What are the rates of recovery from four vasopressors, namely dopamine, norepinephrine, epinephrine, and vasopressin (Vasopressin)?

From the Guidelines

The rates of recovery from four common vasopressors (norepinephrine, epinephrine, vasopressin, and phenylephrine) vary based on their pharmacokinetic profiles, with norepinephrine and epinephrine having the shortest half-lives and thus the fastest recovery times. The half-lives of these vasopressors are as follows:

• Norepinephrine has a half-life of 2-2.5 minutes, allowing for rapid titration and recovery within 5-10 minutes after discontinuation 1.
• Epinephrine similarly has a short half-life of 2 minutes with effects dissipating within 5-10 minutes after stopping the infusion 1.
• Vasopressin has a longer half-life of 10-20 minutes, with clinical effects potentially persisting for 30-60 minutes after discontinuation 1.
• Phenylephrine has an intermediate half-life of 5-10 minutes, with effects typically resolving within 15-20 minutes 1. These recovery times are important considerations when selecting vasopressors in hemodynamically unstable patients, particularly when rapid titration may be necessary. Some key points to consider when choosing a vasopressor include:
• The short half-lives of norepinephrine and epinephrine make them preferable when quick adjustments are needed 1.
• Vasopressin's longer duration may provide more stable blood pressure support but less flexibility for rapid weaning 1.
• Patient-specific factors including liver and kidney function can significantly alter these recovery times, as these organs are responsible for metabolism and elimination of these medications 1. It is also worth noting that the choice of vasopressor may depend on the specific clinical scenario, with norepinephrine recommended as the first-choice vasopressor 1, and epinephrine and vasopressin potentially used as alternative or adjunctive agents 1. Additionally, the use of vasopressors should be guided by careful monitoring of hemodynamic parameters and clinical response, with the goal of optimizing blood pressure and perfusion while minimizing potential adverse effects 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Rates of Recovery from Vasopressors

• The rates of recovery from vasopressors, including norepinephrine, dopamine, epinephrine, and vasopressin, have been studied in various clinical trials 2, 3, 4, 5, 6.
• A systematic review and meta-analysis published in 2015 found that norepinephrine was associated with decreased all-cause mortality compared to dopamine, with an absolute risk reduction of 11% and a number needed to treat of 9 2.
• Another study published in 2020 found that early administration of norepinephrine may allow for faster achievement of the initial mean arterial pressure target and reduce the risk of fluid overload 3.
• A systematic review and meta-analysis published in 2021 found that norepinephrine was superior to other vasopressors in minimizing the occurrence of arrhythmia, but there was insufficient evidence concerning mortality and achievement of the target mean arterial pressure outcomes 4.
• The concept of "norepinephrine equivalent" score has been proposed as a marker of shock severity, which quantifies the total amount of vasopressors considering the potency of each agent 5.
• Alternative vasopressors to norepinephrine, such as epinephrine, vasopressin, and angiotensin II, have been studied, but their use is associated with specific advantages and disadvantages, and further studies are needed to define their role in the management of septic shock 6.

Comparison of Vasopressors

• Norepinephrine is currently recommended as the first-line vasopressor in septic shock, due to its association with decreased all-cause mortality and lower risk of major adverse events compared to dopamine 2, 3.
• Epinephrine is considered a second-line vasopressor therapy, due to its higher rate of associated metabolic and cardiac adverse effects compared to norepinephrine 6.
• Vasopressin is recommended as second-line vasopressor therapy, due to its potential effects on mortality and renal function, and its norepinephrine-sparing effect 6.
• Dopamine is no longer recommended in patients with septic shock, due to its association with a higher rate of cardiac arrhythmias without any benefit in terms of mortality or organ dysfunction 6.

Clinical Implications

• The choice of vasopressor should be individualized based on the patient's specific clinical condition and response to treatment 3, 6.
• The use of alternative vasopressors, such as epinephrine and vasopressin, should be considered in patients with refractory septic shock or those who are unresponsive to norepinephrine 6.
• Further studies are needed to define the role of novel vasopressors, such as angiotensin II, in the management of septic shock 6.