Midodrine Utilization After Medical Intensive Care Unit Initiation

Introduction: Midodrine is an oral alpha 1-adrenergic agonist used off-label in intensive care units (ICUs) to facilitate vasopressor weaning and therefore ICU discharge. While observational studies had shown benefit, randomized controlled trials failed to demonstrate a significant difference. Given midodrine’s unclear role, this study aimed to describe the clinical course and prevalence of patients newly initiated on midodrine in the medical ICU (MICU).


Methods: This single-center, retrospective, descriptive study included patients initiated on midodrine while admitted to the MICU between January and December 2023. Patients were excluded if they received fewer than 24 hours of midodrine. The primary outcome was the percentage of patients discharged home on midodrine. Secondary outcomes included ICU and hospital length of stay, in-hospital mortality, incidence of ICU re-admission following initial MICU discharge and incidence of bradycardia.


Results: Twenty-five patients were included. There were 2 (8%) patients that were discharged from the hospital on midodrine after initiation in the MICU. Of the patients discharged on midodrine, neither were discharged on co-prescribed antihypertensives. Midodrine was started for ICU hypotension in 98% of patients, and 60% of patients were on pressors at the time of midodrine initiation. At ICU discharge, 84% (16/19) of patients remained on midodrine. In-hospital mortality was 40%, higher than the hospital’s average (26%) but was consistent with severity of illness based on the cohorts’ average SOFA score. There were 5 (20%) ICU readmissions, 4 of whom died prior to discharge. Upon hospital discharge, 66% (10/15) of patients had a discharge disposition that necessitated a higher level of care than their original admission. No bradycardia was observed during midodrine use.


Conclusions: Overall, patients were infrequently discharged on midodrine after ICU initiation, their mortality was in line with their SOFA score estimate, and they often necessitated a higher level of care at discharge.