Midodrine Therapy in Cirrhosis with Refractory Ascites: Impact on Survival and Paracentesis Frequency Compared with Large-volume Paracentesis

Abstract

Background: Refractory ascites is a major complication of cirrhosis with a 1-year survival rate of less than 50%. Large-volume paracentesis (LVP) is the standard treatment but does not improve survival and carries risks of circulatory dysfunction. Midodrine, an oral alpha-adrenergic agonist, with or without octreotide, has been studied as a potential alternative or adjunct therapy. Methods: A systematic review was conducted using Ovid Medline, CINAHL, and Scopus. After screening, eight studies met inclusion criteria that evaluated midodrine, alone or in combination, in patients with cirrhosis and refractory ascites. Results: Midodrine consistently improved systemic hemodynamics and renal function. Evidence for its role in reducing paracentesis-induced circulatory dysfunction and decreasing paracentesis frequency was mixed. Combination therapy with propranolol reduced first variceal bleeding and improved ascites control, while midodrine with octreotide was not superior to albumin. A pediatric study suggested renal protection but no improvement in ascites outcomes. Discussion: Discussion: Midodrine appears to provide circulatory and renal benefits and may be useful as an adjunct therapy. However, current evidence does not support its use as a replacement for albumin or as a treatment that reliably improves survival or reduces paracentesis frequency. The strength of evidence is limited by small sample sizes, heterogeneity in study design and interventions, and reliance on several pilot trials. Additionally, many studies had short follow-up periods and were underpowered to detect meaningful differences in survival outcomes.