A global perspective on vasoactive agents in shock
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We set out to summarize the current knowledge on vasoactive drugs and their use in the management of shock to inform physicians’ practices.
This is a narrative review by a multidisciplinary, multinational—from six continents—panel of experts including physicians, a pharmacist, trialists, and scientists.
Results and conclusions
Vasoactive drugs are an essential part of shock management. Catecholamines are the most commonly used vasoactive agents in the intensive care unit, and among them norepinephrine is the first-line therapy in most clinical conditions. Inotropes are indicated when myocardial function is depressed and dobutamine remains the first-line therapy. Vasoactive drugs have a narrow therapeutic spectrum and expose the patients to potentially lethal complications. Thus, these agents require precise therapeutic targets, close monitoring with titration to the minimal efficacious dose and should be weaned as promptly as possible. Moreover, the use of vasoactive drugs in shock requires an individualized approach. Vasopressin and possibly angiotensin II may be useful owing to their norepinephrine-sparing effects.
KeywordsShock Cardiovascular system Adrenergic agonists Clinical trials Practice guidelines
ACG is funded by an NIHR Research Professorship award (RP-2015-06-018).
Compliance with ethical standards
Conflicts of interest
DA reports having received a grant from the French Ministry of Health to conduct a trial comparing epinephrine to norepinephrine plus dobutamine for septic shock (CATS). DDB reports that he acts as a consultant to and material for studies by Edwards Lifesciences. ACG reports that outside of this work he has received speaker fees from Orion Corporation Orion Pharma and Amomed Pharma. He has consulted for Ferring Pharmaceuticals, Tenax Therapeutics, Baxter Healthcare, Bristol-Myers Squibb and GSK, and received grant support from Orion Corporation Orion Pharma, Tenax Therapeutics and HCA International with funds paid to his institution. GH reports no financial conflict of interest. JR reports patents owned by the University of British Columbia (UBC) that are related to PCSK9 inhibitor(s) and sepsis and related to the use of vasopressin in septic shock. JR is an inventor on these patents. JR is a founder, Director and shareholder in Cyon Therapeutics Inc. (developing a sepsis therapy (PCSK9 inhibitor)). JR has share options in Leading Biosciences Inc. JR is a shareholder in Molecular You Corp. JR reports receiving consulting fees in the last 3 years from: (1) Asahi Kesai Pharmaceuticals of America (AKPA)(developing recombinant thrombomodulin in sepsis). (2) La Jolla Pharmaceuticals (developing angiotensin II; JR chaired the DSMB of a trial of angiotensin II from 2015 to 2017)—no longer actively consulting. (3) Ferring Pharmaceuticals (manufactures vasopressin and was developing selepressin)—no longer actively consulting. (4) Cubist Pharmaceuticals (now owned by Merck; formerly Trius Pharmaceuticals; developing antibiotics)—no longer 3 actively consulting. (5) Leading Biosciences (was developing a sepsis therapeutic that is no longer in development)—no longer actively consulting. (6) Grifols (sells albumin)—no longer actively consulting. (7) CytoVale Inc. (developing a sepsis diagnostic)—no longer actively consulting. JR reports having received an investigator-initiated grant from Grifols (entitled “Is HBP a mechanism of albumin’s efficacy in human septic shock?”) that is provided to and administered by UBC.
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