What is the best approach to manage patients with both lymphoedema and Postural Orthostatic Tachycardia Syndrome (POTS)?

From the Guidelines

Managing patients with both lymphoedema and Postural Orthostatic Tachycardia Syndrome (POTS) requires a multifaceted approach that prioritizes compression therapy, fluid and salt management, exercise, and tailored medications to mitigate morbidity, mortality, and improve quality of life. When considering the management of lymphoedema, complete decongestive therapy including manual lymphatic drainage, compression garments (20-30 mmHg or higher as tolerated), meticulous skin care, and specialized exercises should be implemented, as suggested by studies on lymphoedema management 1. For POTS management, increased fluid intake (2-3 liters daily), increased salt consumption (8-10g daily), compression garments extending to the waist, and a gradual exercise program focusing on recumbent exercises initially is recommended, taking into account the need to avoid deconditioning and exacerbating orthostatic intolerance 1. Medication options include beta-blockers like propranolol or midodrine for tachycardia, and fludrocortisone for volume expansion, with the consideration of using shorter-acting drugs that affect baroreceptor activity for blood pressure management at bedtime, as seen in the treatment of orthostatic hypotension 1. Key considerations include:

• Balancing the treatment approach to avoid worsening lymphoedema with increased salt and fluids while benefiting from compression therapy for both conditions.
• Regular monitoring of symptoms, heart rate, blood pressure, and limb measurements to adjust treatment accordingly.
• Addressing the underlying pathophysiology of both conditions - autonomic dysfunction in POTS and impaired lymphatic drainage in lymphoedema - to minimize contradictory interventions and prioritize patient outcomes.

From the Research

Management of Lymphoedema

• The management of lymphoedema involves a combination of therapies, including complex decongestive lymphatic therapy (CDT), manual lymphatic drainage (MLD), compression bandaging, and physical exercises 2, 3, 4.
• CDT has been shown to be effective in reducing lymphoedema volume, with a reduction of 45-70% achievable with this treatment 4.
• The use of compression bandaging and garments is also an essential part of lymphoedema management, as it helps to reduce swelling and prevent further fluid accumulation 2, 3, 5.

Considerations for Patients with POTS

• Patients with Postural Orthostatic Tachycardia Syndrome (POTS) may require additional considerations when managing lymphoedema, as they may be more susceptible to orthostatic intolerance and other cardiovascular complications 6.
• A collaborative approach to lymphoedema management, involving a team of healthcare professionals, including physiotherapists, nurses, and doctors, may be beneficial in improving patient outcomes 6.
• The development of a clinical protocol for lymphoedema management, tailored to the individual needs of patients with POTS, may help to improve access to effective treatment and reduce symptoms 6.

Treatment Options

• Complete decongestive physiotherapy (CDT) is a combination of four methods (manual lymphatic drainage, lymphoedema rehabilitation exercises, compression therapy, skin care) that can achieve a significant reduction in lymphoedema volume 4.
• Other treatment options, such as pneumatic compression, elevation of the extremities, thermal therapy, and aqua lymphatic therapy, may also be beneficial in managing lymphoedema 4.
• Surgical options, such as excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, may be considered for patients who are unresponsive to conservative therapy 5.