Utilidad de la midodrina para controlar el síncope vasovagal: ¿la recomienda la evidencia? / Usefulness of Midodrine for the Control of Recurrent Vasovagal Syncope: Does the Evidence Recommend it? / Utilidade da midodrina no controle da síncope vasovagal: as evidencias a recomendam?

Introducción:El síncope vasovagal es la principal causa de pérdida transitoria de la conciencia, y es un motivo de consulta cada vez más frecuente en pediatría y medicina del adulto. La midodrina es un agonista de los recepto-res alfa, de acción periférica, empleada principalmente en el manejo de la hipotensión ortostática; sin embargo, también se ha evaluado en el síncope vasovagal, con resultados prometedores.Objetivo:Analizar la evidencia más reciente sobre la utilidad de la midodrina para el control y la prevención del síncope vasovagal.Materiales y métodos: Se realizó una búsqueda bibliográfica utilizando términos de búsqueda como Vasovagal Syncope y Midodrine, así como sinónimos, que se combinaron con operadores booleanos, en cinco bases de datos, hasta octubre del 2022. Se incluyeron estudios originales, revisiones sistemáticas y metanálisis, publicados tanto en inglés como en español.Resultados:Ensayos controlados aleatorizados y revisiones sistemáticas y metanálisis difieren ligeramente entre resultados, pero estos demuestran un efecto global protector. La evidencia más reciente y completa indica que utilizar este agente reduce significativamente la positividad al realizar la prueba de la mesa inclinada y que previene la aparición de episodios sincopales.Conclusiones:Aunque la evidencia actual sobre la eficacia de la midodrina respecto a la prevención y control del síncope vasovagal es limitada, se observa un efecto protector significativo, porque disminuye el riesgo de sufrir un episodio sincopal, aproximadamente hasta en un 50 %.Palabras clave: midodrina; síncope vasovagal; síncope; adrenérgicos; medicina basada en la evidencia

Introduction: Vasovagal syncope is the main cause of transient loss of consciousness, being an in-creasingly frequent reason for consultation in pediatrics and adult medicine. Midodrine, a periphe-rally acting alpha-receptor agonist, is mainly used in the management of orthostatic hypotension. However, it has also been evaluated in vasovagal syncope, with promising results. Objective: To analyze the most recent evidence on the usefulness of midodrine for the control and prevention of vasovagal syncope. Materials and Methods: A literature search was performed using search terms such as "Vasovagal Syncope" and "Midodrine," as well as synonyms, which were combined with Boolean operators, in 5 databases until October 2022. Original studies, systematic reviews and meta-analyses, published in both English and Spanish, were included. Results: Randomized controlled trials and systematic reviews and meta-analyses differ slightly between results, but these demonstrate an overall protective effect. The most recent and complete evidence shows that using this agent significantly reduces the probability of positivity when performing the tilt table test and prevents the occurrence of syncopal episodes. Conclusions: Although current evidence on the efficacy of midodrine with respect to the prevention and control of vasovagal syncope is limited, a significant protective effect is observed, reducing the risk of suffering syncopal episode by approximately up to 50%

Introdução: a síncope vasovagal é a principal causa de perda transitória de consciência e é um motivo cada vez mais comum de consulta em pediatria e medicina de adultos. A midodrina é um agonista do receptor alfa de ação periférica usado principalmente no tratamento da hipotensão ortostática; no entanto, ela também foi avaliada na síncope vasovagal, com resultados promissores. Objetivo: Revisar as evidências mais recentes sobre a utilidade da midodrina para o controle e a pre-venção da síncope vasovagal. Materiais e métodos: Foi realizada uma pesquisa na literatura usando termos de pesquisa como Va-sovagal, Syncope e Medodrine, bem como sinônimos, que foram combinados com operadores boo-leanos, em cinco bancos de dados, até outubro de 2022. Foram incluídos estudos originais, revisões sistemáticas e metanálises, publicados em inglês e espanhol. Resultados: Os ensaios clínicos randomizados, as revisões sistemáticas e as metanálises diferem ligei-ramente entre os resultados, mas demonstram um efeito protetor geral. As evidências mais recentes e abrangentes indicam que o uso desse agente reduz significativamente a positividade no teste de inclinação da mesa e evita a ocorrência de episódios de síncope. Conclusões: Embora as evidências atuais sobre a eficácia da midodrina em relação à prevenção e ao controle da síncope vasovagal sejam limitadas, observa-se um efeito protetor significativo, pois ela diminui o risco de sofrer um episódio sincopal em aproximadamente 50%

