Pragmatic trial of midodrine as a vasopressor-sparing agent in septic shock

Mayo Clinic received a $783,661 Project Grant from the National Heart, Lung, and Blood Institute (NHLBI) under the Cardiovascular Diseases Research program (CFDA 93.837), awarded September 5, 2025, with completion scheduled for August 31, 2026. The award funds a pragmatic, randomized clinical trial evaluating the effectiveness and safety of oral midodrine as a vasopressor-sparing agent in patients with sepsis-associated hypotension. The study seeks to reduce intensive care unit (ICU) burden by investigating midodrine, an oral vasopressor agent originally approved for orthostatic hypotension, as an alternative to intravenous vasopressor infusions that typically require ICU admission and invasive catheterization.

The research addresses a significant clinical challenge: approximately 1.7 million sepsis cases occur annually in the United States, with cardiovascular compromise manifesting as persistent hypotension despite fluid resuscitation. Current standard treatment requiring intravenous vasopressor administration prolongs ICU stays and exposes patients to risks associated with excess fluid administration and arterial and central venous catheterization. The single-blinded randomized trial will generate clinical evidence on midodrine's potential to reduce vasopressor dependence, decrease catheterization requirements, shorten ICU length of stay, and improve patient outcomes while minimizing treatment-related harms—ultimately supporting evidence-based clinical decision-making for sepsis management in critically ill populations.

Abstract

The objective of this study is to conduct a pragmatic, randomized clinical trial to evaluate the effectiveness and safety of oral midodrine in patients with sepsis associated hypotension. This patient-centered study approach is seeking alternatives to minimize the burden of intensive care unit (ICU) stay in these patients. Sepsis is one of the leading causes of death and disability worldwide. Cardiovascular compromise in sepsis manifests as hypotension due to arterial vasodilation. Hypotension often persists despite initial fluid resuscitation, prompting additional fluid boluses and subsequent administration of intravenous vasopressor agents. Although peripheral intravenous access could be used to initiate vasopressor treatment, the need for close blood pressure monitoring requires ICU admission and, for any but very short-term use, arterial and central venous catheter placement. Both excess intravenous fluid and arterial and venous catheterization may expose the patients to risks, unintended harms and discomfort. Moreover, a persistent need for intravenous vasopressor infusion prolongs ICU stay with associated burdens and cost. Midodrine is an oral vasopressor agent originally approved for use to treat orthostatic hypotension. Observational studies have suggested increasing off-label use of oral midodrine as a vasopressor-sparing agent in various groups of critically ILL patients. Randomized controlled trials showed mixed results likely due to the heterogeneous general ICU patient population. Our preliminary data and the existing evidence point to clear equipoise and the need for conducting the proposed pragmatic single-blinded randomized clinical trial to evaluate both the safety and effectiveness of midodrine for sepsis associated hypotension. Our hypothesis is that administering oral midodrine to patients with septic shock who have received initial fluid resuscitation, appropriate antimicrobial treatment, and source control will decrease the duration of intravenous vasopressor treatment. If efficacious, midodrine can facilitate less invasive sepsis treatment and decrease the burdens and cost of ICU stay.