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Continuation of Newly Initiated Midodrine Therapy After Intensive Care and Hospital Discharge: A Single-Center Retrospective Study

Rizvi, Mahrukh S. MD1; Nei, Andrea M. PharmD2; Gajic, Ognjen MD, MSc, FCCP, FCCM1; Mara, Kristin C. MS3; Barreto, Erin F. PharmD, MSc, FCCM1,4

doi: 10.1097/CCM.0000000000003814
Online Clinical Investigations

Objectives: Midodrine is an α1-agonist approved for orthostatic hypotension. Recently, it has received attention as an oral vasopressor to facilitate ICU discharge. The purpose of this study was to identify the incidence of continuation of newly initiated midodrine upon ICU and hospital discharge and identify risk factors associated with its occurrence.

Design: Single-center retrospective study.

Setting: ICU patients from January 2011 to October 2016 at Mayo Clinic, Rochester.

Patients: Adult patients admitted to any ICU who received new midodrine for hypotension and survived to discharge.

Interventions: None.

Measurements and Main Results: During the study period, 1,010 patients were newly started on midodrine and survived to ICU discharge. Midodrine was continued in 67% (672/1,010) of patients at ICU discharge. Admission to cardiovascular surgery ICU and mixed medical/surgical ICU was a risk factor for midodrine continuation at ICU discharge (odds ratio, 3.94 [2.50–6.21] and 2.03 [1.29–3.20], respectively). At hospital discharge, 34% (311/909) of patients were continued on midodrine therapy. History of congestive heart failure predicted midodrine continuation at hospital discharge (odds ratio, 1.49 [1.05–2.12]). Hypertension and use of mechanical ventilation were associated with a decreased odds of midodrine prescription at both ICU and hospital discharge. Of those discharged from the ICU or hospital on midodrine, 50% were concomitantly prescribed antihypertensives. Discharge from the ICU on midodrine was associated with a significantly shorter ICU length of stay (7.5 ± 8.9 vs 10.6 ± 13.4 d) and reduced risk of in-hospital mortality (hazard ratio, 0.47 [95% CI, 0.32–0.70]; p < 0.001), despite no difference in baseline severity of illness scores. In contrast, patients discharged from the hospital on midodrine had a higher risk of 1-year mortality (hazard ratio, 1.60 [95% CI, 1.26–2.04]; p < 0.001).

Conclusions: This study established a high prevalence of midodrine continuation in transitions of care. The risks and benefits of this practice remain unclear. Future studies should explore the impact of this practice on patient outcomes and resource utilization. These insights could be used to model interventions for proper tapering, discontinuation, or follow-up of new start midodrine.

1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.

2Department of Pharmacy, Mayo Clinic, Rochester, MN.

3Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN.

4Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.

This work was performed at the Mayo Clinic, Rochester, MN.

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Drs. Nei and Barreto disclosed off-label product use of midodrine. Dr. Barreto received funding from Fast Medical. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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