Introduction: Patients admitted to intensive care units (ICU) often require vasopressors to maintain normotension and can be difficult to wean, potentially leading to longer ICU stays. Midodrine has been used off-label for vasopressor-sparing hypotension in the ICU but according to the MIDAS trial, did not accelerate liberation from vasopressors when compared to placebo. However, midodrine is still used for vasopressor weaning but there is no evidence describing an appropriate starting dose. Therefore, the purpose of this study was to evaluate the safety, efficacy, and impact on the patient outcomes of the midodrine starting dose in patients with various shock states on vasopressors. Methods: This was a single-center, retrospective cohort study comparing patients receiving midodrine at low dose (< 15 mg/day) or high dose (≥ 15 mg/day) and concomitant vasopressors. Patients in the ICU at Baptist Health Medical Center from January 31, 2021 to June 1, 2024 receiving both therapies for at least 24 hours were evaluated. The primary outcome was time to vasopressor discontinuation between the two groups. Secondary outcomes included ICU length of stay, hospital length of stay, in-hospital mortality, number of midodrine dose escalations, time to midodrine discontinuation, rebound hypotension, and percent change in total vasopressor requirements at 24 and 48 hours post-midodrine initiation. Results: A total of 84 patients were included, 30 patients in the low dose group and 54 patients in the high dose group. The primary end-point showed a median of 96 hours (IQR 48-144) to vasopressor discontinuation in the high-dose group, as compared to 48 hours (IQR 24-162) in the low-dose group (p=0.458).Patients in the high-dose group exhibited higher predicted ICU morality (SAPS II score of 52.6 vs. 41.5, P=0.011), had a longer duration of vasopressors prior to midodrine initiation. There were no differences in secondary outcomes. Conclusions: Among patients receiving vasopressors and midodrine concomitantly, the high dose (≥ 15 mg) group did not lead to a quicker time to vasopressor discontinuation when compared to the low dose (< 15 mg) group.
Wiley et al. (Sun,) studied this question.