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 non-pharmacological and pharmacological approaches, starting with lifestyle modifications such as increased fluid intake, salt consumption, and a gradual exercise program, as well as considering medications like beta-blockers, fludrocortisone, and midodrine, as supported by the 2022 ACC expert consensus decision pathway 1.

Non-Pharmacological Interventions

Non-pharmacological interventions are crucial in managing POTS, focusing on addressing the reduction in plasma volume that follows deconditioning. This includes:

• Salt and fluid loading, with a recommendation of liberalized sodium intake (5-10 g or 1-2 teaspoons of table salt per day) and drinking 3 liters of water or an electrolyte-balanced fluid per day 1.
• Elevation of the head of one’s bed with 4–6-inch (10–15-cm) blocks during sleep.
• Use of support stockings (waist-high) 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.

Pharmacological Interventions

Pharmacological therapies may be used empirically, considering the patient's specific symptoms:

• Low-dose beta-blockers (e.g., bisoprolol, metoprolol, nebivolol, propranolol) or nondihydropyridine calcium-channel blockers (e.g., diltiazem, verapamil) may be added to slow the heart rate 1.
• Nonselective beta-blockers like propranolol may help control debilitating symptoms in those with orthostatic intolerance with a hyper-adrenergic state, and also in those with coexisting anxiety or migraine.
• Ivabradine may be used in those with severe fatigue exacerbated by beta-blockers and calcium-channel blockers, as supported by a trial showing improvement in heart rate and quality of life 1.
• Fludrocortisone (up to 0.2 mg taken at night) may be used in conjunction with salt loading to increase blood volume and help with orthostatic intolerance, with careful monitoring to guard against hypokalemia.
• Midodrine (2.5-10 mg) may 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.

Individualized Treatment Approach

Treatment should be individualized, typically starting with one medication and gradually adding others if needed, and focusing on addressing the autonomic nervous system dysfunction that causes blood pooling in the lower extremities upon standing, leading to decreased cardiac output and compensatory tachycardia 1. Patients should monitor symptoms, stay hydrated, avoid prolonged standing, and rise slowly from lying or sitting positions to minimize symptoms.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The treatment options for 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 it does not explicitly mention POTS.

• The label mentions that midodrine hydrochloride tablets should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment. However, the FDA drug label does not provide information on the treatment of POTS. 2

From the Research

Treatment Options for Postural Orthostatic Tachycardia Syndrome (POTS)

The treatment options for POTS can be categorized into non-pharmacological and pharmacological approaches.

• Non-pharmacological interventions:

  • Increased fluid and salt intake to expand blood volume 3, 4, 5, 6, 7
  • Exercise training, starting with horizontal exercises and progressing to upright exercises as tolerated 3, 4, 5, 6, 7
  • Use of compression garments to reduce venous pooling 3, 4, 6
  • Physical countermeasure maneuvers, such as squeezing a rubber ball, leg crossing, and muscle pumping 3, 4
  • Postural training and education on managing symptoms 4, 5, 6, 7

• Pharmacological interventions:

  • Beta-blockers to reduce heart rate and alleviate symptoms 4, 5, 6, 7
  • Pyridostigmine to enhance vascular tone 4, 6
  • Midodrine to increase blood pressure and reduce symptoms 4, 5, 6
  • Fludrocortisone to increase blood volume 4
  • Serotonin reuptake inhibitors to manage pain and anxiety 7

Phenotype-Based Treatment Approaches

Recent studies have identified three primary POTS phenotypes: hyperadrenergic, neuropathic, and hypovolemic 6. Each phenotype requires tailored management strategies:

• Hyperadrenergic POTS: Beta-blockers to reduce sympathetic overactivity 6
• Neuropathic POTS: Agents that enhance vascular tone, such as pyridostigmine and midodrine 6
• Hypovolemic POTS: Volume expansion and exercise to improve physical conditioning 6