 26, 2024. doi: 10.12998/wjcc.v12.i36.6892
Drug | Ref. | Study type | Population | Drug dosing | Duration of IVV | ICU LOS | Adverse reactions | Outcomes |
Midodrine | Sharma et al[33], 2008 | Case series | Coronary artery stenting (n = 55), midodrine (n = 4), dopamine (n = 11) | 10 mg Q8H x 3 doses | 15 hours in dopamine group and 0 hour in midodrine group | 2 days vs 0 day | None | Midodrine was well tolerated. Cost of hospitalization was higher in the dopamine group because of the need for ICU admission |
Levine et al[34], 2013 | Prospective | Surgical ICU (n = 20) | 5-20 mg Q8H | Median 17 hours after midodrine initiation | NR | NR | The change in IVV rate decreased from -0.62 to –2.20 mcg/minutes/hour of phenylephrine equivalents following the initiation midodrine, P = 0.01 | |
Poveromo et al[35], 2016 | Retrospective | Mixed ICU (n = 188) | 10 mg Q8H | Median 1.2 days (0.5–2.8 days) after midodrine initiation (not compared to control group) | No difference | Bradycardia in 12.8% midodrine group vs 0% in control group | Discharge from the ICU occurred sooner after IVV discontinuation in the midodrine group compared to the control group (0.8 days vs 1.5 days, P = 0.01). There was no difference in ICU LOS; and hospital LOS was longer in the midodrine group | |
Whitson et al[45], 2016 | Retrospective | MICU, septic shock (n = 275), IVV only (n = 140), IVV plus midodrine (n = 135) | 10 mg Q8H | Mean duration 3.8 vs 2.9 days, P < 0.001 | 9.4 vs 7.5 days, P = 0.02 | Bradycardia requiring midodrine discontinuation in 1 patient | Midodrine decreased duration of IVV use and ICU LOS | |
Rizvi et al[48], 2019 | Observational | ICU patients that received midodrine and survived to discharge (n = 1119) | 5-30 mg Q8H | NA | NA | NA | The study assessed continuation of midodrine during transition of care and 34% of patients were continued on midodrine at hospital discharge | |
Tremblay et al[47], 2020 | Retrospective | Cardiac surgery patients (n = 148), IVV only (n = 74), IVV plus midodrine (n = 74) | 10 mg Q8H | Median duration 44 hours (26-66 hours) vs 63 hours (40-86.5 hours), P = 0.05 | 68 hours (48-99 hours) vs 99 hours (68-146 hours), P < 0.01 | No significant difference in acute kidney injury | Negative results with midodrine use association with an increased ICU LOS | |
Santer et al[36], 2020 | RCT | ICU patients (n = 132), midodrine (n = 66), placebo (n = 66) | 20 mg Q8H | Median duration 23.5 hours (10.0–54.0 hours) vs 22.5 hours (10.4–40.0 hours), P = 0.62 | 6.0 days (5.0–8.0 days) vs 6.0 days (4.0–8.0 days), P = 0.46 | Bradycardia 5 (7.6%) vs 0 (0%), P = 0.02 | No difference in IVV use duration or ICU LOS | |
Macielak et al[46], 2021 | Observational | ICU and floor patients, (n = 44), received IVV (n = 23) | 5-20 mg Q6H | NR | 12 days (5–27 days) | The 1 case of mesenteric ischemia | NEE requirements decreased from 0.1 to 0.05 norepinephrine equivalents at 24 hours after midodrine was ordered for Q6H | |
Lal et al[49], 2021 | RCT | MICU (n = 32), midodine (n = 17), placebo (n = 15) | 10 mg Q8H | Median duration 14.5 hours ± 8.1 hours vs 18.8 hours ± 7.1 hours, P = 0.19 | 2.29 days vs 2.45 days, P = 0.36 | No major adverse events | Study not powered to detect statistically significant results | |
Adly et al[37], 2022 | RCT | Septic shock (n = 60) | 10mg Q8H | Median duration NE 4 days with midodrine vs 6 days control, P < 0.01 | NR | NR | Use of midodrine resulted in reduced IVV duration and improved mortality rates | |
Droxidopa | Zundel et al[38], 2016 | Case report | 53F with vasoplegic shock post cardiac transplant | Titrated to 600 mg 4× daily. | Not weaned off despite 10 days of droxidopa | NR | No apparent adverse effects | Droxidopa temporarily increased MAP and reduction in vasoactive requirements after midodrine was not effective. Patient died on post-op day 60 with multiorgan failure |
