Can postural orthostatic tachycardia syndrome (POTS) due to Long COVID be managed with the same therapies used for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)?

POTS in Long COVID: Management Approaches

POTS is a common condition in patients newly diagnosed with Long COVID, and many therapies used for ME/CFS are effective for managing POTS symptoms in Long COVID patients. 1

Relationship Between POTS and Long COVID

POTS represents one of the most prevalent autonomic disorders in Long COVID patients. Research indicates that:

• POTS is not merely a pre-existing condition exacerbated by Long COVID, but rather a direct consequence of SARS-CoV-2 infection
• Studies show that SARS-CoV-2 can act as a trigger for the development of POTS, similar to SARS-CoV-1 2
• Early-onset orthostatic intolerance symptoms and high pre-illness physical activity levels in Long COVID patients suggest that POTS is not simply due to deconditioning 2
• All Long COVID patients in comparative studies developed POTS during tilt table testing 2

Management Strategies for POTS in Long COVID

Non-Pharmacological Interventions

• Salt and fluid loading:

  • Liberalize sodium intake (5-10g or 1-2 teaspoons of table salt per day)
  • Encourage drinking 3 liters of water or electrolyte-balanced fluid daily
  • Avoid salt tablets to minimize nausea and vomiting 1

• Positional modifications:

  • Elevate the head of the bed with 4-6 inch (10-15 cm) blocks during sleep
  • Use waist-high support stockings to ensure sufficient central blood volume support 1

• Activity management:

  • Implement pacing strategies to avoid worsening fatigue
  • Avoid recommending exercise for patients with post-exertional malaise, as physical activity worsened the condition in 75% of Long COVID patients 1
  • For those without post-exertional malaise, a carefully structured, gradual exercise program may be beneficial 1

Pharmacological Interventions

• First-line medications:

  • Low-dose beta-blockers (e.g., bisoprolol, metoprolol, nebivolol, propranolol)
  • Non-dihydropyridine calcium-channel blockers (e.g., diltiazem, verapamil) 1
  • Nonselective beta-blockers (e.g., propranolol) may help control debilitating symptoms in those with orthostatic intolerance with a hyper-adrenergic state 1

• Second-line medications:

  • Ivabradine for patients with severe fatigue exacerbated by beta-blockers and calcium-channel blockers
  • Fludrocortisone (up to 0.2 mg taken at night) in conjunction with salt loading to increase blood volume (monitor for hypokalemia)
  • Midodrine (2.5-10 mg) for orthostatic intolerance (first dose in morning before getting out of bed, last dose no later than 4 pm) 1

• Additional options for symptom management:

  • Low-dose naltrexone for neuroinflammation, pain, and fatigue
  • H1 and H2 antihistamines (particularly famotidine) for mast cell activation symptoms 1, 3

Supplements and Nutritional Support

• Coenzyme Q10 and D-ribose for fatigue and mitochondrial support 1, 3
• Pycnogenol for endothelial function and microcirculation improvement 1
• Probiotics for gastrointestinal and other symptoms 1, 3

Clinical Pearls and Pitfalls

• Important caveat: Exercise is harmful for patients with Long COVID who have ME/CFS or post-exertional malaise and should not be used as a treatment 1
• Avoid factors that contribute to dehydration, such as alcohol, caffeine, large heavy meals, and excessive heat exposure 1
• Treatment responses between ME/CFS and Long COVID patients are significantly correlated (R² = 0.68), suggesting similar therapeutic approaches may be effective 4
• Patients with POTS as a dominant symptom cluster benefit most from autonomic modulators 4
• Monitor for improvement in both objective measures (heart rate response to standing) and subjective symptoms 5
• Be attentive to psychological symptoms that may require psychiatric intervention 5

Expected Outcomes

Research suggests that approximately 94% of patients with POTS complicated by Long COVID will show improvement within approximately 159 days with appropriate management 5. However, for some patients, especially those who develop ME/CFS following COVID-19, symptoms may be long-lasting or potentially lifelong 1.