Why should we care about using Midodrine in the ICU?
Use of midodrine can shorten the duration of vasopressor use in our patients during the recovery phase of distributive shock, helping us transfer patients out of the ICU faster.
Is this use of midodrine FDA-approved?
Nope, it’s off-label. Midodrine is only FDA-approved for symptomatic orthostatic hypotension (1).
How does it work?
Desglymidodrine, the active metabolite of midodrine, stimulates the alpha-1 adrenergic receptors of the arteriolar and venous capacitance vessels causing vasoconstriction (1). Some call it “oral phenylephrine.”
The FDA-recommended dose for orthostatic hypotension is 10mg orally 3 times daily (1). For the purposes of weaning IV vasopressors, doses found in the literature range from 5 to 40mg orally every 8 hours (2,3,4).
Side effects to actually worry about:
Sure, we all know about piloerection, urinary retention and others, but what about compensatory reflex bradycardia? This is shown to have an incidence of up to 9-15% in the literature (4).
How much money can we save our hospitals?
Word on the street is that a hospital bed costs $3000-$4000 a day (5). A 10mg tab of midodrine costs up to $10. Simple math will reflect big time savings, even if this only works on several patients at your shop per week.
How long until more robust data is published?
It shouldn’t be long. Three randomized, double-blind, placebo controlled trials are in the works as per clinicaltrials.gov. The MIDAS trial out should be out relatively soon (5).
Levine AR, Meyer MJ, Bittner EA, et al. Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions. J Crit Care. 2013;28(5):756–762. doi:10.1016/j.jcrc.2013.05.021
Whitson MR, Mo E, Nabi T, et al. Feasibility, Utility, and Safety of Midodrine During Recovery Phase From Septic Shock. Chest. 2016;149(6):1380–1383. doi:10.1016/j.chest.2016.02.657
Rizvi MS, Trivedi V, Nasim F, et al. Trends in Use of Midodrine in the ICU: A Single-Center Retrospective Case Series. Crit Care Med. 2018;46(7):e628–e633. doi:10.1097/CCM.0000000000003121
Anstey MH, Wibrow B, Thevathasan T, et al. Midodrine as adjunctive support for treatment of refractory hypotension in the intensive care unit: a multicenter, randomized, placebo controlled trial (the MIDAS trial). BMC Anesthesiol. 2017;17(1):47.
should one use the oral midodrine and dose of iv hydrocortisone in the ed before starting pressors iv? But myself as the ed doc before any micu consultation? My micu colleagues do this to hold off iv pressor use. Or taper off patients on low dose iv pressors for septic shock.
I would be perfectly cool if my buddies the ED did not worry about using midodrine in their arena. Some may delay starting vasopressors waiting for midodrine to work when in fact it won’t work for everyone. The latter is the best use noted in the literature.
I’m not sure what to do with this now that MIDAS is out (3 Sept 2020) showing no reduction in time on vasopressors with midodrine. I’ve always found phenylephrine to be pretty ineffective when the patient is already on levophed/epi/vasopressin (or some combo of that). Maybe it’s better left for hemodialysis associated hypotension, or those borderline patients?
Justin, depends on your patient population. The MIDAS trial was extremely well done and worth consideration. Amongst the patients, however, 19.7% of those were patients recovering from septic shock. The majority were surgical patients. Later this year or perhaps early next year there will be a focused 3-arm study looking at midodrine specifically in septic shock. Amongst the people who I’ve discussed the MIDAS trial personally with, including myself, no one who is a midodrine believer has changed their stance which is the opposite of what EBM is supposed to do (haha).