Oral blood pressure augmenting agents for intravenous vasopressor weaning

Abstract

Intravenous (IV) vasopressors are essential in the management of hypotension and shock. Initiation of oral vasoactive agents to facilitate weaning of IV vasopressors to liberate patients from the intensive care unit is common despite conflicting evidence regarding the benefits of this practice. While midodrine appears to be the most frequently studied oral vasoactive agent for this purpose, its adverse effect profile may preclude its use in certain populations. In addition, some patients may require persistent use of IV vasopressors for hypotension refractory to midodrine. The use of additional and alternative oral vasoactive agents bearing different mechanisms of action is emerging. This article provides a comprehensive review of the pharmacology, clinical uses, dosing strategies, and safety considerations of oral vasoactive agents and their application in the intensive care setting.

Keywords: Vasopressor; Shock; Hypotension; Midodrine; Droxidopa; Atomoxetine; Pseudoephedrine

Core Tip: This paper sets to explore the evolving role of oral blood pressure augmenting agents in the intensive care setting. With their ability to increase blood pressure through direct or indirect vasoconstriction, these agents have been increasingly utilized to facilitate weaning from intravenous (IV) vasopressors. Use of these agents may have a role in reducing IV vasopressor exposure, intensive care unit lengths of stay, and overall healthcare resource utilization. Despite being commonly used, their role in practice should be tempered by lack of demonstrable efficacy in major trials and important adverse effect considerations.