What medications are used to treat Postural Orthostatic Tachycardia Syndrome (POTS)?

Medications for Postural Orthostatic Tachycardia Syndrome (POTS)

Low-dose propranolol (10mg twice daily) is the first-line pharmacological treatment for POTS, particularly for patients experiencing tachycardia upon standing. 1

Non-Pharmacological Interventions (First-Line)

Before initiating medications, these non-pharmacological approaches should be implemented:

• Volume expansion:

  • Increase fluid intake to 2-3 liters per day 2, 1
  • Increase sodium intake to 10g daily 2, 1
  • Elevate head of bed by 10° during sleep 2, 1

• Physical countermeasures:

  • Compression garments (waist-high stockings) 2, 1
  • Physical counter-maneuvers (leg crossing, squatting, muscle tensing) 2, 1

• Exercise protocol:

  • Begin with recumbent exercise (swimming, rowing, recumbent bike)
  • Gradually transition to upright exercise as tolerance improves 1, 3

Pharmacological Treatment Algorithm

First-Line Medications:

• Low-dose propranolol (10-20mg twice daily) - Reduces heart rate without exacerbating fatigue 1
  • Most effective for hyperadrenergic POTS subtype
  • Start at low dose to avoid exacerbating fatigue

Second-Line Medications:

• Midodrine (2.5-10mg three times daily) 2, 1

  • Peripheral selective α1-adrenergic agonist
  • Last dose should not be taken after 6 PM to avoid supine hypertension
  • Most effective for neuropathic POTS subtype with impaired vasoconstriction

• Fludrocortisone (0.1-0.2mg daily) 2, 1

  • Mineralocorticoid that stimulates renal sodium retention
  • Expands fluid volume
  • Monitor for hypokalemia
  • Most effective for hypovolemic POTS subtype

Third-Line Medications:

• Ivabradine 1

  • Useful for patients with severe fatigue exacerbated by beta-blockers
  • Reduces heart rate without affecting blood pressure

• Pyridostigmine 2, 1

  • Acetylcholinesterase inhibitor
  • Enhances parasympathetic tone
  • Particularly useful for neuropathic POTS subtype

• Low-dose calcium channel blockers (diltiazem, verapamil) 1

  • Alternative for patients who cannot tolerate beta-blockers

POTS Phenotype-Based Treatment Approach

Hyperadrenergic POTS:

• Characterized by excessive norepinephrine production
• Best treatment: Beta-blockers (propranolol, metoprolol)
• Avoid norepinephrine reuptake inhibitors

Neuropathic POTS:

• Characterized by impaired vasoconstriction during orthostatic stress
• Best treatment: Midodrine, pyridostigmine

Hypovolemic POTS:

• Characterized by reduced blood volume
• Best treatment: Fludrocortisone, high salt/fluid intake

Medications to Avoid in POTS

• Vasodilators
• Diuretics
• Certain antidepressants that exacerbate orthostatic symptoms

Monitoring and Follow-Up

• Reassess every 3-6 months to adjust therapy based on symptoms
• Continue medications only for patients reporting significant symptomatic improvement
• Approximately 50% of patients may spontaneously recover within 1-3 years 1

Important Considerations

• No medications are FDA-approved specifically for POTS 4
• Treatment goals focus on minimizing postural symptoms rather than restoring normotension 2
• POTS can severely impact quality of life and daily activities in otherwise healthy individuals 1, 5
• Treatment should be tailored to the specific POTS subtype for optimal results 4