Is it appropriate to use midodrine (midodrine) and octreotide (octreotide) with albumin instead of terlipressin (terlipressin) and albumin for a patient with hypotension requiring minimal noradrenaline (noradrenaline) support?

From the Guidelines

Terlipressin and albumin remains the first-line therapy for patients with hypotension requiring minimal noradrenaline support, due to more robust evidence of its efficacy in improving renal function and hemodynamics. However, midodrine and octreotide with albumin can be considered as an alternative in settings where terlipressin is unavailable, contraindicated, or poorly tolerated. The combination of midodrine (typically 7.5-15 mg orally three times daily) and octreotide (100-200 mcg subcutaneously three times daily) with albumin (typically 20-40 g/day) has shown some efficacy in improving renal function and hemodynamics in patients with hepatorenal syndrome and hypotension, as suggested by 1. This regimen works by combining midodrine's alpha-adrenergic vasoconstriction effects with octreotide's splanchnic vasoconstrictive properties, while albumin expands plasma volume. When implementing this therapy, it is essential to monitor blood pressure closely as midodrine can cause significant hypertension in supine positions, and gradually taper noradrenaline as the patient responds to this combination therapy. It is crucial to note that the most recent and highest quality study, 1, suggests that terlipressin is the vasoactive drug of choice in the treatment of HRS-AKI, and its use with concurrent albumin can be considered when accounting for the patient's volume status. Therefore, the decision to use midodrine and octreotide with albumin should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances. Some key points to consider when using midodrine and octreotide include:

• Initiating midodrine at doses of 7.5 mg and titrating upward to 12.5 mg 3 times daily, as suggested by 1
• Using octreotide starting with 100 mg and titrating upward to 200 mg subcutaneously 3 times daily, as suggested by 1
• Monitoring blood pressure closely and gradually tapering noradrenaline as the patient responds to this combination therapy
• Considering the use of albumin to expand plasma volume, while being mindful of the patient's volume status, as suggested by 1.

From the Research

Treatment Options for Hypotension

• The use of midodrine and octreotide with albumin as an alternative to terlipressin and albumin for a patient with hypotension requiring minimal noradrenaline support is a topic of interest.
• Studies have compared the efficacy of these alternative regimens, with some showing that terlipressin plus albumin is more effective than midodrine and octreotide plus albumin in improving renal function in patients with hepatorenal syndrome 2.
• Another study found that norepinephrine plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with hepatorenal syndrome 3.

Efficacy of Midodrine and Octreotide

• A study published in 2009 found that the combination of octreotide, midodrine, and albumin improved survival in patients with type 1 and type 2 hepatorenal syndrome 4.
• A 2021 study found that a standardized approach with albumin, midodrine, and octreotide led to a trend towards improved treatment response rate and significantly lower rates of renal replacement therapy and liver transplantation 5.
• Another study published in 2004 found that medical therapy with midodrine, octreotide, and albumin improved renal function in patients with type 1 hepatorenal syndrome, and that TIPS insertion further improved renal function and sodium excretion in responders 6.

Comparison with Terlipressin

• The study by 2 found that terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with hepatorenal syndrome.
• The study by 3 found that norepinephrine plus albumin is more effective than midodrine and octreotide plus albumin, but did not directly compare terlipressin with midodrine and octreotide.
• Overall, the evidence suggests that terlipressin may be a more effective treatment option for hepatorenal syndrome, but midodrine and octreotide with albumin may still be a viable alternative in certain situations 3, 2.