The Role of Midodrine for Hypotension Outside of the Intensive Care Unit

Gutman, Lawrence; Wilson, Ben

doi:10.22374/1710-6222.24.3.4

Cited by 6 publications

(7 citation statements)

References 26 publications

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“…Common adverse events are supine hypertension, piloerection, and scalp pruritus. 76 Screening for hypovolaemia is important as midodrine is not effective when plasma volume is reduced. Caution should be exercised in patients with renal failure or urinary retention.…”

Section: Discussionmentioning

confidence: 99%

Treatment strategies for clozapine-induced hypotension: a systematic review

Tanzer

Brouard

Pra

et al. 2022

Therapeutic Advances in Psychopharmacology

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Background: Clozapine is the most effective medication for treatment–refractory schizophrenia but is associated with significant adverse drug effects, including hypotension and dizziness, which have a negative impact on quality of life and treatment compliance. Available evidence for the management of clozapine-induced hypotension is scant. Objectives: Due to limited guidance on the safety and efficacy of pharmacological treatments for clozapine-induced hypotension, we set out to systematically review and assess the evidence for the management of clozapine-induced hypotension and provide guidance to clinicians, patients, and carers. Design: We undertook a systematic review of the safety and efficacy of interventions for clozapine-induced hypotension given the limited available evidence. Data Sources and Methods: PubMed, Embase, PsycINFO, CINAHL, and the Cochrane trial Registry were searched from inception to November 2021 for literature on the treatment strategies for clozapine-induced hypotension and dizziness using a PROSPERO pre-registered search strategy. For orthostatic hypotension, we developed a management framework to assist in the choice of intervention. Results: We identified nine case studies and four case series describing interventions in 15 patients. Hypotension interventions included temporary clozapine dose reduction, non-pharmacological treatments, and pharmacological treatments. Midodrine, fludrocortisone, moclobemide and Bovril® combination, and etilefrine were associated with improvement in symptoms or reduction in orthostatic hypotension. Angiotensin II, arginine vasopressin, and noradrenaline successfully restored and maintained mean arterial pressure in critical care situations. A paradoxical reaction of severe hypotension was reported with adrenaline use. Conclusion: Orthostatic hypotension is a common side effect during clozapine titration. Following an assessment of the titration schedule, salt and fluid intake, and review of hypertensive and nonselective α1-adrenergic agents, first-line treatment should be a temporary reduction in clozapine dose or non-pharmacological interventions. If orthostatic hypotension persists, fludrocortisone should be trialled with monitoring of potassium levels and sodium and fluid intake. Midodrine may be considered second-line or where fludrocortisone is contraindicated or poorly tolerated. For patients on clozapine with hypotension in critical care settings, the use of adrenaline to maintain mean arterial pressure should be avoided. Registration: PROSPERO (Registration No. CRD42020191530)

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Section: Discussionmentioning

confidence: 99%

Treatment strategies for clozapine-induced hypotension: a systematic review

Tanzer

Brouard

Pra

et al. 2022

Therapeutic Advances in Psychopharmacology

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“…Midodrine is an oral alpha agonist that is currently indicated in patients with orthostatic hypotension, intradialytic hypotension and blood pressure management in cirrhosis and hepatorenal syndrome. [7][8][9][10][11][12] Prior work has assessed midodrine efficacy in critically ill patients with mixed results. Earlier trials have demonstrated reduced duration of intravenous vasopressor therapy and a decreased ICU LoS with midodrine therapy.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis

et al. 2022

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IntroductionIntensive 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 analysisWe 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 disseminationEthics 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 numberCRD42021260375.

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“…Midodrine (a vasoconstrictor and αSNS-agonist) has been used for patients with low BP and HR with reduced EF (HFrEF), who have been precluded from instituting β-blockers and renin-angiotensin system blockers. Midodrine raises BP so patients may tolerate conventional pharmacological therapy [ 19 ].…”

Section: Pharmacological Therapymentioning

confidence: 99%

Autonomic Testing Optimizes Therapy for Heart Failure and Related Cardiovascular Disorders

DePace

Colombo²,

Mandal

et al. 2022

Curr Cardiol Rep

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Purpose of Review Cardiovascular autonomic control is an intricately balanced dynamic process. Autonomic dysfunction, regardless of origin, promotes and sustains the disease processes, including in patients with heart failure (HF). Autonomic control is mediated through the two autonomic branches: parasympathetic and sympathetic (P&S). HF is arguably the disease that stands to most benefit from P&S manipulation to reduce mortality risk. This review article briefly summarizes some of the more common types of autonomic dysfunction (AD) that are found in heart failure, suggests a mechanism by which AD may contribute to HF, reviews AD involvement in common HF co-morbidities (e.g., ventricular arrhythmias, AFib, hypertension, and Cardiovascular Autonomic Neuropathy), and summarizes possible therapy options for treating AD in HF. Recent Findings Autonomic assessment is important in diagnosing and treating CHF, and its possible co-morbidities. Autonomic assessment may also have importance in predicting which patients may be susceptible to sudden cardiac death. This is important since most CHF patients with sudden cardiac death have preserved left ventricular ejection fraction and better discriminators are needed. Summary Many life-threatening cardiovascular disorders will require invasive testing for precise diagnoses and therapy planning when modulating the ANS is important. In cases of non-life-threatening disorders, non-invasive ANS testing techniques, especially those that individually assess both ANS branches simultaneously and independently, are sufficient to diagnose and treat serially.

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The Role of Midodrine for Hypotension Outside of the Intensive Care Unit

Cited by 6 publications

References 26 publications

Treatment strategies for clozapine-induced hypotension: a systematic review

Treatment strategies for clozapine-induced hypotension: a systematic review

Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis

Autonomic Testing Optimizes Therapy for Heart Failure and Related Cardiovascular Disorders

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