Crisis hipertensiva y bradicardia secundaria a intoxicación por midodrina / Hypertensive crisis and bradycardia secondary to midodrine intoxication

Resumen El síncope, definido como una pérdida transitoria de la conciencia que cursa con recuperación espontánea y completa, es secundario a un amplio grupo etiológico, incluido el de origen vasovagal desencadenado por una descarga adrenérgica u ortostatismo. El tratamiento de esta entidad incluye medidas no farmacológicas y farmacológicas, como la administración de midodrina, un agonista de los receptores a de acción periférica, usada en el control de la hipotensión ortostática y cuyo empleo ha demostrado mejoría en los síntomas de esta alteración. Se presenta el caso de una mujer de 18 años, con antecedente de síncope vasovagal en tratamiento con medidas no farmacológicas y midodrina desde seis meses antes, quien consultó al servicio de urgencias de un centro de atención de nivel IV por cuadro clínico consistente en ingestión intencionada de una sobredosis de midodrina. En el ingreso se documentaron crisis hipertensiva, bradicardia extrema y compromiso hepático y renal. Se indicó tratamiento sintomático con resolución de las alteraciones clínicas y paraclínicas e intervención del equipo de salud mental.

Abstract Syncope, defined as a transitory loss of consciousness characterised by its rapid onset, short duration, and spontaneous complete recovery, is secondary to a wide ethiological group, such as the vasovagal origin triggered by an adrenergic discharge or orthostatism. The management of this entity includes both non-pharmacological measures and pharmacological treatment such as the use of midodrine, a peripherally acting alpha receptor agonist, used in the management of orthostatic hypotension, whose use has shown improvement in the symptoms of this condition. We present a clinical case of an 18-year-old woman, with a history of vasovagal syncope under treatment with midodrine and non-pharmacological measures for 6 months, who was admitted to the emergency department of a level IV care center due to an intentional intake of midodrine overdose. Upon admission, a hypertensive crisis with extreme bradycardia, and liver and kidney involvement were documented. Symptom´s management was started with resolution of clinical and paraclinical alterations, and intervention by the mental health team.

Efficacy of Midodrine on Hemodynamics

Objectives: To assess the use of Midodrine among patients with orthostatic hypotension and withdrawal vasopressin in King Abdulaziz Medical City (KAMC), demonstrate the effectiveness and safety of Midodrine and detect side effects to provide clear evidence of the efficacy and safety of the drug. Methods: A retrospective cohort study was done in King Abdulaziz Medical City in Riyadh (Saudi Arabia). The study targeted adult patients who suffered from hypotension between January 2015 and January 2018. The data was extracted using the BESTCare system. Result: A total of 173 patients were included (55.5% male and 44.5% female). The mean age of the study participants was 67.34 ± 16.0 years. The differences in patients’ parameters before and after midodrine administration were detected and analyzed. The mean difference in hemoglobin (g/l) level was significantly changed before (94.97 ± 21.9) and after (90.84 ± 20.4) the use of Midodrine (p=0.031). However, there were no significant changes in the level of the other parameters before and after the use of Midodrine. The mean dose of Midodrine was 5.3 mg, with mean treatment duration of 41.5 days, and mean hospitalization of 28.7 days. For the medication history, 8% of patients were on betablockers (n=97), 5%were on diuretics (n=64), and 2% were on calcium channel blockers (n=19). Conclusion: Our data suggest that the administration of Midodrine does not affect patients’ hemodynamics significantly; however, it has a notable effect on decreasing hemoglobin levels.

