Abstract Introduction Prolonged dependence on intravenous (IV) vasopressors in intensive care unit (ICU) patients carries significant risks including prolonged ICU stay. While midodrine is often utilized as an oral adjunct, outcomes can be variable. Recent literature has investigated the use of droxidopa, an oral norepinephrine prodrug, to assist with vasopressor weaning. Droxidopa has been approved by the FDA for use in neurogenic orthostatic hypotension (nOH). Several studies have demonstrated that droxidopa improves nOH symptoms. Here, we present a case where droxidopa was used to wean norepinephrine in a patient on IV vasopressors for twenty-four days. Case Presentation 62-year-old male with multiple comorbidities, including end stage renal disease and chronic hypotension, was initially admitted with cellulitis of the left index finger. Further workup revealed a thrombosed left brachial artery pseudoaneurysm warranting surgical intervention. Intraoperatively, he required blood transfusions and was then transferred to the ICU on IV vasopressors. Despite fluid challenges, clinical improvement, and maximally tolerated dose of midodrine, he remained hypotensive with mean arterial pressures (MAP) less than 60 when attempts were made to discontinue norepinephrine. To account for vasoplegic shock refractory to catecholamines, a trial of titratable vasopressin was initiated. Attempts were also made to liberalize blood pressure goals by allowing for a lower systolic goal of 80 or higher at night. However, these measures were insufficient at maintaining hemodynamic stability. On day twenty-four of his ICU stay, he remained on low dose norepinephrine (0.01-0.025 mcg/kg/min) and midodrine (15mg every 8 hours). After exhausting all options, droxidopa was initiated, and the patient was successfully weaned off of norepinephrine within three days. Discussion Our case reinforces the use of droxidopa for weaning IV vasopressors in critically ill patients. Droxidopa is converted to norepinephrine by dopa-decarboxylase, and unlike midodrine, acts on both alpha- and beta-adrenergic receptors. While its approved indication is nOH, recent studies have shown that administration of droxidopa decreases IV vasopressor requirements and increases MAP. In one study, IV vasopressors were discontinued within a median time of seventy hours after initiating droxidopa. In this case, droxidopa provided a solution for persistent hypotension when standard measures were ineffective. This medication may allow for safer transition from IV therapy to reduce ICU length of stay and complications of prolonged IV vasopressor use. Limitations include the absence of large clinical trials, cost, and dosing protocols. This abstract is funded by: none
Jilani et al. (Fri,) studied this question.