From the Guidelines
Management of Postural Orthostatic Tachycardia Syndrome (POTS) should prioritize a combination of non-pharmacological and pharmacological approaches, with a focus on lifestyle modifications and individualized treatment plans. The most recent and highest quality study, published in 2022 in the Journal of the American College of Cardiology 1, emphasizes the importance of addressing the reduction in plasma volume that follows deconditioning through non-pharmacological interventions. These interventions include:
- Salt and fluid loading, with liberalized sodium intake (5-10g or 1-2 teaspoons of table salt per day) and encouragement to drink 3 liters of water or an electrolyte-balanced fluid per day
- Elevation of the head of the bed by 4-6 inches during sleep
- Use of support stockings (waist-high) to ensure sufficient support of central blood volume
- Avoidance of factors that contribute to dehydration, such as consumption of alcohol and/or caffeine, ingestion of large heavy meals, and excessive heat exposure
Pharmacological therapies may be used empirically, with options including:
- Low-dose beta-blockers (e.g., bisoprolol, metoprolol, nebivolol, propranolol) or nondihydropyridine calcium-channel blockers (e.g., diltiazem, verapamil) to slow the heart rate and improve exercise tolerance
- Ivabradine for severe fatigue exacerbated by beta-blockers and calcium-channel blockers
- Fludrocortisone (up to 0.2mg taken at night) to increase blood volume and help with orthostatic intolerance, with careful monitoring to guard against hypokalemia
- Midodrine (2.5-10mg) to help with orthostatic intolerance, with the first dose taken in the morning before getting out of bed and the last dose taken no later than 4pm
A formalized exercise program should be initiated, with consideration of a supervised setting with a physical therapist or specific instructions for implementation at home or in a gym. Treatment should be individualized based on the predominant symptoms and underlying pathophysiology, with gradual titration of medications to minimize side effects. Management of POTS requires patience, as improvement may take weeks to months, and a multidisciplinary approach involving cardiologists, neurologists, and rehabilitation specialists often yields the best outcomes 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The management options for Postural Orthostatic Tachycardia Syndrome (POTS) are not directly addressed in the provided drug label. Midodrine is indicated for symptomatic orthostatic hypotension, but its use in POTS is not explicitly mentioned.
- The label discusses the treatment of orthostatic hypotension, which may be a related condition, but it does not provide information on the management of POTS. 2
From the Research
Management Options for Postural Orthostatic Tachycardia Syndrome (POTS)
The management of POTS involves a combination of lifestyle modifications, pharmacologic therapies, and other interventions. The primary goal of treatment is to alleviate symptoms, improve quality of life, and enhance functional capacity.
Lifestyle Modifications
- Increased fluid and salt intake to expand blood volume 3, 4
- Compression garment use to improve venous return 3, 4
- Physical reconditioning and exercise training to enhance cardiovascular function 3, 4, 5
- Postural training to improve orthostatic tolerance 3
Pharmacologic Therapies
- Beta-blockers for hyperadrenergic POTS to reduce sympathetic overactivity 3, 4, 5
- Pyridostigmine for neuropathic POTS to enhance vascular tone 3, 6
- Midodrine for neuropathic POTS to enhance vascular tone 3, 4, 5
- Fludrocortisone for hypovolemic POTS to expand blood volume 4, 5
- Ivabradine for reducing heart rate 5
- Supplemental therapies such as iron, vitamin D, and α-lipoic acid may also be considered 5
Other Interventions
- Cognitive-behavioral therapy to address emotional and behavioral factors contributing to symptom chronicity 4
- Cardiac neuromodulation, a promising but preliminary therapy 5
- Experimental pharmacological therapies, such as erythropoietin, IVIG, and desmopressin, may be considered in select cases 5