Comparison of Health Education, Oral Rehydration Solution, Metoprolol and Midodrine Intervention in Children with POTS

Introduction: The postural orthostatic tachycardia syndromeis heterogeneous group of disorder. When a healthy individualstands up, gravity causes about 10%-15% of his or her bloodto settle in the abdomen or limbs. This pooling of bloodmeans that less blood reaches the brain, the result of whichcan be a feeling of lightheadedness, darkening of vision, oreven fainting. Hence, the aim of the present study was toevaluate the clinical features and the effectiveness of nonpharmacological and pharmacological treatment in patientswith POTS.Material and Methods: A retrospective medical recordanalysis of the patients referred to pediatric cardiology unitof our Second Xiangya Hospital of Central South Universitysince June 2003 to February 2010 was done. This studyincluded 33 children patients aged 6 to 16 years old among17 male (mean 10.62±2.88 years) and 16 female (mean11.81±1.64 years) after medication within 14 days to 6 monthswith follow up record.Results: The most common presenting symptoms of POTSwere found to be dizziness or light-headedness (66.66%)followed by chest tightness (30.30%), syncope (27.27%),headache (24.24%) and pallor (24.24%) respectively. About75.5% of children patients met diagnostic criteria for POTSduring 5 to 10 minute of HUTT. There was significant statisticdifference in heart rate between before and after treatment oftotal patients during 5 and 10 minute of HUTT (P<0.05). Theoverall improvement found in 24(72.72%) patients whereas9(27.27%) patients not respond to the given treatment regimen.Conclusion: The most common presenting symptom of POTSwas dizziness or light-headedness. Most of the patients meetdiagnostic criteria for POTS during 5 to 10 minute durationof HUTT. Health education, ORS, propranolol and midodrinewere effective in treatment of POTS and helpful to diminishthe upright tachycardia. Whereas health education and healtheducation with midodrine hydrochloride treatment methodwere more likely effective than health education with ORSand health education with metoprolol method

Use of fludrocortisone for intradialytic hypotension

Intradialytic hypotension during dialysis adversely affects a patient's prognosis and increases mortality. We report a case in which intradialytic hypotension that persisted after the administration of midodrine was relieved after the use of fludrocortisone. Administration of 0.2 mg of fludrocortisone occurred 30 minutes before dialysis. We compared 45 sessions of dialysis without fludrocortisone administration and 45 sessions of dialysis with fludrocortisone administration in one patient. The number of times in which systolic blood pressure became lower than 80 mmHg and the number of early terminations of dialysis due to a decrease in systolic blood pressure were higher in the sessions without fludrocortisone administration than in the sessions with fludrocortisone administration (P < 0.05). Fludrocortisone may be helpful for the treatment of intradialytic hypotension that does not respond to midodrine administration.

Effect of Alpha-1-Adrenergic Agonist, Midodrine for the Management of Long-Standing Neurogenic Shock in Patient with Cervical Spinal Cord Injury: A Case Report / 대한신경손상학회지

We report a rare case of a 71-year-old male patient who had suffered from long-lasting neurogenic shock for 13 weeks after cervical spinal cord injury (SCI) caused by a bicycle accident. The neurogenic shock was resolved dramatically 2 weeks after the administration of alpha-1-adrenergic agonist, midodrine hydrochloride. In usual cases, neurogenic shock tends to improve between 2 and 6 weeks after SCI; however, in a few cases, the shock lasts for several months. In our case, spinal shock lasted for 13 weeks and exhibited very sensitive decline of blood pressure for even a slight decrease of dopamine despite recovered bulbospongiosus reflex. Three days after midodrine hydrochloride was added, hypotension improved dramatically. We discuss our rare case with pertinent literatures.

