What are the treatment options for Postural Orthostatic Tachycardia Syndrome (POTS)?

From the Guidelines

Treatment for Postural Orthostatic Tachycardia Syndrome (POTS) should prioritize a combination of lifestyle modifications, including salt and fluid loading, elevation of the head of the bed, and use of support stockings, alongside a formalized exercise program, as these interventions address the pathophysiology of reduced plasma volume and deconditioning, and have been shown to support long-term cardiovascular health 1.

Key Lifestyle Modifications:

• Salt loading through liberalized sodium intake (5-10 g or 1-2 teaspoons of table salt per day) to expand blood volume
• Drinking 3 liters of water or an electrolyte-balanced fluid per day
• Elevation of the head of the bed with 4–6-inch (10–15-cm) blocks during sleep
• Use of waist-high support stockings to ensure sufficient support of central blood volume

Exercise Program:

• A formalized exercise program should be initiated, which may be best done in a supervised setting with a physical therapist or through specific instructions for implementation at home or in a gym 1
• The program should focus on supporting long-term cardiovascular health and addressing deconditioning

Pharmacological Interventions:

• Low-dose beta-blockers (e.g., bisoprolol, metoprolol, nebivolol, propranolol) or nondihydropyridine calcium-channel blockers (e.g., diltiazem, verapamil) may be used to slow the heart rate and improve exercise tolerance 1
• Ivabradine may be considered for patients with severe fatigue exacerbated by beta-blockers and calcium-channel blockers, as it has shown improvement in heart rate and quality of life in patients with POTS 1
• Fludrocortisone and midodrine may also be used to increase blood volume and help with orthostatic intolerance, with careful monitoring to guard against hypokalemia and other side effects 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Postural Orthostatic Tachycardia Syndrome (POTS)

The treatment options for POTS can be categorized into lifestyle modifications, pharmacologic therapies, and experimental therapies.

• Lifestyle modifications are the first line of treatment and include:
  • Increased fluid and salt intake
  • Compression garment use
  • Physical reconditioning
  • Postural training 2, 3
• Pharmacologic therapies are used to manage specific symptoms and include:
  • Beta-blockers for hyperadrenergic POTS
  • Pyridostigmine and midodrine for neuropathic POTS
  • Fludrocortisone for hypovolemic POTS 2, 4
• Experimental therapies are being explored, including:
  • Cardiac neuromodulation
  • Erythropoietin
  • IVIG
  • Desmopressin
  • Supplemental therapies such as iron, vitamin D, and α lipoic acid 5

Management Strategies

Management of POTS typically begins with patient education and non-pharmacologic treatment options 3. A multidisciplinary approach is recommended, encompassing pharmacological treatments, lifestyle modifications, and psychological support 6.

Phenotype-Based Approaches

Recent studies have identified three primary POTS phenotypes: hyperadrenergic, neuropathic, and hypovolemic, each requiring tailored management strategies 2. Improved characterization of pathophysiological phenotypes is essential to individualize management 5.

Current Limitations

Currently, there are no medications approved by the United States Food and Drug Administration (FDA) for POTS, and evidence for many of the medications used to treat POTS is limited 2, 3, 4.