Use of droxidopa for blood pressure augmentation after acute spinal cord injury: case reports

Acute and Critical Care, 2025 · DOI: https://doi.org/10.4266/acc.2021.01662 · Published: February 1, 2025

Spinal Cord Injury Critical Care Pharmacology

Simple Explanation

Acute spinal cord injury (SCI) can lead to low blood pressure due to autonomic dysregulation, increasing the risk of poor outcomes. Intravenous vasopressors are typically used to manage this, but they require central venous access, which can be problematic. Midodrine, an oral medication, is commonly used to raise blood pressure, but it can cause reflex bradycardia, limiting its effectiveness. Droxidopa, another oral medication, is a precursor to norepinephrine and may offer an alternative without the same risk of bradycardia. This paper presents two cases where droxidopa was successfully used to manage hypotension in patients with acute SCI who could not tolerate midodrine. The findings suggest droxidopa is a viable alternative to manage hypotension and wean off IV vasopressors.

Study Duration

Not specified

Participants

2 patients with acute spinal cord injury

Evidence Level

Level 4; Case Reports

Key Findings

1
Droxidopa was successfully used to manage hypotension in two patients with acute SCI who experienced bradycardia with midodrine.
2
In one patient, droxidopa helped avoid the need for a pacemaker.
3
Droxidopa facilitated earlier weaning of intravenous vasopressors and earlier transfer out of the ICU.

Research Summary

This paper presents two case reports detailing the successful use of droxidopa to manage hypotension in acute spinal cord injury (SCI) patients who could not tolerate midodrine due to reflex bradycardia. Droxidopa, an enteral precursor of norepinephrine, was used as an alternative treatment strategy. The addition of droxidopa as a monotherapy or in combination with midodrine, facilitated the cessation of vasopressors and avoided pacemaker placement in one patient. The dosages of droxidopa varied greatly between the two patients, ranging from 300 mg to 1,800 mg daily. The case studies suggest that droxidopa may be a more optimal option than midodrine for SCI-related hemodynamic pathology due to less risk of bradycardia. Further case studies are necessary to define the parameters and dosages for which droxidopa administration may be indicated.

Practical Implications

Alternative Treatment Option

Droxidopa can be considered as an alternative enteral agent for managing hypotension in acute SCI patients who cannot tolerate midodrine.

Reduced ICU Stay

The use of droxidopa may facilitate earlier weaning from IV vasopressors and reduce the length of stay in the ICU, potentially saving resources.

Avoidance of Pacemaker Placement

Droxidopa may help avoid the need for pacemaker placement in some patients with SCI-related bradycardia and hypotension.

Study Limitations

1
Small sample size of only two case reports.
2
Lack of well-accepted guidelines for the use of droxidopa or midodrine in acute SCI.
3
Variability in required dosing and duration of droxidopa therapy.

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