An open multicentre clinical trial for the treatment of intradialytic hypotension with midodrine-hydrochloride / 中华肾脏病杂志

Objective To evaluate the efficacy and safety of midodrine hydrochloride in the treatment of intradialysis hypotension (IDH)in maintenance hemodialysis (MHD)patients.Methods One hundred and tburteen MHD patients from 8 dialysis centers with IDH were enrolled in the study.These patients took orMly midodfine for 4～6 weeks.Midodrine(2.5～10 mg)was given 15～30 minutes after the beginning of hemodialysis,and another 2.5～10 mg was used during hemodialysis if systolic blood pressure(SBP)increased less than 20 mm Hg.The total usage of each dialysis session was not more than 20 mg.The pre-,intra-,post-hemodialysis blood pressure and heart rate,the pre-and post-hemodialysis body weight,the uhrafiitrated volume of each dialysis,the pre-and post-treatment liver and renal function and electrocardiogram were measured and recorded.The symptoms of IDH were observed. Results Compared to those before treatment with midodrine hydrochloride,the minimum intradialysis SBP and heart rate at that time,the post-dialysis SBP and heart rate,and total uhrafiitrated volume changed significanlly (P＜0.01).The total effective rate was 84.2%.And the symptoms of IDH were improved significantly (P＜0.01).The side effects were observed in only 2 patients.Conclusion Midodrine iS safe and effective for the treatment of IDH.

The Effect of Midodrine on Exercise-induced Hypotension in Cervical Cord Injury Patients

OBJECTIVE: To evaluate the effect of midodrine, an alpha(1) agonist, on symptom and hemodynamic response during standing and arm bicycle ergometer exercise in patients with cervical cord injury. METHOD: Twelve cervical spinal cord injury patients with orthostatic hypotension symptoms and post-exercise hypo- tension were enrolled. They were positioned on a 90degrees standing frame for 3 minutes. After 15 minutes of resting on supine position, 5 minutes of arm bicycle ergometer exercise was done. These tests were done without midodrine initially, but, with 5 mg midodrine on the next day. Heart rate, self-perceived presyncope score (PPS), systolic and diastolic blood pressure were measured before, during and after the exercise. RESULTS: With 5 mg midodrine, the decrease of systolic and diastolic blood pressures after 3 minutes' standing was significantly smaller than without midodrine (p<0.05). PPS was also significantly decreased with midodrine on standing frame test. Arm ergometer exercise induced less systolic blood pressure decrease and better PPS on immediate and 5 minutes after exercise with midodrine (p<0.05). The change of diastolic blood pressure and heart rate was not significant after the exercise with midodrine. CONCLUSION: In cervical spinal cord injury patients with orthostatic and post-exercise hypotension, 5 mg midodrine significantly improved the symptoms and the systolic blood pressures.

Midodrine for the Treatment of Hypotension in a Tetraplegic Patient with Cervical Cord Injury in ICU: A case report / 대한구급학회지

Cervical spinal cord injury results in significant dysfunction of the sympathetic nervous system. Reduced sympathetic activity below the level of spinal cord injury is associated with low resting blood pressure,orthostatic hypotension,and reflex bradycardia.Hypotension can be treated with vasoactive agents,such as dopamine,epinephrine,norepinephrine, and phenylephine .Orally administered midodrine is an alpha adrenergic receptor agonist that increases blood pressure with vasoconstriction.Its action is fast and effective in treating hypotension in patients with spinal cord injury,and it has less severe side effects.A 70-year-old tetraplegic patient with fracture and dislocation of C6-7 after a motor vehicle accident was admitted to ICU and underwent anterior cervical intervertebral body fusion.Symptomatic hypotension following postural changes was treated with intravenous infusion of dopamine,but it was difficult to reduce the dose of dopamine without causing severe hypotension.Midodrine was prescribed and the patient was well tolerated without any adverse effect.With adequately maintained blood pressure,intravenous infusion of dopamine was successfully switched to the oral midodrine.This case suggests that the midodrine is effective for the treatment of hypotension in tetraplegic patients with spinal cord injury and enables patients to participate in early rehabilitation therapies.

