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Abstract

We appreciate the correspondence of Drs Hammond, Smith, and Meena and their interest in our study examining the use of midodrine during resolution of septic shock.1Whitson M.R. Mo E. Nabi T. et al.Feasibility, utility, and safety of midodrine during recovery phase from septic shock.Chest. 2016; 149: 1380-1383Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar In response to their comments regarding the findings of our study compared with a recent retrospective study by Poveromo et al,2Poveromo 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/10.1111/jcpt.12375.Google Scholar we agree that the populations in the two studies were markedly different. In the study by Poveromo et al,2Poveromo 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/10.1111/jcpt.12375.Google Scholar < 15% of patients received a diagnosis of septic shock, and “providers elected to use midodrine in a patient population inherently different from those who did not receive midodrine.” In their study, midodrine was used predominantly in patients who had already failed IV vasopressor weaning. In addition, the midodrine doses observed in our study were twice those observed by Poveromo et al.2Poveromo 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/10.1111/jcpt.12375.Google Scholar Midodrine has been shown to reduce the dosage of IV vasopressors,3Levine 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: 756-762Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar and our findings of a shortened ICU length of stay may be secondary to our unique patient population experiencing vasoplegia in septic shock and the early institution of higher doses of midodrine prior to failed or difficult weaning of IV vasopressors. We had no written protocol for patient selection or administration of midodrine, but in accordance with our usual practice, midodrine was not given to patients taking multiple vasopressors, including vasopressin in combination with norepinephrine or phenylephrine. A minority of patients in our study received corticosteroids (26% and 28% in each group), and it is our practice to rapidly reduce steroid doses after IV vasopressor discontinuation simultaneous with a reduction in midodrine dosing. In our institution, midodrine is routinely initiated at 20 mg every 8 h and increased by 10 mg with each subsequent dose to a maximum of 40 mg every 8 h. Most patients receiving midodrine are discharged from the ICU once IV vasopressors have been discontinued for 24 h, and the dose of midodrine is then decreased by the primary team assuming care. We recommend the dose be decreased by 5 to 10 mg daily until discontinuation, but we cannot comment on the routine decremental titration of midodrine outside the ICU. We agree that randomized, placebo-controlled studies are needed to determine efficacy and the most appropriate patient selection and dosing protocols for midodrine use in patients with hypotension. Feasibility, Utility, and Safety of Midodrine During Recovery Phase From Septic ShockCHESTVol. 149Issue 6PreviewWe describe the feasibility, utility, and safety of oral midodrine to replace IV vasopressors during recovery from septic shock. Full-Text PDF Considerations on Midodrine Use in Resolving Septic ShockCHESTVol. 149Issue 6PreviewWe read the study by Whitson et al1 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.2 These disparate findings may be due to different patient populations and midodrine dosing schemes. Full-Text PDF