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Gramish J, Hattan A, Aljuhani O, Parameaswari PJ, Alshehri S, Korayem GB, Alkofide H, Alalawi M, Vishwakarma R, Alsowaida YS, Alqahtani R, Binorayir L, Abutaleb M, Alotaibi A, Aljohani M, Aljohani S, Samreen S, Jawhari S, Alanazi R, Al Sulaiman KA. The Impact of Midodrine Tapering Versus Nontapering Regimens on the Clinical Outcomes of Critically Ill Patients: A Retrospective Cohort Study. Ann Pharmacother 2024; 58:223-233. [PMID: 37248667 DOI: 10.1177/10600280231173290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Midodrine has been used in the intensive care unit (ICU) setting to reduce the time to vasopressor discontinuation. The limited data supporting midodrine use have led to variability in the pattern of initiation and discontinuation of midodrine. OBJECTIVES To compare the effectiveness and safety of 2 midodrine discontinuation regimens during weaning vasopressors in critically ill patients. METHODS A retrospective cohort study was conducted at King Abdulaziz Medical City. Included patients were adults admitted to ICU who received midodrine after being unable to be weaned from intravenous vasopressors for more than 24 hours. Patients were categorized into two subgroups depending on the pattern of midodrine discontinuation (tapered dosing regimen vs. nontapered regimen). The primary endpoint was the incidence of inotropes and vasopressors re-initiation after midodrine discontinuation. RESULTS The incidence of inotropes or vasopressors' re-initiation after discontinuation of midodrine was lower in the tapering group (15.4%) compared with the non-tapering group (40.7%) in the crude analysis as well as regression analysis (odd ratio [OR] = 0.15; 95% CI = 0.03, 0.73, P = 0.02). The time required for the antihypertensive medication(s) initiation after midodrine discontinuation was longer in patients who had dose tapering (beta coefficient (95% CI): 3.11 (0.95, 5.28), P = 0.005). Moreover, inotrope or vasopressor requirement was lower 24 hours post midodrine initiation. In contrast, the two groups had no statistically significant differences in 30-day mortality, in-hospital mortality, or ICU length of stay. CONCLUSION AND RELEVANCE These real-life data showed that tapering midodrine dosage before discontinuation in critically ill patients during weaning from vasopressor aids in reducing the frequency of inotrope or vasopressor re-initiation. Application of such a strategy might be a reasonable approach among ICU patients unless contraindicated.
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Affiliation(s)
- Jawaher Gramish
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Hattan
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - P J Parameaswari
- Research Support Department, Research and Innovation Center, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Shaden Alshehri
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mai Alalawi
- Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
| | | | - Yazed Saleh Alsowaida
- Department of Clinical Pharmacy, College of Pharmacy, Hail University, Hail, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Luluh Binorayir
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Abutaleb
- Pharmaceutical Care Services, King Fahad Central Hospital, Jazan Health, Jazan, Saudi Arabia
| | - Alanoud Alotaibi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Majidah Aljohani
- Pharmaceutical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Sarah Aljohani
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sana Samreen
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Suad Jawhari
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Raghad Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research Platform, Riyadh, Saudi Arabia
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2
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Athar ZM, Arshad M, Shrivastava S. Exploring the Efficacy of Midodrine for Tapering Off Vasopressors. Cureus 2024; 16:e55192. [PMID: 38558716 PMCID: PMC10981505 DOI: 10.7759/cureus.55192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Sepsis and septic shock represent critical conditions, often necessitating vasopressor support in the intensive care unit (ICU). Midodrine, an oral vasopressor, has gathered attention as a potential adjunct to vasopressor therapy, aiming to facilitate weaning and improve clinical outcomes. However, the efficacy of midodrine remains questionable, with conflicting evidence from clinical trials and meta-analyses. This article provides a comprehensive review of the literature on midodrine's role in ICU settings by gathering evidence from multicenter trials, retrospective studies, and meta-analyses. While some studies suggest a limited benefit of midodrine in expediting vasopressor weaning and reducing ICU/hospital stays, others report potential advantages, particularly in reducing mortality rates among septic shock patients. Ongoing efforts aim to address knowledge gaps surrounding midodrine's efficacy and safety.
