What is the treatment for Postural Orthostatic Tachycardia Syndrome (POTS)?

Treatment of Postural Orthostatic Tachycardia Syndrome (POTS)

The treatment of POTS should begin with non-pharmacological measures including increased fluid intake, salt consumption, compression garments, and exercise, followed by targeted pharmacological therapy based on the specific POTS phenotype if symptoms persist.

Non-Pharmacological Management (First-Line)

Fluid and Salt Management

• Increase daily fluid intake to 2-3 liters per day 1
• Increase salt consumption to 5-10g (1-2 teaspoons) of table salt daily 1
• Encourage liberalized dietary sodium intake rather than salt tablets to minimize gastrointestinal side effects 1

Physical Measures

• Use waist-high compression garments to improve venous return 1
• Implement physical counter-pressure maneuvers (leg-crossing, stooping, squatting, muscle tensing) during symptomatic episodes 1, 2
• Elevate the head of the bed during sleep 1
• Begin with horizontal exercise (rowing, swimming, recumbent bike) to avoid upright posture that triggers symptoms 2
• Gradually progress to upright exercise as fitness improves 2

Pharmacological Management (Second-Line)

Based on POTS Phenotype

Hypovolemic POTS

• Fludrocortisone for volume expansion 1, 3

Neuropathic POTS

• Midodrine (2.5-10 mg three times daily) to enhance vascular tone 1, 4
  • First dose in morning before rising
  • Last dose no later than 4 PM to avoid supine hypertension
• Pyridostigmine to enhance vascular tone 1, 3

Hyperadrenergic POTS

• Propranolol for resting tachycardia 1, 3
• Avoid medications that inhibit norepinephrine reuptake 1

Medication Precautions

• Monitor for supine hypertension with vasoconstrictors like midodrine 1
• Use midodrine with caution in older males due to potential urinary outflow issues 1
• Carefully adjust or withdraw medications that may cause hypotension 1
• Avoid medications that lower CSF pressure or reduce blood pressure as they may worsen postural symptoms 1

Monitoring and Follow-up

• Follow up at regular intervals to adjust treatment as needed 1:
  • Early review at 24-48 hours
  • Intermediate follow-up at 10-14 days
  • Late follow-up at 3-6 months
• Monitor peak symptom severity, time able to spend upright before needing to lie down, and cumulative hours able to spend upright per day 1
• Assess response to treatment by monitoring standing heart rate and symptom improvement 1

Important Considerations

• Currently, there are no FDA-approved medications specifically for POTS 5, 4
• Treatment should target the underlying pathophysiologic mechanism 3
• For heart rates as high as 180 bpm, consider cardiac evaluation to rule out other arrhythmias before attributing solely to POTS 1
• POTS is frequently associated with deconditioning, recent infections, chronic fatigue syndrome, and joint hypermobility syndrome 1

Treatment Algorithm

1. Start with non-pharmacological measures for all patients
2. If symptoms persist after 4-6 weeks, identify POTS phenotype and add appropriate medication:
   • Hypovolemic → Fludrocortisone
   • Neuropathic → Midodrine or pyridostigmine
   • Hyperadrenergic → Propranolol
3. Reassess at regular intervals and adjust therapy as needed
4. Consider combination therapy for refractory cases