Nonocclusive mesenteric ischemia in a patient on maintenance hemodialysis

Nonocclusive mesenteric ischemia (NOMI) is known to occupy about 25+ACU- to 60+ACU- of intestinal infarction. NOMI has been reported to be responsible for 9+ACU- of the deaths in the dialysis population and the postulated causes of NOMI include intradialytic hypotension, atherosclerosis and medications, such as diuretics, digitalis and vasopressors. Clinical manifestations, such as fever, diarrhea and leukocytosis, are nonspecific, which makes early diagnosis of NOMI very difficult. Case: A 66-year-old woman on maintenance hemodialysis for 5 years was admitted with syncope, abdominal pain and chilly sensation. Since 7 days prior to admission, blood pressure on the supine position during hemodialysis had frequently fallen to 80/50 mmHg. Four days later, she complained of progressive abdominal pain. Rebound tenderness and leukocytosis (WBC 13900/mm3) with left shift were noted. Stool examination was positive for occult blood. Abdominal CT scan showed a distended gall bladder with sludge. Under the impression of acalculous cholecystitis, she was operated on. Surgical and pathologic findings of colon colon were compatible with NOMI. Because of recurrent intradialytic hypotension, we started midodrine 2.5 mg just before hemodialysis and increased the dose up to 7.5 mg. After midodrine therapy, blood pressure during dialysis became stable and the symptoms associated with hypotension did not recur. CONCLUSION: As NOMI may occur within several hours or days after an intradialytic hypotensive episode, abdominal pain should be carefully observed and NOMI should be considered as a differential diagnosis. In addition, we suggest that midodrine be considered to prevent intradialytic hypotensive episodes.

Midodrine hydrochloride for the treatment of female patients with stress incontinence / 中华泌尿外科杂志

Objective To evaluate the efficacy and tolerability of midodrine (Gutron) in female patients with stress incontinence. Methods A randomized,double-blind,parallel,placebo-controlled,multicentric study was carried out.136 female patients with stress incontinence.68 cases in study group received Gutron (2.5 mg,thrice daily) for a course of 4 weeks.68 cases in control group received placebo in the same manner. Results 129 cases completed the treatment.The mean quantity of incontinent urine decreased by 9.9 g in those receiving Gutron ( n =66) and by 3.1 g in placebo ( n =63),respectively ( P 0.05). Conclusions Midodrine hydrochloride at the dose of 2.5 mg thrice daily has greater efficacy on female patients with stress incontinence than placebo, and the tolerability of midodrine was equivalent to that of placebo.

Influence of low calcium dialysate and midodrine hydrochloride on blood pressure in hemodialysis patients / 中华肾脏病杂志

Objective To investigate the influence of low calcium dialysate (DCa1.25) and midodrine hydrochloric (MHC) on blood pressure in hemodialysis patients. Methods Dialysate calcium concentration was changed from 1.5% (DCa1.5) to 1.25% in patients with hypercalcaemia pre- or post-dialysis.For patients with intradialytic hypotension(IDH), pre-dialysis antihypertensive drugs were ceased.If that didn′t work, MHC 2.5 or 5 mg was administered to them 30 minutes before dialysis were ceased.MHC was also administered to patients who had not taken antihypertensive drugs. The blood pressure (BP) and blood volume were recorded during dialysis. UCG and autonomic nerves function test including BP supine and standing test and sustained hand-grip test were measured as well. Results Twenty-one hemodialysis patients were involved in this study including male 9 and female 12. The average age was (54.4?14.2) years old,the time on dialysis (33.04?30.1) months. When DCa1.5 was changed to DCa1.25, 9 cases (42.9%) could maintain stable BP, but IDH occurred in 10 patients(47.6%) with symptoms such as swirl,sweat or cramp, one with lower extremities cramp and one with heart discomfort but without IDH. Patients with IDH had higher proportion of abnormal BP supine and standing tests compared with patients without IDH(50% vs. 0%, P