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Affiliation(s)
| | - Mahnoor Arshad
- Internal Medicine, BronxCare Health System, New York, USA
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Lessing JK, Kram SJ, Levy JH, Grecu LM, Katz JN. Droxidopa or Atomoxetine for Refractory Hypotension in Critically Ill Cardiothoracic Surgery Patients. J Cardiothorac Vasc Anesth 2024; 38:155-161. [PMID: 37838507 DOI: 10.1053/j.jvca.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To evaluate the effects of droxidopa or atomoxetine on intravenous (IV) vasoactive agent discontinuation in cardiothoracic intensive care unit (ICU) patients with hypotension refractory to midodrine. DESIGN Single-center, retrospective cohort study. SETTING Tertiary- and quaternary-care university teaching hospital. PARTICIPANTS Included patients who received at least 4 consecutive doses of droxidopa or atomoxetine and remained on concurrent midodrine. Patients were excluded if they received study medication before admission, had clinical deterioration after study medication initiation requiring additional vasoactives/escalation of IV vasoactive dosage for at least 12 hours, had a diagnosis of hepatorenal syndrome, were prisoners, or were pregnant. INTERVENTIONS Droxidopa, atomoxetine, or both. MEASUREMENTS AND MAIN RESULTS The primary endpoint was time to discontinuation of IV vasoactive agents after initiation of study medication, analyzed using a Kaplan-Meier estimate with the Wilcoxon method, censoring death within 24 hours of the last dose of study medication. No adjustment for repetitive analyses was made, as the analysis was hypothesis-generating. Of the 72 charts reviewed, 45 patients met inclusion criteria (18 atomoxetine, 17 droxidopa, and 10 both). There were no differences in median time to discontinuation of IV vasoactive agents (21.9 days v 8.0 days v 13.9 days, respectively; p = 0.259) or ICU or hospital length of stay between groups. A higher percentage of patients who survived to hospital discharge received both study medications or droxidopa alone (90% v 76.5%) than atomoxetine alone (44.4%, p = 0.028). CONCLUSIONS Droxidopa and atomoxetine are oral vasoactive agents with potential mechanisms to facilitate IV vasopressor weaning for patients in the ICU with hypotension refractory to midodrine, but further prospective research is needed.
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Affiliation(s)
- Julia K Lessing
- Duke University Hospital, Department of Pharmacy, Durham, NC.
| | - Shawn J Kram
- Duke University Hospital, Department of Pharmacy, Durham, NC
| | - Jerrold H Levy
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Loreta M Grecu
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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Khokher W, Iftikhar S, Beran A, Burmeister C, Abrahamian A, Abuhelwa Z, Malhas SE, Khuder S, Assaly R. Utility of Midodrine During the Recovery Phase of Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Ther 2023; 30:e274-e278. [PMID: 37278709 DOI: 10.1097/mjt.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Saffa Iftikhar
- Department of Medicine, University of Kansas St Francis Health, Topeka, KS
| | - Azizullah Beran
- Department of Gastroenterology, Indiana University, Indianapolis, IN
| | | | | | - Ziad Abuhelwa
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | | | - Sadik Khuder
- Department of Medicine, University of Toledo, Toledo, OH; and
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH
- Department of Pulmonology and Critical Care Medicine, University of Toledo, Toledo, OH
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The Use of Midodrine as an Adjunctive Therapy to Liberate Patients from Intravenous Vasopressors: A Systematic Review and Meta-analysis of Randomized Controlled Studies. Cardiol Ther 2023; 12:185-195. [PMID: 36670331 PMCID: PMC9986154 DOI: 10.1007/s40119-023-00301-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 01/03/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Studies evaluating the role of midodrine as an adjunctive therapy to liberate patients with shock from intravenous (IV) vasopressors have yielded mixed results. The aim of our study was to evaluate the efficacy and safety of midodrine as an adjunctive therapy to liberate patients with shock from IV vasopressors. METHODS Electronic searches of the MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) that evaluated the use of midodrine versus control in patients with shock and a low dose of IV vasopressors. The primary outcome was total IV vasopressor time, while the secondary outcomes included time-to-IV vasopressor discontinuation, IV vasopressor restart, intensive care unit (ICU) length of stay (LOS), hospital LOS, and incidence of bradycardia. RESULTS The final analysis included four RCTs with a total of 314 patients: 158 in the midodrine group and 156 in the control group, with a weighted mean age of 64 years (54.2% men). There was no significant difference in the total IV vasopressor time between the midodrine and control groups (standardized mean difference [SMD] - 0.53; 95% confidence interval [CI] - 1.38 to 0.32, p = 0.22; I2 = 92%). Also, there were no significant differences between the two groups in the time-to-IV vasopressor discontinuation (SMD - 0.05; 95% CI - 0.57 to 0.47, p = 0.09), IV vasopressor restart (19.3 vs. 28.3%; risk ratio [RR] 0.74; 95% 0.25-2.20, p = 0.59), ICU LOS (SMD - 0.49; 95% CI - 1.30 to 0.33, p = 0.24), and hospital LOS (SMD 0.01; 95% CI - 0.27 to 0.29, p = 0.92). However, compared with the control group, the midodrine group had a higher risk of bradycardia (15.3 vs. 2.1% RR 5.56; 95% CI 1.54-20.05, p = 0.01). CONCLUSIONS Among patients with vasopressor-dependent shock, midodrine was not associated with early liberation of vasopressor support or shorter ICU or hospital length of stay. Adding midodrine increased the risk of bradycardia. Further large RCTs are needed to better evaluate the efficacy and safety of midodrine in liberating patients from IV vasopressors.
