Hypotension secondary to autonomic dysfunction is a common complication of acute
spinal cord injury (SCI) that may worsen neurologic outcomes.
Midodrine, an enteral α-1 agonist, is often used to facilitate weaning intravenous (IV) vasopressors, but its use can be limited by reflex
bradycardia. Alternative enteral agents to facilitate this wean in the acute post-SCI setting have not been described. We aim to describe novel application of
droxidopa, an enteral precursor of
norepinephrine that is approved to treat neurogenic
orthostatic hypotension, in the acute post-SCI setting.
Droxidopa may be an alternative enteral
therapy for those intolerant of
midodrine due to reflex
bradycardia. We describe two patients suffering traumatic cervical SCI who were successfully weaned off IV vasopressors with
droxidopa after failing with
midodrine. The first patient was a 64-year-old male who underwent C3-6
laminectomies and fusion after a ten-foot fall resulting in
quadriparesis. Post-operatively, the addition of
midodrine in an attempt to wean off IV vasopressors resulted in significant reflexive
bradycardia. Treatment with
droxidopa facilitated rapidly weaning IV vasopressors and transfer to a lower level of care within 72 hours of treatment initiation. The second patient was a 73-year-old male who underwent C3-5
laminectomies and fusion for a traumatic hyperflexion injury causing
paraplegia. The addition of
midodrine resulted in severe
bradycardia, prompting consideration of pacemaker placement. However, with the addition of
droxidopa, this was avoided, and the patient was weaned off IV vasopressors on dual oral
therapy with
midodrine and
droxidopa.
Droxidopa may be a viable enteral
therapy to treat
hypotension in patients after acute SCI who are otherwise not tolerating
midodrine in order to wean off IV vasopressors. This strategy may avoid pacemaker placement and facilitate shorter stays in the intensive care unit, particularly for patients who are stable but require continued intensive care unit admission for IV vasopressors, which can be cost ineffective and human resource depleting.