(March 28, 2023)

Dobutamine, a synthetic catecholamine, is one of the most studied and used inotropic agents in cardiovascular critical care for the treatment of cardiogenic shock (CS), with approval of the US-FDA for that condition. 

• USA and European guidelines recommend norepinephrine as first-line vasopressor to manage hypotension in CS (3, 6). Subsequently, if needed, an inotrope and/or mechanical cardiovascular support (MCS) may be added to improve perfusion and facilitate definitive intervention. 

• It has inodilator properties as a beta-receptors agonist (𝛽1 and 𝛽2), with subsequent positive chronotropism, inotropism and mild peripheral vasodilation. This may provoke myocardial ischemia, arrhythmias and severe cardiovascular events. Use with extreme caution. 

• Dobutamine is preferred over epinephrine for CS, as the latter is associated with an increased risk of refractory shock, lactic acidosis and mortality (1, 4).
  
  

Adult dose for cardiogenic shock (4, 5)

2-20 ug/kg/min

Adult dose for cardiogenic shock (6, 8)
2-20 ug/kg/min

• Titrate up with a starting dose of 5ug/kg/min.

• Usually norepinephrine is indicated as a first-line intervention, and then dobutamine added if necessary. The combination may have the advantage of diminishing vasodilatory effects of dobutamine. 

Indications

• US-FDA labeled (8)

  • Inotropic support in the short-term treatment of cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures.

• Off-label

  • Inotropic support in other types of shock (other than cardiogenic shock), who fail to respond to resuscitation with fluids and vasopressors. 

• Inotropes, especially those with adrenergic mechanisms, can cause sinus tachycardia, increase ventricular rate in patients with AF, may induce myocardial ischaemia and arrhythmias, and increase mortality (6).

• Levosimendan or type-3-phosphodiesterase inhibitors may be preferred over dobutamine for patients on beta-blockers as they act through independent mechanisms (6).

• No solid evidence supports one drug over another to be recommended as the first-line inotrope for cardiogenic shock. From a pathophysiological point of view, their mechanism of action should guide as an initial preference depending on the clinical context (eg. beta-blocker toxicity). 

• Excluding beta-blocker users or toxicity, experts recommend dobutamine as a second-line drug to improve cardiac output as adjunct to norepinephrine for cardiogenic shock (2, 5). 

• Milrinone or levosimendan are considered to be first-line inotropes in the case of beta-blocker users or toxicity as their mechanism of action bypasses adrenergic receptors (5). 

• The 2021 DOREMI trial, a recent study that compared dobutamine with milrinone in cardiogenic shock showed no significant differences in composite outcome of in-hospital death, resuscitated cardiac arrest, cardiac transplant or mechanical support, non-fatal myocardial infarction, cerebrovascular event or renal replacement therapy. Also no differences in the secondary outcomes were found (in-hospital all cause mortality, arrhythmia requiring medical intervention)(7).

• Dobutamine has a shorter half-life, is easier to titrate, and is considerably less expensive than milrinone. With current evidence, EMDrugs supports dobutamine as a first-line inodilator added to norepinephrine for cardiogenic shock management. 

1. Levy B, Perez P, Perny J, Thivilier C, Gerard A. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med. 2011;39(3):450-455. doi:10.1097/CCM.0b013e3181ffe0eb
   Pubmed

2. Moskovitz JB, Levy ZD, Slesinger TL. Cardiogenic Shock. Emerg Med Clin North Am. 2015;33(3):645-652. doi:10.1016/j.emc.2015.04.013
   Pubmed

3. van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017;136(16):e232-e268. doi:10.1161/CIR.0000000000000525
   Circulation (Open Access)

4. Léopold V, Gayat E, Pirracchio R, et al. Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients [published correction appears in Intensive Care Med. 2018 Nov;44(11):2022-2023]. Intensive Care Med. 2018;44(6):847-856. doi:10.1007/s00134-018-5222-9
   Springer (Open Access)

5. Levy B, Buzon J, Kimmoun A. Inotropes and vasopressors use in cardiogenic shock: when, which and how much?. Curr Opin Crit Care. 2019;25(4):384-390. doi:10.1097/MCC.0000000000000632
   Pubmed

6. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure [published correction appears in Eur Heart J. 2021 Oct 14;:]. Eur Heart J. 2021;42(36):3599-3726. doi:10.1093/eurheartj/ehab368
   European Society of Cardiology (Open Access)

7. Mathew R, Di Santo P, Jung RG, et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock. N Engl J Med. 2021;385(6):516-525. doi:10.1056/NEJMoa2026845ç
   NEJM 

8. NIH-NLM (National Institutes of Health - National Library of Medicine). DailyMed. Label: Dobutamine injection, solution. Updated in December 2022. Accessed March 16, 2023.
   DailyMed