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Correspondence |

Considerations on Midodrine Use in Resolving Septic Shock FREE TO VIEW

Drayton Adam Hammond, PharmD, MBA; Melanie N. Smith, PharmD; Nikhil Meena, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Drayton Adam Hammond, PharmD, MBA, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, 4301 W Markham St, Slot 522, Little Rock, AR 72205


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(6):1582-1583. doi:10.1016/j.chest.2016.03.054
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We read the study by Whitson et al in this issue of CHEST (June 2016) with great interest. We applaud their creativity regarding the replacement of IV vasopressors with midodrine in the recovery phase of septic shock, which may have financial benefits without compromising patient care. The investigators suggest that adding midodrine reduced the duration of vasopressor use and ICU length of stay, a finding different from that of Poveromo et al. These disparate findings may be due to different patient populations and midodrine dosing schemes.

In the study by Whitson et al, midodrine was initiated during a period of clinical stability associated with stable or decreasing doses of IV vasopressors; however, patients receiving stable doses of IV vasopressors are in a different stage in the recovery phase of septic shock than patients receiving decreasing doses. Further distinction of each group should help guide clinical interpretation of midodrine’s effect. In addition, comparing the time IV vasopressors are administered after protocolized initiation of midodrine according to set guidelines may better elucidate the true impact of midodrine on vasopressor duration and ICU length of stay.

Whitson et al did not describe vasopressin usage in their study. If vasopressin were used, a description of the order in which IV vasopressors were discontinued would allow for better interpretation of IV vasopressor reinitiation. Discontinuation of vasopressin prior to discontinuation of norepinephrine is associated with a greater incidence of hypotension requiring intervention. In addition, we would appreciate direction regarding corticosteroid titration, as many institutions use different strategies. The investigators reported that 1 patient developed bradycardia compared with zero patients and 12.8% in other studies. The low complication rates are encouraging and will be verified in an ongoing trial.

Our institution initiates midodrine 20 mg every 8 h, which was the modal dose in this study and a previous prospective study. We increase the midodrine dose by 10 mg per dose per day each day to a maximum dosage of 40 mg every 8 h until IV vasopressors have been discontinued. We do not decrease the midodrine dose until patients are free of IV vasopressors for at least 24 h. Despite the investigators’ lack of a dosing protocol, insight into the most commonly used dose titration strategies would be useful. We routinely titrate down our corticosteroids at the same time as midodrine, which may resemble the practice of Whitson et al as well.

We appreciate this study and anticipate results from a prospective, randomized trial to help guide safe and effective midodrine use in resolving septic shock.

References

Whitson M.R. .Mo E. .Nabi T. .et al Feasibility, utility, and safety of midodrine during recovery phase from septic shock. Chest. 2016;149:1380-1383 [PubMed]journal
 
Poveromo LB, Michalets EL, Sutherland SE. Midodrine for the weaning of vasopressor infusions [published online ahead of print March 4, 2016].J Clin Pharm Ther.http://dx.doi.org/10.1016/10.1111/jcpt.12375.
 
Bauer S.R. .Aloi J.J. .Ahrens C.L. .Yeh J.Y. .Culver D.A. .Reddy A.J. . Discontinuation of vasopressin before norepinephrine increases the incidence of hypotension in patients recovering from septic shock: a retrospective cohort study. J Crit Care. 2010;25:362.e7-362.e11 [PubMed]journal
 
Levine A.R. .Meyer M.J. .Bittner E.A. .et al Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions. J Crit Care. 2013;28:756-762 [PubMed]journal. [CrossRef] [PubMed]
 
National Institutes of Health Clinical Center. Midodrine for the treatment of refractory hypotension.NCT01531959.ClinicalTrials.gov. Bethesda, MD: National Institutes of Health; 2016.https://clinicaltrials.gov/ct2/show/NCT01531959. Updated March 29, 2016.
 

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References

Whitson M.R. .Mo E. .Nabi T. .et al Feasibility, utility, and safety of midodrine during recovery phase from septic shock. Chest. 2016;149:1380-1383 [PubMed]journal
 
Poveromo LB, Michalets EL, Sutherland SE. Midodrine for the weaning of vasopressor infusions [published online ahead of print March 4, 2016].J Clin Pharm Ther.http://dx.doi.org/10.1016/10.1111/jcpt.12375.
 
Bauer S.R. .Aloi J.J. .Ahrens C.L. .Yeh J.Y. .Culver D.A. .Reddy A.J. . Discontinuation of vasopressin before norepinephrine increases the incidence of hypotension in patients recovering from septic shock: a retrospective cohort study. J Crit Care. 2010;25:362.e7-362.e11 [PubMed]journal
 
Levine A.R. .Meyer M.J. .Bittner E.A. .et al Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions. J Crit Care. 2013;28:756-762 [PubMed]journal. [CrossRef] [PubMed]
 
National Institutes of Health Clinical Center. Midodrine for the treatment of refractory hypotension.NCT01531959.ClinicalTrials.gov. Bethesda, MD: National Institutes of Health; 2016.https://clinicaltrials.gov/ct2/show/NCT01531959. Updated March 29, 2016.
 
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