American Board of Internal Medicine (ABIM) Certification Practice Exam

Which medication is recommended as adjunctive therapy for patients with refractory ascites, particularly those with hypotension?

1. Atenolol

2. Losartan

3. Midodrine

4. Furosemide

The correct answer is: Midodrine

In cases of refractory ascites, particularly in patients exhibiting hypotension, midodrine is considered an appropriate adjunctive therapy. Midodrine is an alpha-1 adrenergic agonist that acts by causing vasoconstriction, which helps to increase blood pressure in patients who are experiencing difficulty with maintaining adequate perfusion due to low blood volume or hypotension. This can be particularly beneficial in patients with liver cirrhosis, where both ascites and hypotension can arise as a result of portal hypertension and systemic vasodilation. Using midodrine in these patients not only improves blood pressure but can also enhance kidney perfusion, potentially aiding in the management of ascites by avoiding further diuretic resistance. Increased renal perfusion may help with urine output and better manage fluid balance, which is crucial for patients who already face challenges from intense fluid retention due to ascites. The other medications listed have different primary actions. Atenolol, as a beta-blocker, is used more for managing hypertension and certain arrhythmias rather than directly addressing hypotension associated with ascites. Losartan, an angiotensin receptor blocker, might help reduce portal pressure but does not directly combat hypotension. Furosemide is a diuretic