Oral Agents for the Treatment of Refractory Hypotension in the Acute Care Setting - A Narrative Review

Refractory hypotension is a common occurrence in the acute care setting and is associated with a variety of conditions and underlying disease states. Persistent hypotension is associated with negative outcomes including organ failure and mortality. While initial management of hypotension often involves parenteral agents such as vasopressors, long term use is not desirable or feasible in many cases. The use of oral agents for refractory hypotension in the acute care setting gives providers options in these clinical scenarios, specifically vasopressor weaning, intradialytic hypotension, and orthostatic hypotension. Common agents used for refractory hypotension include droxidopa, fludrocortisone, midodrine, pseudoephedrine, and pyridostigmine. The use of midodrine has been extensively studied in the setting of vasopressor weaning with no clear benefit to its use, however smaller studies and case reports indicate pseudoephedrine may be useful. In the setting of intradialytic hypotension, there are data to support the use of midodrine, however there are questions about the long-term safety of its use. Midodrine and fludrocortisone alone or in combination with each other has shown benefits in the treatment of refractory orthostatic hypotension as has the use of droxidopa. In this review, the literature evaluating the use of these oral agents for refractory hypotension is assessed with a particular focus on acute care management.