Reactions Weekly | 2021
Fludrocortisone/midodrine
Abstract
Lack of efficacy: case report A 73-year-old man exhibited lack of efficacy during treatment with fludrocortisone and midodrine for syncope. The man presented with local recurrence of hypopharyngeal squamous cell cancer. He underwent laryngopharyngectomy, left cervical lymph node dissection, thyroidectomy and oesophageal reconstruction with free jejunal autograft. However, he experienced a total of 9 episodes of vasodepressor-type syncope during hospitalisation from 23–41 days postoperation that occurred during the same time period (10:00–12:00). He had no coronary risk factors, such as smoking history. He had never experienced syncopal episodes before the operation. On detailed investigations, he was diagnosed with carotid sinus syndrome (CSS). Thus, the syncopal episodes were attributed to CSS caused by dilatation of the edematous autograft, which induced obstruction at the stenotic site due to food debris. He received oral midodrine [midodrine hydrochloride] 4 mg/day on postoperative day 26 and fludrocortisone [fludrocortisone acetate] 0.1 mg/day on post-operative day 28. However, both were not effective in preventing syncopal episodes. Thus, oral disopyramide administration from post-operative day 33 resulted in markedly decreased syncopal episodes. Fifty days after the first surgery, surgical release and re-anastomosis of the pharyngoesophageal stenosis (second surgery) was performed via an open-neck approach. After which, no recurrence of syncopal episodes had been reported even without disopyramide administration. He was discharged on post-operative day 65 after the first surgery in a good postoperative state. During 4 months of follow-up visits, he did not experience any syncope recurrences.