What are the different types of vasopressors (pressors)?

From the Guidelines

The primary vasopressors used in clinical practice include norepinephrine, epinephrine, dopamine, vasopressin, and phenylephrine, with norepinephrine being the first-choice vasopressor for most shock states, particularly septic shock, as recommended by the Surviving Sepsis Campaign guidelines 1. The different types of vasopressors can be categorized based on their mechanism of action and clinical use.

• Norepinephrine is a potent alpha-adrenergic agonist with some beta activity, making it the first-line agent for septic shock, with a recommended starting dose of 0.01-0.3 mcg/kg/min 1.
• Epinephrine provides strong alpha and beta effects, making it useful for anaphylactic shock and as a second-line agent in septic shock, with a dose range of 0.01-0.5 mcg/kg/min 1.
• Dopamine has dose-dependent effects, with low doses affecting dopaminergic receptors, medium doses stimulating beta receptors, and high doses activating alpha receptors, making it an alternative vasopressor agent in highly selected patients, with a dose range of 1-20 mcg/kg/min 1.
• Vasopressin works through V1 receptors and is often added as a second agent in refractory shock, with a recommended dose of 0.01-0.04 units/min 1.
• Phenylephrine is a pure alpha-agonist useful in situations where tachycardia must be avoided, with a dose range of 0.1-5 mcg/kg/min 1. When administering vasopressors, it is essential to consider the underlying cause of shock, hemodynamic goals, and patient-specific factors like cardiac function and arrhythmia risk, as well as to monitor blood pressure, heart rate, urine output, and tissue perfusion regularly, with dose adjustments based on patient response 1.

From the FDA Drug Label

Vasopressin causes vasoconstriction by binding to V1 receptors on vascular smooth muscle coupled to the Gq/11-phospholipase C-phosphatidyl-inositol-triphosphate pathway, resulting in the release of intracellular calcium. In addition, vasopressin stimulates antidiuresis via stimulation of V2 receptors which are coupled to adenyl cyclase. At therapeutic doses exogenous vasopressin elicits a vasoconstrictive effect in most vascular beds including the splanchnic, renal and cutaneous circulation. In patients with vasodilatory shock vasopressin in therapeutic doses increases systemic vascular resistance and mean arterial blood pressure and reduces the dose requirements for norepinephrine. Epinephrine overdosage may produce extremely elevated arterial pressure, which may result in cerebrovascular hemorrhage, particularly in elderly patients.

The different types of vasopressors (pressors) mentioned are:

• Vasopressin: causes vasoconstriction by binding to V1 receptors
• Norepinephrine: mentioned as a drug that has reduced dose requirements when used with vasopressin
• Epinephrine: can produce extremely elevated arterial pressure when overdosed 2, 3

From the Research

Types of Vasopressors

The following are different types of vasopressors:

• Norepinephrine: currently recommended as the first-line vasopressor in septic shock patients 4, 5, 6, 7
• Dopamine: no longer recommended as a first-line vasopressor due to its association with a higher rate of cardiac arrhythmias 4, 5, 7
• Epinephrine: considered as a second-line vasopressor therapy due to its higher rate of associated metabolic and cardiac adverse effects 4, 5, 7
• Vasopressin: recommended as a second-line vasopressor therapy due to its potential effects on mortality and renal function 4, 8, 7
• Terlipressin: a synthetic analog of vasopressin, not commonly used in septic shock due to its association with a higher rate of digital ischemia 4, 5, 7
• Selepressin: a synthetic analog of vasopressin, not commonly used in septic shock due to its association with a higher rate of digital ischemia 4
• Angiotensin II: a promising vasopressor in septic shock, especially in severe cases, but its use is limited due to concerns regarding safety 4
• Phenylephrine: considered as a second-line agent in septic shock 5
• Dobutamine: often used in combination with norepinephrine to treat septic shock 7

Comparison of Vasopressors

Studies have compared the efficacy and safety of different vasopressors, including:

• Norepinephrine vs. dopamine: norepinephrine is associated with a lower risk of mortality and cardiac arrhythmias 5, 6
• Norepinephrine vs. epinephrine: norepinephrine is associated with a lower risk of metabolic and cardiac adverse effects 4, 5
• Norepinephrine vs. vasopressin: vasopressin may be associated with a lower risk of mortality and renal dysfunction 4, 8
• Norepinephrine plus dobutamine vs. other vasoactive medications: associated with a lower risk of 28-day mortality in septic shock patients 7