Oral midodrine does not expedite liberation from protracted vasopressor infusions: A case-control study

Abstract

Vasopressor dependence is a common problem affecting patients in the recovery phase of critical illness, often necessitating intensive care unit (ICU) admission and other interventions which carry associated risks. Midodrine is an orally administered vasopressor which is commonly used off-label to expedite weaning from vasopressor infusions and facilitate discharge from ICU. We performed a single-centre, case-control study to assess whether midodrine accelerated liberation from vasopressor infusions in patients who were vasopressor dependent. Cases were identified at the discretion of treating intensivists and received 20 mg oral midodrine every eight h from enrolment. Controls received placebo. Data on duration and dose of vasopressor infusion, haemodynamics and adverse events were collected. Between 2012 and 2019, 42 controls and 19 cases were recruited. Cases had received vasopressor infusions for a median of 94 h versus 29.3 h for controls, indicating prolonged vasopressor dependence amongst cases. Midodrine use in cases was not associated with faster weaning of intravenous (IV) vasopressors (26 h versus 24 h for controls, P = 0.51), ICU or hospital length of stay after adjustment for confounders. Midodrine did not affect mean heart rate but was associated with bradycardia. This case-control study demonstrates that midodrine has limited efficacy in expediting weaning from vasopressor infusions in patients who have already received relatively prolonged courses of these infusions.

Response to “What is a case-control study? Comment on ‘Oral midodrine does not expedite liberation from protracted vasopressor infusions: A case-control study’”

“…We thank Professor Myles for his correspondence ‘What is a case-control study?’ published in this edition of Anaesthesia and Intensive Care which clarifies the classification of case-control and cohort studies, in response to our original manuscript. 1 We agree our study is more appropriately categorised as a cohort study and thank Professor Myles for his constructive feedback.…”

The Impact of Midodrine Tapering Versus Nontapering Regimens on the Clinical Outcomes of Critically Ill Patients: A Retrospective Cohort Study

“…Several studies have documented the widespread use of midodrine among critically ill hypotensive patients despite the controversy over its effectiveness and safety. 15-18 There are studies showing that midodrine is useful for patients in the ICU receiving intravenous vasopressor treatment to expedite their discharge from the hospital 15,16 due to its impact on reducing intravenous vasopressor duration and improving their weaning period and mortality. 19-23 However, other studies reported that using midodrine resulted in extreme adverse events of bradycardia 10,11 and is not associated with a significant decrease in either ICU or hospital LOS, mortality, or ICU readmissions.…”

“…19-23 However, other studies reported that using midodrine resulted in extreme adverse events of bradycardia 10,11 and is not associated with a significant decrease in either ICU or hospital LOS, mortality, or ICU readmissions. 17,18 A recently published meta-analysis including 314 patients of four randomized controlled trials found no significant difference in the duration of vasopressor treatment between patients in the midodrine group versus the control groups. 24 It also found no difference between the two groups in the time to vasopressor stop, vasopressor restart, ICU LOS, and hospital LOS.…”

Midodrine for the early liberation from vasopressor support in the ICU (LIBERATE): A feasibility study

“…Previous studies have evaluated the use of midodrine for hemodynamic support in the ICU (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). The earliest of these involved retrospective exploratory cohort studies with inconsistent midodrine administration protocols, heterogeneous and poorly de ned patient populations, small sample sizes, and variable study outcomes (13)(14)(15).…”