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Trends in Use of Midodrine in the ICU: A Single-Center Retrospective Case Series
Mahrukh S Rizvi1, Vrinda Trivedi1, Faria Nasim1
1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
Objectives:
Midodrine is an oral alpha-agonist approved for orthostatic hypotension. The use of midodrine as a vasopressor sparing agent has steadily increased in the ICU despite limited evidence for its safety in that setting. We describe the trends in use and reported side effects and complications of midodrine in multidisciplinary ICUs of a tertiary care institution.
Design:
Single-center retrospective case series.
Setting:
Medical and surgical ICU patients from January 2011 to October 2016 at Mayo Clinic, Rochester.
Patients:
Adult patients admitted to any ICU who received midodrine for hypotension were eligible.
Interventions:
None.
Measurements And Main Results:
We reviewed the mean arterial pressures and cumulative vasopressor dose before and after midodrine administration and assessed for reported complications. During the study period, a total of 1,119 patients were initiated on midodrine, 56% in surgical ICUs, 42% in medical ICUs, and 2% in a mixed medical and surgical neurology ICU. There was a significant decrease in the number of patients on vasopressors 24 hours after initiation of midodrine (663 to 344; p < 0.001); among the patients that remained on vasopressors, there was a significant decrease in the median cumulative vasopressor dose (p = 0.002). There was a significant increase in median mean arterial pressure 24 hours after initiation of midodrine among patients who were not on vasopressors (65-68; p < 0.01). Asymptomatic bradycardia (heart rate < 50 beats/min) was the most common side effect (n = 172 patients, median 39 beats/min). Two patients developed bowel ischemia after initiation of midodrine that prompted discontinuation of midodrine in one case. Evaluating trends of utilization, the off-label use of midodrine has increased steadily over the years across ICUs.
Conclusions:
Our results suggest that midodrine is being increasingly used as an adjunct to increase mean arterial pressure and facilitate weaning of vasopressors in the ICU. Prospective trials are required to further establish the appropriate timing, efficacy, safety, and cost-effectiveness of midodrine use in ICU patients.
Insights
Midodrine use in ICUs is increasing for hypotension management. It effectively reduces vasopressor needs and improves blood pressure, though asymptomatic bradycardia is common and further trials are needed.
Area of Science:
- Critical Care Medicine
- Pharmacology
- Clinical Trials
Background:
- Midodrine, an oral alpha-agonist, is approved for orthostatic hypotension.
- Its use as a vasopressor-sparing agent in intensive care units (ICUs) is increasing.
- Evidence for midodrine's safety and efficacy in the ICU setting is limited.
Purpose of the Study:
- To describe trends in midodrine utilization within multidisciplinary ICUs.
- To report on the safety and complications associated with midodrine use in critically ill patients.
- To evaluate midodrine's impact on vasopressor requirements and hemodynamic parameters.
Main Methods:
- Retrospective case series analysis of adult patients receiving midodrine for hypotension.
- Data collected from January 2011 to October 2016 at a tertiary care institution.
- Review of mean arterial pressures, vasopressor doses, and reported complications before and after midodrine initiation.
Main Results:
- Midodrine initiation significantly decreased vasopressor use (663 to 344 patients) and cumulative vasopressor dose (p = 0.002).
- Mean arterial pressure increased significantly in patients not on vasopressors (p < 0.01).
- Asymptomatic bradycardia (n=172) was the most frequent side effect; two cases of bowel ischemia were reported.
Conclusions:
- Midodrine is increasingly used in ICUs to improve blood pressure and reduce vasopressor dependence.
- Further prospective trials are necessary to confirm efficacy, safety, and cost-effectiveness.
- Optimal timing and specific indications for midodrine in ICU patients require further investigation.
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