In this episode, I’ll discuss the first randomized controlled trial of midodrine for weaning vasopressors.
Using midodrine to wean ICU patients off of vasopressors is a common strategy and one that I have used in my practice and discussed in previous episodes.
The general principle is that some ICU patients seem otherwise medically stable, yet cannot completely wean off of their vasopressor without episodes of hypotension. This delays their stay in the ICU when they would otherwise be eligible for transfer to a lower level of care.
Previous studies using midodrine to wean ICU patients off vasopressors have been prospective, observational trials and/or retrospective trials of dozens to several hundred patients that have suggested a benefit to using midodrine in this manner.
The primary issue of concern in these trials was, after the patient was transferred out of the ICU, when was the midodrine to be discontinued?
In Intensive Care Medicine authors recently published the first randomized controlled trial looking at midodrine for weaning ICU patients off vasopressors.
The authors enrolled adult patients with hypotension requiring a single-agent intravenous vasopressor for at least 24 h. Subjects received oral midodrine 20 mg or placebo every 8 hours in addition to usual care until the vasopressor could be weaned, ICU discharge, or occurrence of adverse events. The primary outcome was time to vasopressor discontinuation.
136 patients were enrolled. Time to vasopressor discontinuation was not different between midodrine and placebo groups. Several secondary outcomes were examined but these too were no different than placebo.
The only statistically significant difference between groups was that bradycardia occurred more often after midodrine administration (5 vs 0, p = 0.02).
Because there was no benefit and a higher rate of bradycardia in the midodrine group, this trial does not support the practice of routinely using midodrine to wean ICU patients off of vasopressors.
It is possible the study’s population was too heterogeneous, and that a subpopulation of patients exists that might benefit from this therapy. However, the higher rate of bradycardia and the finding of no benefit from the only randomized trial must be considered before using midodrine for weaning off vasopressors.
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