Abdalla Ammar, PharmD, BCCCP, BCPS,
Critical Care Pharmacist, Neurocritical Care
New York Presbyterian Hospital - Weill Cornell Medical College
New York, NY
Disclosure information not submitted.
Christopher Hong, MD
Neurosurgery Resident
Yale New Haven Hospital, United States
Disclosure information not submitted.
Andrew Koo, MD
Neurosurgery Resident
Yale New Haven Hospital, United States
Disclosure information not submitted.
Aladine Elsamadicy, MD
Neurosurgery Resident
Yale New Haven Hospital, United States
Disclosure information not submitted.
Mahmoud Ammar, BCCCP, PharmD, BCPS,
Critical Care Pharmacist
Yale New Haven Hospital
New Haven, Connecticut
Disclosure information not submitted.
Maxwell Laurans, MD, MBA, FAANS
Assistant Professor of Neurosurgery; Vice President, Surgical Services
Yale New Haven Hospital, United States
Disclosure information not submitted.
Mark Landreneau, MD
Assistant Professor Neurology
Yale New Haven Hospital, United States
Disclosure information not submitted.
Title: Combination of Droxidopa and Midodrine for Hemodynamic Augmentation in Acute Spinal Cord Injury
Case Report Body:
Introduction: Autonomic dysfunction is a complication of acute spinal cord injury (SCI), and subsequent hypotension may worsen neurologic and mortality outcomes. In severe cases, due to profound bradycardia or asystole, a cardiac pacemaker placement may be required. Guidelines recommend maintaining mean arterial pressure (MAP) >85mmHg within the first 7 days. This is often achieved by intravenous vasopressors. The use of midodrine, an enteral alpha-1 agonist, is limited by its reflex bradycardia side effect. While droxidopa, an enteral precursor of norepinephrine, is approved to treat neurogenic orthostatic hypotension, its use in sustaining MAP after acute SCI has not been previously described.
Description: A 73-year old male with existing severe cervical spinal stenosis suffered a bicycle crash with hyperflexion SCI causing new onset paraplegia, secondary to retropulsion disc fragments at C3-4 and C4-5, and fracture of the right C3 transverse process. He underwent decompressive laminectomies at C3-5 with posterior fusion. Post-operatively, was started on norepinephrine (NE) infusion to maintain a goal MAP >85mmHg. Vasopressors could not be weaned off without sustaining MAP >65mmHg, which was attributed to autonomic dysfunction. On post-SCI day (PSCID) 12, midodrine was started and administered as high as 70mg daily in an attempt to wean off NE. This resulted in several episodes of bradycardia (heart rates of 20-30 beats per minute) On PSCID 18, droxidopa monotherapy was started at 100mg twice daily and up titrated to 300mg three times daily (TID). A pacemaker was considered but deferred in favor of monitoring for response to droxidopa. On PSCID 21, midodrine was restarted at 20mg TID and droxidopa titrated up to 600mg TID facilitating weaning off NE by PSCID 27. By PSCID 32, midodrine and droxidopa were tapered to 5mg TID and 400mg TID, respectively and the patient was discharged to acute rehabilitation.
Discussion: Enteral droxidopa combination therapy with midodrine may be considered to augment MAP in patients with autonomic dysfunction post-acute SCI and facilitate weaning of vasopressors. This strategy may avoid pacemaker placement and liberalize stable patients that require continued admission in the intensive care unit for intravenous vasopressors, which can be cost-ineffective and human resource-depleting.