Thread by @MayoPharmRes

PGY1 Resident @NatalieHaddadRx will be presenting an exciting Grand Rounds topic today. Join us with live tweets starting at 11 am CST as she discusses the role of midodrine for vasopressor discontinuation!

Use of #midodrine has increased nearly 50% from 2011 through 2016, and its use has likely increased further in recent years. What is its role in vasopressor discontinuation?

Midodrine is a prodrug with its active metabolite desglymidodrine acting as an alpha-1 agonist. Its peak effect on blood pressure occurs in 1-2 hours with a half life of 3-4 hours. ⌛️

So, why might we want to use midodrine for this purpose? In recent years, many more studies assessing this off-label use have been published.

When we add midodrine, are we able to titrate of vasopressors more quickly? While Levine et al. found decreased vasopressor use after addition of midodrine, limitations include the observational design and TID midodrine dosing strategy.

Whitson et al. included patients with higher APACHE scores and baseline vasopressor doses compared to Levine et al. Patients on midodrine had significantly shorter ICU length of stay.

13% were continued on midodrine at hospital discharge - this is likely inappropriate!🏥

In another retrospective study, we saw every 6 hour dosing, which may be more appropriate given midodrine's half life. There were several significant differences in the baseline characteristics between the two groups.

While the authors found no difference in ICU length of stay, they actually found a significant difference in hospital length of stay that favored the group who received vasopressors alone. Many limitations of this study that must be considered when interpreting these findings.

What have we learned from the presented studies so far?

#PharmICU #TwitteRx

In 2020, the #MIDAS trial was published to further investigate the role of midodrine in vasopressor discontinuation. Interestingly, they looked at ICU discharge readiness to eliminate interference of logistical barriers to discharge.

#MIDAS included only 66 patients in each arm, while recruitment lasted ~7 years. Patients had low baseline vasopressor requirements. They did not find a statistically significant difference between groups in efficacy outcomes, but did see more bradycardia in the midodrine group.

There are several characteristics of the #MIDAS trial that may limit the applicability of results to a more acutely ill ICU patient population.

Would you/do you use midodrine in ICU patients for vasopressor discontinuation?

Comment below to describe your ideal patient who may benefit from #midodrine!

#TwitteRx #PharmICU #MedEd #ICU

@NatalieHaddadRx presents an algorithm that may guide place in therapy of midodrine as well as pearls for midodrine use in this setting.

Several questions remain to be answered regarding midodrine use in vasopressor discontinuation. Thank you @NatalieHaddadRx for reviewing what we know thus far!

Next week, join us next week to hear PGY1 Mankato Residnet Madison Fazio present on gout management!