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

From the Guidelines

Initial treatment for Postural Orthostatic Tachycardia Syndrome (POTS) should focus on non-pharmacological approaches, including increasing fluid intake to 3 liters daily and sodium consumption to 5-10 grams per day, as well as implementing a structured exercise program and using support stockings to address the reduction in plasma volume and orthostatic intolerance. According to the 2022 ACC expert consensus decision pathway 1, patients with POTS should be encouraged to drink 3 liters of water or an electrolyte-balanced fluid per day and to liberalize their sodium intake to 5-10 g or 1-2 teaspoons of table salt per day. Key non-pharmacological interventions include:

• 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 consumption of alcohol and/or caffeine, ingestion of large heavy meals, and excessive heat exposure If these measures prove insufficient, medications may be considered, 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. These approaches work by addressing the underlying pathophysiology of POTS, which involves blood pooling in the lower extremities and excessive sympathetic activation when upright, leading to inadequate cerebral perfusion despite increased heart rate, as noted in the 2022 ACC expert consensus decision pathway 1.

From the FDA Drug Label

Midodrine hydrochloride is indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

The initial treatment recommendations for Postural Orthostatic Tachycardia Syndrome (POTS) are not directly addressed in the provided drug label.

• Non-pharmacologic treatments such as support stockings, fluid expansion, and lifestyle alterations are mentioned as standard clinical care for symptomatic orthostatic hypotension (OH).
• Midodrine hydrochloride is indicated for the treatment of symptomatic orthostatic hypotension (OH), but its use in POTS is not explicitly stated. 2

From the Research

Initial Treatment Recommendations for Postural Orthostatic Tachycardia Syndrome (POTS)

The initial treatment recommendations for POTS can be categorized based on the underlying pathophysiologic mechanisms.

• For patients with partial autonomic neuropathy, treatments such as stockings, abdominal binders, and vasoconstrictors like midodrine 3 are used to enhance venous return.
• For patients with hypovolemia, exercise and volume expansion are the main treatment strategies.
• For patients with hyperadrenergic POTS, beta-blockers and avoidance of norepinephrine reuptake inhibitors are important 4.
• Compression garments, such as abdominal and lower body compression, have been shown to reduce heart rate and improve symptoms during head-up tilt tests in adult patients with POTS 5.
• Salt supplementation has also been found to improve symptoms, plasma volume, and orthostatic responses in patients with POTS, particularly those with low baseline sodium excretion 6.
• Other interventions, such as intravenous saline, midodrine, propranolol, clonidine, and phenobarbital, have been studied for their acute effects on hemodynamic indices and symptom scores in patients with POTS 7.

Treatment Considerations

When considering treatment options for POTS, it is essential to individualize treatment regimens based on the underlying pathophysiologic mechanism(s) afflicting each patient 4.

• Patients should be monitored for their response to treatment, including improvements in subjective and objective markers of orthostatic intolerance, as well as potential deleterious effects on supine blood pressure 6.
• The efficacy of different treatments may vary depending on the specific characteristics of each patient, such as their baseline sodium excretion and supine blood pressure 6.