Midodrine use in critically ill patients: a narrative review

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.

Exploring the Efficacy of Midodrine for Tapering Off Vasopressors

“…There are different kinds of vasopressors such as norepinephrine, vasopressin, epinephrine, phenylephrine, and dobutamine to name a few, each having a different mechanism of action. Midodrine is an oral vasopressor that was patented in 1965 in Austria [3,4] and was first reported in 1970 as a novel orally administered peripherally acting alpha receptor agonist with good enteral absorption [3,5]. It increases blood pressure by raising systemic vascular resistance.…”

In this Issue of CCR

“…Among such potentially useful agents, midodrine has been more systematically investigated than others. In this issue of Critical Care and Resuscitation, the evidence behind its use and the accruing data of limited efficacy in the ICU population are presented in a narrative review 1 and commented upon by the associated editorial. 2 Such assessment of current knowledge about midodrine is of clear relevance to all practising intensivists.…”