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Anstey M, Shaefi S, Wibrow B. Midodrine - why don't you just work better? CRIT CARE RESUSC 2022; 24:296-297. [PMID: 38047007 PMCID: PMC10692598 DOI: 10.51893/2022.4.e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Matthew Anstey
- Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
- School of Public Health, Curtin University, Perth, WA, Australia
| | - Shahzad Shaefi
- Harvard Medical School, Harvard University, Boston, MA, United States
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Bradley Wibrow
- Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
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Costa-Pinto R, Jones DA, Udy AA, Warrillow SJ, Bellomo R. Midodrine use in critically ill patients: a narrative review. CRIT CARE RESUSC 2022; 24:298-308. [PMID: 38047013 PMCID: PMC10692611 DOI: 10.51893/2022.4.r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Midodrine is a peripherally acting, oral α-agonist that is increasingly used in intensive care units despite conflicting evidence for its effectiveness. It has pharmacological effects on blood vessels as well as pupillary, cardiac, renal, gastrointestinal, genitourinary, lymphatic and skin tissue. It has approval for use as a treatment for orthostatic hypotension, but a surge in interest over the past decade has prompted its use for a growing number of off-label indications. In critically ill patients, midodrine has been used as either an adjunctive oral therapy to wean vasoplegic patients off low dose intravenous vasopressor infusions, or as an oral vasopressor agent to prevent or minimise the need for intravenous infusion. Clinical trials have mostly focused on midodrine as an intravenous vasopressor weaning agent. Early retrospective studies supported its use for this indication, but more recent randomised controlled trials have largely refuted this practice. Key questions remain on its role in managing critically ill patients before intensive care admission, during intensive care stay, and following discharge. This narrative review presents a comprehensive overview of midodrine use for the critical care physician and highlights why lingering questions around ideal patient selection, dosing, timing of initiation, and efficacy of midodrine for critically ill patients remain unanswered.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl A. Jones
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew A. Udy
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Stephen J. Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
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8
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Costa-Pinto R, Bellomo R. Randomised-control trials do not support midodrine as an intravenous vasopressor weaning strategy. J Crit Care 2022; 72:153996. [PMID: 35115215 DOI: 10.1016/j.jcrc.2022.153996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 01/18/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
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9
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Kamaleldin M, Kilcommons S, Opgenorth D, Fiest K, Karvellas CJ, Kutsogiannis J, Lau V, MacIntyre E, Rochwerg B, Senaratne J, Slemko J, Sligl W, Wang X, Bagshaw SM, Rewa OG. Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e064060. [PMID: 36418124 PMCID: PMC9684992 DOI: 10.1136/bmjopen-2022-064060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Intensive care unit (ICU) lengths of stay are modified by ongoing need for haemodynamic support in critically ill patients. This is most commonly provided by intravenous vasopressor therapy. Midodrine has been used as an oral agent for haemodynamic support in patients with orthostatic hypotension or cirrhosis. However, its efficacy in treating shock in the ICU, particularly for patients weaning from intravenous vasopressors, remains uncertain. The objective of this systematic review is to determine the efficacy of midodrine in vasopressor dependent shock. METHODS AND ANALYSIS We will search Ovid MEDLINE, Ovid Embase, CINAHL and Cochrane Library for observational trials and randomised controlled trials evaluating midodrine in critically ill patients from inception to 21 April 2022. We will also review unpublished data and relevant conference abstracts. Outcomes will include ICU length of stay, duration of intravenous vasopressor support, ICU mortality, hospital mortality, hospital length of stay and rates of ICU readmission. Data will be analysed in aggregate, where appropriate. We will evaluate risk of bias using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology. We will perform trial sequential analysis for the outcome of ICU length of stay. ETHICS AND DISSEMINATION Ethics approval is not required as primary data will not be collected. Findings of this review will be disseminated through peer-related publication and will inform future clinical trials. PROSPERO REGISTRATION NUMBER CRD42021260375.
