Use of midodrine to discontinue intravenous vasopressors in intensive care unit patients

ABSTRACT

Purpose: Midodrine, an oral alpha-adrenergic agonist, has been used off-label in critically ill patients to facilitate discontinuation of intravenous (IV) vasopressors. The proposed benefits include earlier liberation from vasopressors and expedited ICU discharge. However, existing evidence has been inconsistent.

Methods: We searched PubMed using the MeSH terms “midodrine” and “vasoconstrictor agents” with filters for clinical studies in adults (≥19 years). Studies in patients with cirrhosis were excluded.

Results: Seven clinical studies were identified: three randomized controlled trials (RCTs), three retrospective studies, and one case-control study. Two RCTs with 62 and 132 patients found no difference in vasopressor duration or ICU length of stay with midodrine. One RCT demonstrated reduced vasopressor use and costs. Retrospective and case-control studies suggested limited or adjunctive benefits. Bradycardia was the most consistent adverse effect, reported in up to 15% of patients.

Conclusions: Evidence regarding midodrine’s efficacy in facilitating IV vasopressor dis­continuation is inconsistent. While some studies suggest potential benefit, most trials demonstrate no significant impact on vasopressor duration or ICU length of stay. Safety concerns, particularly bradycardia, warrant caution. Large, multicenter RCTs are needed before midodrine can be recommended as standard practice in ICU vasopressor management.