4. Midodrine for diuretic intractable ascites with hyponatremia

Abstract

Background and Aims: Midodrine hydrochloride is an orally available, α-adrenergic agonist that increases effective circulating blood volume and renal perfusion by increasing systemic and splanchnic blood pressure. There is scanty data besides the study from North India, on use of midodrine in patients with cirrhosis and ascites with an additional component persistent hyponatremia and hypotension. Methods: In this single center observational study patients with diuretic intractable ascites (EASL criteria) with persistent hyponatremia (Serum Sodium <130 mEq/L) even after withholding the diuretics and albumin replacement (100 ml 20% per day) for 3 consecutive days were started on Midodrine 5 mg three times a day. The dose was increased to 7.5 mg three times a day at the end of 7 days if mean arterial pressure (MAP) remained less than 80. Tolvaptan 15 mg once a day was added at 15 days if serum sodium remained <125 mEq/L at 2 weeks. We excluded patients if there was proven sepsis or renal dysfunction (serum creatinine 1 mg/dl). Serum sodium was measured every week. Results: Ten patients were included (7 NASH, 3 ALD). The Mean age was 49 ± 2.1 years, with pretreatment MAP 73 mm of Hg (Range 70–78) serum sodium of 127 mEq/L (Range 118–130). At the end of six weeks, 6 patients were on 5 mg dose while 4 patients were on 7.5 mg dose. Only one patient required tolvaptan for 14 days (stopped once serum sodium reached 140). The mean arterial pressure was 86 mg of Hg (P < 0.05) and mean serum sodium levels were 136 mEq/L (Range 132–139) (p < 0.05). We were able to reintroduce low dose diuretics in 4 patients. Conclusions: Midodrine use can successfully reverse hyponatremia related diuretic intractable refractory ascites in 40% cases besides significantly improving serum sodium levels and mean arterial blood pressures. The author has none to declare.