(914) Use of Droxidopa to Facilitate Intravenous Vasopressor Weaning in Critically Ill Patients

Introduction: Limited evidence exists regarding the use of enteral droxidopa for intravenous (IV) vasopressor weaning in critically ill patients. At Stanford Health Care (SHC), midodrine is often the first line enteral agent for weaning IV vasopressors in patients with refractory vasoplegia in the intensive care unit (ICU). In patients who have vasodilatory shock refractory to midodrine or are unable to tolerate midodrine, droxidopa, an alpha/beta- agonist, is often trialed. This study describes the efficacy and safety of droxidopa for facilitating IV vasopressor weaning.

Methods: This was a single-center, retrospective study of adult patients admitted to the ICU at SHC. Patients were included if they received > 4 consecutive doses of droxidopa for IV vasopressor weaning from 1/2016 – 7/2024. Patients were excluded if they were on droxidopa prior to admission, if they clinically deteriorated, or transitioned to comfort care within 48 hours. The primary outcome was discontinuation of IV vasopressor without re-initiation within 72 hours of droxidopa initiation. Adverse events assessed included hypotension, hypertension, and arrythmias.

Results: Thirty-three patients were included for analysis. Patients were on a median of 1 (IQR 1-2) vasopressor at time of droxidopa initiation. The most common IV vasopressors were norepinephrine (49%) and vasopressin (33%). Thirty patients (91%) were on midodrine at the time of droxidopa initiation with a median daily midodrine dose of 80 mg (IQR 60-120). Median time from ICU admission to droxidopa initiation was 25 days (IQR 11-38). The median droxidopa initial total daily dose was 300 mg (IQR 300-300) and median maximum daily dose was 600 mg (IQR 300-1200) with a median duration of 8 days. Eighteen (55%) patients received concomitant steroids and 6 (18%) received concomitant sedatives. Vasopressors were stopped within 72 hours of droxidopa initiation in 11 (40%) patients with no adverse events or ICU readmissions related to droxidopa. Seven patients (26%) were discharged from the hospital on droxidopa.

Conclusions: Droxidopa may be a safe and effective option to facilitate weaning IV vasopressors in patients with hypotension refractory to midodrine. Given the retrospective nature of this study, larger prospective studies are warranted to confirm these findings.