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. According to the 2022 ACC expert consensus decision pathway 1, increasing fluid intake to 3 liters of water or an electrolyte-balanced fluid per day and liberalizing sodium intake to 5-10 grams per day can help expand blood volume. Additionally, patients should be advised to avoid factors that contribute to dehydration, such as alcohol and caffeine consumption, large heavy meals, and excessive heat exposure.

Key lifestyle modifications include:

• Salt loading through liberalized sodium intake (5-10 g or 1-2 teaspoons of table salt per day)
• 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

Pharmacological therapies may be used empirically, 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
• Ivabradine for severe fatigue exacerbated by beta-blockers and calcium-channel blockers
• Fludrocortisone (up to 0.2 mg taken at night) to increase blood volume and help with orthostatic intolerance
• Midodrine (2.5-10 mg) 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 4 pm, as suggested by the study 1.

From the Research

Treatment Options for Postural Orthostatic Tachycardia Syndrome (POTs)

The treatment of Postural Orthostatic Tachycardia Syndrome (POTS) is multifaceted and depends on the specific phenotype of the condition. According to 2, there are three primary POTS phenotypes: hyperadrenergic, neuropathic, and hypovolemic, each requiring tailored management strategies.

Lifestyle Modifications

• Increased fluid and salt intake to expand blood volume and reduce symptoms of orthostatic intolerance 2, 3
• Compression garment use to improve venous return and reduce pooling of blood in the legs 2, 3
• Physical reconditioning and postural training to improve orthostatic tolerance and reduce symptoms of POTS 2, 3

Pharmacologic Therapies

• Beta-blockers for hyperadrenergic POTS to reduce excessive norepinephrine production and sympathetic overactivity 2
• Agents that enhance vascular tone, such as pyridostigmine and midodrine, for neuropathic POTS to improve vasoconstriction and reduce symptoms of orthostatic intolerance 2, 3
• Volume expansion and exercise for hypovolemic POTS to improve blood volume and reduce symptoms of dehydration and physical deconditioning 2

Alternative Therapies

• Craniosacral therapy, specifically the compression of the fourth ventricle (CV4), has been proposed as a successful single management modality in patients with POTS, particularly those with post-viral neuropathic POTS 4

Challenges and Limitations

• There are no medications approved by the United States Food and Drug Administration (FDA) for the treatment of POTS 2
• Pharmacologic therapies are primarily used to manage specific symptoms, and the evidence supporting their efficacy is limited 2, 5, 6
• Most studies on pharmacologic treatments for POTS have small sample sizes and are underpowered, making it difficult to draw definitive conclusions about their effectiveness 5, 6