Midodrine initiation criteria, dose titration, and adverse effects when administered to treat shock: A systematic review and semi-quantitative analysis
Categoria dell'articolo: Review
Pubblicato online: 31 gen 2025
Pagine: 5 - 22
Ricevuto: 15 mag 2024
Accettato: 16 gen 2025
DOI: https://doi.org/10.2478/jccm-2025-0007
Parole chiave
© 2025 Madeleine M. Puissant et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Objective
Systematically examine the literature describing midodrine to treat shock and to summarize current administration and dosing strategies.
Data sources
Structured literature search conducted in MEDLINE (PubMed) from inception through May 10, 2023.
Study Selection and Data Extraction
Abstracts and full texts were assessed for inclusion by two blinded, independent reviewers. English-language publications describing use of midodrine in adult patients with shock were included. Data were extracted by two blinded, independent abstractors using a standardized extraction tool. Quality assessments were completed by paired reviewers using JBI methodology.
Data Synthesis
Fifteen of 698 (2%) screened manuscripts were included with 1,714 patients with a variety of shock types. Seven studies (47%) were retrospective, two (13%) prospective observational, and six (40%) randomized controlled studies. Midodrine was initiated to facilitate intravenous vasopressor (IVP) weaning in most (11, 73%) studies; only two (13%) reported IVP weaning protocol use. Starting doses were 10 mg every 8 hours (4, 27%) or three times a day (3, 20%), 20 mg every 8 hours (2, 13%); six studies (40%) did not report initial midodrine dosing. A midodrine titration protocol was reported in 6 (40%) studies. Thirteen (87%) studies evaluated for bradycardia, identified in 6 (46%) studies among 204 patients; only one (0.5%) patient required midodrine discontinuation. Three (20%) studies reported on hypertension with an incidence of 7–11%. Four (27%) studies assessed for ischemia; 5/1128 (0.4%) patients experienced mesenteric ischemia requiring midodrine discontinuation.
Relevance to Patient care and Clinical Practice
This review explores the pragmatic details involved in initiating, titrating, and weaning midodrine for the bedside clinician and identifies rates of adverse events and complications.
Conclusions
Published literature describing midodrine use for shock is heterogeneous and comprised primarily of low or very low quality data. Future controlled trials addressing the shortcomings identified in this systematic review are warranted.