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Affiliation(s)
| | | | - Dawn Opgenorth
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Constantine Jason Karvellas
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jim Kutsogiannis
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Vincent Lau
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Erika MacIntyre
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Janek Senaratne
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jocelyn Slemko
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Wendy Sligl
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Statistical and Analytical Methods, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Oleksa G Rewa
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
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10
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Sinagra G, Fabris E. Might midodrine be useful in patients with decompensated and worsening chronic heart failure? Author's reply. Eur J Intern Med 2022; 105:105-106. [PMID: 36130850 DOI: 10.1016/j.ejim.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/13/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Gianfranco Sinagra
- Cardiothoracovascular Department, University of Trieste, Polo Cardiologico-Ospedale di Cattinara, Via Valdoni 7, Trieste 34129, Italy.
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Polo Cardiologico-Ospedale di Cattinara, Via Valdoni 7, Trieste 34129, Italy
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Iovine JA, Villanueva RD, Werth CM, Hlavacek NL, Rollstin AD, Tawil I, Sarangarm P. Contemporary hemodynamic management of acute spinal cord injuries with intravenous and enteral vasoactive agents: A narrative review. Am J Health Syst Pharm 2022; 79:1521-1530. [PMID: 35677966 DOI: 10.1093/ajhp/zxac164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The pathophysiology and hemodynamic management of acute spinal cord injuries, including the use of intravenous and enteral vasoactive agents, are reviewed. SUMMARY Spinal cord injuries are devastating neurological insults that in the acute setting lead to significant hemodynamic disturbances, including hypotension and bradycardia, that are influenced by the level of injury. High thoracic (usually defined as at or above T6) and cervical injuries often manifest with hypotension and bradycardia due to destruction of sympathetic nervous system activity and unopposed vagal stimulation to the myocardium, whereas lower thoracic injuries tend to result in hypotension alone due to venous pooling. Initial management includes maintaining euvolemia with crystalloids and maintaining or augmenting mean arterial pressure with the use of intravenous vasoactive agents to improve neurological outcomes. Choice of vasopressor should be based on patient-specific factors, particularly level of injury and presenting hemodynamics. This review includes the most recent literature on intravenous vasopressors as well as the limited evidence supporting the use of enteral vasoactive agents. Enteral vasoactive agents may be considered, when clinically appropriate, as a strategy to wean patients off of intravenous agents and facilitate transfer outside of the intensive care unit. CONCLUSION The hemodynamic management of acute spinal cord injuries often requires the use of vasoactive agents to meet mean arterial pressure goals and improve neurological outcomes. Patient-specific factors must be considered when choosing intravenous and enteral vasoactive agents.
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Affiliation(s)
- Joseph A Iovine
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Ruben D Villanueva
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Christopher M Werth
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Nicole L Hlavacek
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Amber D Rollstin
- Department of Critical Care and Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Isaac Tawil
- Department of Critical Care and Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
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12
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Riker RR, Gagnon DJ. Letter to the Editor: "Midodrine to liberate ICU patients from intravenous vasopressors: Another negative fixed-dose trial". J Crit Care 2022; 69:153995. [PMID: 35152142 PMCID: PMC9064955 DOI: 10.1016/j.jcrc.2022.153995] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/18/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Richard R. Riker
- Department of Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102, USA
| | - David J. Gagnon
- Departments of Pharmacy and Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102, USA
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13
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Shiu P, Grewal GS, Kozik TM. Midodrine to optimize heart failure therapy in patients with concurrent hypotension. SAGE Open Med Case Rep 2022; 10:2050313X221100400. [PMID: 35601610 PMCID: PMC9121496 DOI: 10.1177/2050313x221100400] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/22/2022] [Indexed: 11/19/2022] Open
Abstract
According to the Centers for Disease Control and Prevention statistics, about 6.2
million adults in the United States have heart failure. Guideline-Directed
Medical Therapy (GDMT) involving the use of renin-angiotensin-aldosterone system
inhibitors with or without a neprilysin inhibitor, β-blockers,
mineralocorticoid-receptor-antagonists, and sodium-glucose cotransporter-2
inhibitors serve as the backbone for heart failure with reduced ejection
fraction (HFrEF) therapy. However, in patients with refractory hypotension, the
initiation of GDMT may not be possible. We present four cases where the use of
midodrine, an alpha adrenergic agonist, serves as bridge therapy for the
initiation or continuation of GDMT with marked clinical improvement. These cases
illustrate how exacerbations of HFrEF may be ameliorated with outpatient
midodrine titration among patients with baseline, persistent hypotension such
that GDMT may be better tolerated.
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Affiliation(s)
- Paul Shiu
- Graduate Medical Education, St. Joseph’s Medical Center, Stockton, CA, USA
| | | | - Teri M Kozik
- Graduate Medical Education, St. Joseph’s Medical Center, Stockton, CA, USA
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