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

From the Guidelines

Treatment for worsening Postural Orthostatic Tachycardia Syndrome (POTS) should prioritize non-pharmacological interventions, including a formalized exercise program, salt and fluid loading, and the use of support stockings, as these approaches address the underlying pathophysiology of reduced plasma volume and deconditioning. According to the 2022 ACC expert consensus decision pathway 1, a structured exercise program can support long-term cardiovascular health and should be initiated in a supervised setting or at home. Key non-pharmacological interventions include:

• Salt loading with 5-10g of sodium per day, achieved through liberalized sodium intake or table salt, while avoiding salt tablets to minimize nausea and vomiting
• Drinking 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 waist-high support stockings to ensure sufficient support of central blood volume
• Avoiding factors that contribute to dehydration, such as alcohol and caffeine consumption, large heavy meals, and excessive heat exposure

Pharmacological therapies may be used empirically, including:

• Low-dose beta-blockers, such as bisoprolol, metoprolol, nebivolol, or propranolol, to slow the heart rate and improve exercise tolerance
• Nonselective beta-blockers, like propranolol, to control debilitating symptoms in those with orthostatic intolerance and a hyper-adrenergic state
• Ivabradine for severe fatigue exacerbated by beta-blockers and calcium-channel blockers
• Fludrocortisone to increase blood volume and help with orthostatic intolerance, with careful monitoring to guard against hypokalemia
• Midodrine to help with orthostatic intolerance, with the first dose taken in the morning and the last dose taken no later than 4 pm.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The treatment options for worsening Postural Orthostatic Tachycardia Syndrome (POTS) are not directly addressed in the provided drug label. Midodrine is indicated for the treatment of symptomatic orthostatic hypotension (OH), but its use in POTS is not explicitly mentioned.

• The label does mention that midodrine should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment. However, the clinical benefits of midodrine, principally improved ability to perform life activities, have not been established for POTS. 2

From the Research

Treatment Options for Worsening Postural Orthostatic Tachycardia Syndrome (POTS)

• The primary objectives of POTS management are to increase the time that patients can stand, perform daily activities, and exercise, and to avoid syncope 3.
• Management involves nonpharmacologic and pharmacologic approaches, including:
  • Nonpharmacologic approaches:
    • Fluid and salt loading
    • Physical countermaneuvers
    • Compression garments
    • Exercise training, such as horizontal exercise (e.g., rowing, swimming, recumbent bike) and progressive upright exercise 3, 4
    • Chronic volume expansion via sleeping in the head-up position
    • Reduction in venous pooling during orthostasis by lower body compression garments or an abdominal binder
    • Physical countermeasure maneuvers, such as squeezing a rubber ball, leg crossing, muscle pumping, squatting, and negative-pressure breathing 4
  • Pharmacologic approaches:
    • β-blockers (e.g., propranolol, bisoprolol) for hyperadrenergic POTS
    • Pyridostigmine for neuropathic POTS
    • Fludrocortisone for hypovolemic POTS
    • Midodrine for neuropathic POTS 3, 5, 6, 7

Pharmacologic Treatment Efficacy

• Studies have shown that pharmacologic treatment can improve symptoms of POTS, including orthostatic intolerance, depression, and quality of life 6, 7.
• A randomized clinical trial found that propranolol, bisoprolol, and pyridostigmine were effective in reducing symptoms of POTS, with similar efficacy among the different treatment groups 6.
• Another study found that treatment with bisoprolol and fludrocortisone improved symptoms and autonomic and hemodynamic profiles in patients with POTS 7.

Lifestyle Modifications

• Lifestyle modifications, such as increased fluid and salt intake, compression garment use, physical reconditioning, and postural training, are recommended as first-line treatment for all POTS patients 5.
• Exercise training, particularly horizontal exercise, can help improve functional capacity and reduce symptoms of POTS 4.