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Niemann B, Zarfoss E, Victory J, Smida T, Petros K, Sestito M, Bardes J. Evaluation of Oral Vasoactive Medications to Maintain Mean Arterial Pressure in Spinal Cord Injury. J Surg Res 2024; 302:339-346. [PMID: 39137515 DOI: 10.1016/j.jss.2024.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 07/09/2024] [Accepted: 07/13/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION An acute spinal cord injury (SCI) results in significant morbidity worldwide. Guidelines recommend mean arterial pressure (MAP) augmentation to prevent hypoperfusion. Although there is no consensus on a single vasoactive agent for MAP augmentation, intravenous vasopressors are commonly utilized, requiring an intensive care unit (ICU). Beyond the financial burden for patients, ICU stays require significant hospital system resource utilization. Oral vasoactive agents, such as pseudoephedrine and midodrine, are also utilized for MAP augmentation, but little data on their efficacy are available. This study investigates the use and dosing of oral vasoactive agents as an alternative in MAP augmentation in SCI. MATERIALS AND METHODS Adult SCI patients were retrospectively investigated. Total daily vasoactive dose, treatment efficacy, and ICU length of stay were evaluated. RESULTS 141 patients were evaluated, with 7.1% receiving oral agents alone, and 80.9% receiving vasopressors who either transitioned to pseudoephedrine, pseudoephedrine plus midodrine, or no oral agent. Patients receiving oral agents trended toward decreased ICU stay, but there was no difference in vasopressor duration. Similar MAP goal success rates were found between groups. A variety of initial and maximum daily doses of PO agents were used. Median doses were 120 mg pseudoephedrine and 30 mg midodrine. Early initiation of pseudoephedrine resulted in shorter ICU stays. CONCLUSIONS This study demonstrated shorter ICU length of stay and similar MAP goal success with PO agents as compared to vasopressors. This may indicate these medications could be utilized to decrease the financial burden placed on patients and the health care system from lengthy ICU courses. This study is limited by a small sample size and variable agent dosing.
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Affiliation(s)
- Britney Niemann
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia.
| | - Erika Zarfoss
- Department of Pharmacy, West Virginia University Medicine, Morgantown, West Virginia
| | - Jack Victory
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Tanner Smida
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Karen Petros
- Department of Pharmacy, West Virginia University Medicine, Morgantown, West Virginia
| | - Michael Sestito
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | - James Bardes
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
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Gramish J, Hattan A, Aljuhani O, Parameaswari PJ, Alshehri S, Korayem GB, Alkofide H, Alalawi M, Vishwakarma R, Alsowaida YS, Alqahtani R, Binorayir L, Abutaleb M, Alotaibi A, Aljohani M, Aljohani S, Samreen S, Jawhari S, Alanazi R, Al Sulaiman KA. The Impact of Midodrine Tapering Versus Nontapering Regimens on the Clinical Outcomes of Critically Ill Patients: A Retrospective Cohort Study. Ann Pharmacother 2024; 58:223-233. [PMID: 37248667 DOI: 10.1177/10600280231173290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Midodrine has been used in the intensive care unit (ICU) setting to reduce the time to vasopressor discontinuation. The limited data supporting midodrine use have led to variability in the pattern of initiation and discontinuation of midodrine. OBJECTIVES To compare the effectiveness and safety of 2 midodrine discontinuation regimens during weaning vasopressors in critically ill patients. METHODS A retrospective cohort study was conducted at King Abdulaziz Medical City. Included patients were adults admitted to ICU who received midodrine after being unable to be weaned from intravenous vasopressors for more than 24 hours. Patients were categorized into two subgroups depending on the pattern of midodrine discontinuation (tapered dosing regimen vs. nontapered regimen). The primary endpoint was the incidence of inotropes and vasopressors re-initiation after midodrine discontinuation. RESULTS The incidence of inotropes or vasopressors' re-initiation after discontinuation of midodrine was lower in the tapering group (15.4%) compared with the non-tapering group (40.7%) in the crude analysis as well as regression analysis (odd ratio [OR] = 0.15; 95% CI = 0.03, 0.73, P = 0.02). The time required for the antihypertensive medication(s) initiation after midodrine discontinuation was longer in patients who had dose tapering (beta coefficient (95% CI): 3.11 (0.95, 5.28), P = 0.005). Moreover, inotrope or vasopressor requirement was lower 24 hours post midodrine initiation. In contrast, the two groups had no statistically significant differences in 30-day mortality, in-hospital mortality, or ICU length of stay. CONCLUSION AND RELEVANCE These real-life data showed that tapering midodrine dosage before discontinuation in critically ill patients during weaning from vasopressor aids in reducing the frequency of inotrope or vasopressor re-initiation. Application of such a strategy might be a reasonable approach among ICU patients unless contraindicated.
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Affiliation(s)
- Jawaher Gramish
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Hattan
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - P J Parameaswari
- Research Support Department, Research and Innovation Center, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Shaden Alshehri
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mai Alalawi
- Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
| | | | - Yazed Saleh Alsowaida
- Department of Clinical Pharmacy, College of Pharmacy, Hail University, Hail, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Luluh Binorayir
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Abutaleb
- Pharmaceutical Care Services, King Fahad Central Hospital, Jazan Health, Jazan, Saudi Arabia
| | - Alanoud Alotaibi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Majidah Aljohani
- Pharmaceutical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Sarah Aljohani
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sana Samreen
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Suad Jawhari
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Raghad Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research Platform, Riyadh, Saudi Arabia
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Athar ZM, Arshad M, Shrivastava S. Exploring the Efficacy of Midodrine for Tapering Off Vasopressors. Cureus 2024; 16:e55192. [PMID: 38558716 PMCID: PMC10981505 DOI: 10.7759/cureus.55192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Sepsis and septic shock represent critical conditions, often necessitating vasopressor support in the intensive care unit (ICU). Midodrine, an oral vasopressor, has gathered attention as a potential adjunct to vasopressor therapy, aiming to facilitate weaning and improve clinical outcomes. However, the efficacy of midodrine remains questionable, with conflicting evidence from clinical trials and meta-analyses. This article provides a comprehensive review of the literature on midodrine's role in ICU settings by gathering evidence from multicenter trials, retrospective studies, and meta-analyses. While some studies suggest a limited benefit of midodrine in expediting vasopressor weaning and reducing ICU/hospital stays, others report potential advantages, particularly in reducing mortality rates among septic shock patients. Ongoing efforts aim to address knowledge gaps surrounding midodrine's efficacy and safety.
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Affiliation(s)
| | - Mahnoor Arshad
- Internal Medicine, BronxCare Health System, New York, USA
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