Hong et al[40], 2022 | Retrospective | The 64M with SS and midodrine-induced bradycardia. The 73M with SS and midodrine-induced bradycardia | 100 mg TID, 100 mg BID titrated up to 600 mg TID | The 1 day after droxidopa initiation and MAP goal reduction. The 9 days after starting droxidopa and 5 days after restarting midodrine | NR | NR | Droxidopa was weaned off prior to patient discharge. Droxidopa in combination with midodrine led to avoidance of pacemaker placement. Patient was discharged to rehabilitation on droxidopa and midodrine | |
Noble et al[39], 2023 | Case report | The 57F with persistent hypotension despite midodrine | 100 mg TID titrated to 500 mg TID | 3 days after droxidopa initiation | NR | NR | After initiation of droxidopa the patient was weaned off IVV and continuous renal replacement therapy and ultimately discharged home on droxidopa | |
Webb et al[25], 2024 | Retrospective | n = 21 (80.5% cardiac ICU) with persistent hypotension despite midodrine | Most frequent starting dose 100 mg TID. Max dose: 600 mg TID | Median time to discontinuation 87 hours (interquartile range 34-175) | NR | Similar rates of tachycardia pre- and post-initiation | NEE requirements were lower after initiation of droxidopa in patients that were trial on alternative oral vasoactive agents prior to droxidopa. About half of the patients died in the hospital. The number of patients discharged on droxidopa was not reported | |
Pseudoephedrine | Patterson et al[41], 2008 | Case report | The 77F with idiopathic autonomic dysfunction | 60 mg Q8H and tapered to 60 mg Q6H | NR | NR | NR | Norepinephrine was weaned off temporarily within 14 hours of PSE initiation, but frequency was increased to Q6H to permanently liberate patient from IVV |
Curran et al[42], 2023 | Case report | Male in 40s with autonomic dysfunction and refractory bradycardia and hypotension on midodrine at home | 60 mg Q6H that was weaned off within 7 days | < 24 hours | NR | NR | Addition of PSE facilitated IVV weaning in a patient with bradycardia and hypotension refractory to midodrine | |
Wood et al[43], 2014 | Case series | n = 38 SS | Daily PSE dose varied widely (30–720 mg) | The mean time to discontinuation of vasopressors and/or atropine was 8 days | Mean: 39 days | No adverse events directly attributed to PSE therapy were documented | ‘Success’: Vasopressor discontinuation or decreased use of atropine was achieved in 82% of patients | |
Atomoxetine | Lessing et al[44], 2024 | Retrospective | Congenital tracheal stenosis patients with midodrine-refractory hypotension (n = 45), atomoxetine (n = 18), droxidopa (n = 17), both (n = 10) | Starting daily dose: Atomoxetine 10-20 mg; droxidopa 300 mg. Maximum daily dose: Atomoxetine 40 mg; droxidopa 1800 mg | Median time to discontinuation 21.9 days vs 8 days vs 13.9 days, P = 0.26 | Median: 30 days vs 18 days vs 35 days | Hypertension requiring treatment in 2 patients receiving atomoxetine and in 2 patients receiving both. Ischemic bowel complication in 1 patient receiving atomoxetine and 1 patient receiving both. New onset arrhythmia in 3 patients receiving atomoxetine and 2 patients receiving droxidopa and 1 patient receiving both | There was no difference in IVV duration or LOS. A higher percentage of patients who survived to hospital discharge received both study medications or droxidopa alone (90% vs 76.5%) compared to atomoxetine alone (44.4%, P = 0.03) |
Desmopressin | Ahmed et al[21], 2022 | RCT | SS, control (n = 30), midodrine (n = 30), minirin (n = 30) | Midodrine 10 mg Q8H. Minirin 60 mcg Q8H | Control 6.93 days, midodine3.3 days, minirin 4.8 days, P <0.01 | 9.03 days, 5.13 days, 5.5 days, P < 0.01 | NR | Midodrine and minirin use significantly reduced duration of pressors and ICU LOS. Duration of pressors was shorter in midodrine group compared to midodrine, but ICU LOS was similar between these two groups |
- Citation: Robinson JC, ElSaban M, Smischney NJ, Wieruszewski PM. Oral blood pressure augmenting agents for intravenous vasopressor weaning. World J Clin Cases 2024; 12(36): 6892-6904
- URL: https://www.wjgnet.com/2307-8960/full/v12/i36/6892.htm
- DOI: https://dx.doi.org/10.12998/wjcc.v12.i36.6892