Safety & Clinical Use of Droxidopa for Midodrine Augmentation in Vasopressor Weaning in Septic Shock

Tuesday, March 24, 2026

12:30 PM - 1:30 PM Central Time

Location: Connections Central - RST 18

PP

Parth Pancholi, MD

New York

Disclosure(s): No relevant financial relationship(s) to disclose.
DY

Daniel Ying, DO

Pulmonary/Critical Care Attending
Mount Sinai Hospital System

Disclosure information not submitted.
JZ

Jordan Zhou, MD

Resident Anesthesiologist
Mount Sinai Hospital System

Disclosure information not submitted.
PS

Pranav Sathe, MD

Hospitalist, Clinical Instructor, Associate Professor of Health Sciences
UCLA

Disclosure information not submitted.
CB

Chirag Bhatia, MD

Internal Medicine Resident
Northwell Health

Disclosure information not submitted.
RM

Rohit Munagala, MD

Pulmonary/Critical Care Fellow
Loyola Medicine Chicago

Disclosure information not submitted.
KF

Keith Falsetta, PharmD, BCCCP

Clinical Pharmacy Specialist
Long Island Jewish Medical Center

Disclosure information not submitted.
EL

Evelyn Luo, PharmD, BCCCP

Clinical Pharmacy Specialist
North Shore Medical Center

Disclosure information not submitted.
KS

Krislyn Schweiger, PharmD, BCPS, BCCCP

Clinical Pharmacy Specialist
Long Island Jewish Medical Center

Disclosure information not submitted.

Introduction: Intravenous vasopressors support blood pressure in shock, with gradual weaning as hemodynamics stabilize. Some patients require prolonged low-dose vasopressors, extending ICU stays. Oral midodrine aids weaning but can cause reflex bradycardia. Droxidopa, an oral norepinephrine prodrug approved for neurogenic orthostatic hypotension, has shown potential in vasopressor weaning based on case reports. However, its safety and efficacy in combination with midodrine are unclear. This study evaluates the clinical use, safety, and effectiveness of droxidopa in augmenting midodrine for IV vasopressor weaning.

Methods: This multicenter retrospective review assessed droxidopa use to support blood pressure in patients on maximal midodrine therapy (30mg q8h) undergoing vasopressor weaning for septic shock between July 19th, 2023, and October 4th, 2024. Electronic medical records were reviewed for demographics, safety outcomes, ICU/hospital lengths of stay, timing of droxidopa initiation, vasopressor discontinuation, discharge regimens, and overall outcomes.

Results: Norepinephrine dose at droxidopa initiation was 0.04 mcg/kg/min [0.02-0.08]. The median [IQR] starting droxidopa dose was 200mg q8h [100-200]. Time to first droxidopa dose was 157.5 hours [94-407.9]. At ICU discharge, the median droxidopa dose was 200mg q8h [100-400]. The ICU length of stay was a median of 7.15 days [5.07-11.79]. Time from droxidopa initiation to IV vasopressor discontinuation was a median of 24.53 hours [7.73-86.62]. Of the 19 patients, 10 were discharged and 9 expired during hospitalization. Among discharged patients, 5 (50%) were off all oral vasopressors, 2 (20%) remained on midodrine, 2 (20%) on droxidopa, and 1 (10%) on both. Seven patients required re-initiation of IV vasopressors more than 24 hours after discontinuation. No sustained tachycardia, bradycardia, or ICU delirium was observed.

Conclusions: Droxidopa augmentation of midodrine for vasopressor weaning in septic shock appears feasible, as it was well tolerated and most patients were successfully weaned off IV vasopressors. Further studies are needed to evaluate the long-term impact of dual therapy on ICU lengths of stay and outcomes in patients requiring extended hospitalization.