(922) Impact of a Pharmacist-Led Titration Protocol on Midodrine Continuation Rates at Transitions of Care

Introduction: Midodrine is an oral vasoconstrictor that is utilized in critically ill patients to aid in weaning intravenous vasoactive agents and expedite transfer out of the intensive care unit (ICU). Due to increased utilization of ICU-initiated midodrine, evidence has shown high rates of unintended continuation without optimal transitions of care post-ICU. This study evaluated the impact of a formalized pharmacist-led titration protocol on midodrine discontinuation rates at ICU and hospital discharge.

Methods: This was a pre-post protocol implementation retrospective study at a community teaching hospital conducted from January 2022 through August 2022 and September 2023 through February 2024, respectively. Patients were included if they were on ICU-initiated midodrine for vasopressor weaning. After protocol implementation, patients were evaluated daily by pharmacists for dose reductions until midodrine discontinuation or hospital discharge. The primary objective was to evaluate the difference in midodrine discontinuation rates at ICU and hospital discharge pre- and post-implementation of a pharmacist-led titration protocol. Secondary objectives included the incidence of antihypertensive therapy initiation while on midodrine and the incidence of vasopressor reorder and re-initiation after the addition of midodrine therapy during the same encounter.

Results: The study included 127 patients, 104 in the pre-implementation phase and 23 in the post-implementation phase. The two groups were similar with the most common ICU admission diagnoses including trauma, respiratory failure, and sepsis/septic shock; and in the average vasoactive-inotropic score at the time of midodrine initiation. Midodrine was continued beyond hospital discharge in 47.2% of patients in the pre-implementation group compared to 21.7% of patients in the post-implementation group, (p=0.0351). There was no statistically significant difference in initiation of antihypertensive therapy, 32.7% vs 30.4% (p=1.0), or re-initiation of vasopressors, 6.7% vs 4.3% (p=1.0).

Conclusions: ICU-initiated midodrine for vasopressor weaning can be continued beyond the ICU and after hospital discharge; however, pharmacist assessment and intervention significantly decreased the number of patients that were discharged on midodrine.