What are the new treatments for Postural Orthostatic Tachycardia Syndrome (POTS)?

From the Guidelines

The most effective treatment approach for Postural Orthostatic Tachycardia Syndrome (POTS) involves a combination of non-pharmacological interventions, such as salt and fluid loading, elevation of the head of the bed, and use of support stockings, along with pharmacological therapies like low-dose beta-blockers, ivabradine, and midodrine, tailored to the individual patient's symptoms and needs. When considering treatment options, it's essential to address the reduction in plasma volume that follows deconditioning, and nonpharmacological interventions should be considered first, as they can support long-term cardiovascular health 1. Some key non-pharmacological interventions include:

• Salt loading, which can be achieved through liberalized sodium intake (5-10 g or 1-2 teaspoons of table salt per day)
• 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)
• Drinking 3 liters of water or an electrolyte-balanced fluid per day Pharmacological therapies may also be used empirically, such as:
• Low-dose beta-blockers (eg, bisoprolol, metoprolol, nebivolol, propranolol) or a nondihydropyridine calcium-channel blocker (eg, diltiazem, verapamil) to slow the heart rate
• Ivabradine, which has been shown to improve heart rate and quality of life in patients with POTS 1
• Midodrine (2.5-10 mg) to help with orthostatic intolerance
• Fludrocortisone (up to 0.2 mg taken at night) to increase blood volume and help with orthostatic intolerance, with careful monitoring to guard against hypokalemia 1. Ultimately, a formalized exercise program should be initiated, and patients should be encouraged to avoid factors that contribute to dehydration, such as consumption of alcohol and/or caffeine, ingestion of large heavy meals, and excessive heat exposure 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets 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 answer to the question is that midodrine is a treatment for symptomatic orthostatic hypotension.

• Key points:
  • Midodrine is used to treat symptomatic orthostatic hypotension.
  • It should be used in patients whose lives are considerably impaired despite standard clinical care.
  • Clinical benefits of midodrine have not been fully established, but it has been shown to increase 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit 2 2. Note that Postural Orthostatic Tachycardia Syndrome (POTS) is not explicitly mentioned in the provided drug labels, and therefore, no conclusion can be drawn about the treatment of POTS specifically.

From the Research

New Treatments for Postural Orthostatic Tachycardia Syndrome (POTS)

• Non-pharmacological interventions, such as physical reconditioning with exercise training and volume expansion via increased salt and fluid intake, are recommended as initial treatments for POTS patients 3.
• Horizontal exercise, such as rowing, swimming, or recumbent bike, is suggested as a starting point, allowing patients to exercise while avoiding upright posture that elicits POTS symptoms 3.
• Other non-pharmacological interventions, including chronic volume expansion, reduction in venous pooling, and physical countermeasure maneuvers, may also be effective in preventing orthostatic intolerance and managing acute clinical symptoms in POTS patients 3, 4.
• Pharmacologic therapies, such as beta-blockers, pyridostigmine, fludrocortisone, and midodrine, are used to manage specific symptoms, although the evidence supporting their efficacy is limited 4, 5, 6, 7.
• A phenotype-based approach to treatment is recommended, with tailored management strategies for each of the three primary POTS phenotypes: hyperadrenergic, neuropathic, and hypovolemic 5, 6.
• Lifestyle modifications, including increased fluid and salt intake, compression garment use, physical reconditioning, and postural training, are considered first-line treatment for all patients 6.
• Beta-blockers are an effective option for hyperadrenergic POTS, while agents that enhance vascular tone, such as pyridostigmine and midodrine, are used for neuropathic POTS 6.
• Volume expansion and exercise are the primary treatments for hypovolemic POTS 6.