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

From the Guidelines

Treatment of Postural Orthostatic Tachycardia Syndrome (POTS) should prioritize a combination of non-pharmacological interventions and individualized pharmacological therapies, focusing on expanding blood volume, reducing symptoms, and improving quality of life, as recommended in the 2022 ACC expert consensus decision pathway 1.

Non-Pharmacological Interventions

Non-pharmacological approaches are crucial in managing POTS and should be initiated first. These include:

• Increasing fluid intake to at least 3 liters of water or an electrolyte-balanced fluid per day to help expand blood volume.
• Liberalizing sodium intake to 5-10 grams per day (approximately 1-2 teaspoons of table salt) to support blood volume expansion, provided blood pressure is controlled.
• Elevation of the head of the bed by 4-6 inches during sleep to reduce nocturnal polyuria and improve morning blood volume.
• Use of waist-high support stockings to enhance central blood volume support.
• Avoiding factors that contribute to dehydration, such as alcohol, caffeine, large heavy meals, and excessive heat exposure.

Pharmacological Therapies

Pharmacological treatments may be added based on the patient's specific symptoms and response to non-pharmacological interventions. Options include:

• Low-dose beta-blockers (e.g., bisoprolol, metoprolol, nebivolol, propranolol) or nondihydropyridine calcium-channel blockers (e.g., diltiazem, verapamil) to slow the heart rate and improve exercise tolerance.
• Ivabradine for patients with severe fatigue exacerbated by beta-blockers and calcium-channel blockers, as it has shown improvement in heart rate and quality of life in a trial of patients with POTS 1.
• Fludrocortisone (up to 0.2 mg at night) in conjunction with salt loading to increase blood volume, with careful monitoring for hypokalemia.
• Midodrine (2.5-10 mg) to help with orthostatic intolerance, with the first dose taken in the morning and the last dose no later than 4 pm.

Exercise and Lifestyle Modifications

A formalized exercise program should be initiated, which may include supervised physical therapy or specific instructions for home or gym exercises, focusing on supporting long-term cardiovascular health and addressing deconditioning 1. The program should start with recumbent exercises before progressing to upright activities, aiming to improve fitness and activity levels gradually.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for POTS

• The approach to treating POTS centers on addressing the underlying pathophysiologic mechanism, which can include partial autonomic neuropathy, hypovolemia, and hyperadrenergic state 2
• Treatment strategies for POTS may involve:
  • Stockings, abdominal binders, and vasoconstrictors to enhance venous return in partial neuropathic POTS 2
  • Exercise and volume expansion for hypo-volemic POTS 2
  • Beta-blockers and avoidance of norepinephrine reuptake inhibitors for hyperadrenergic POTS 2
• Management of POTS can also include:
  • Avoidance of precipitating factors 3
  • Volume expansion 3
  • Physical countermaneuvers 3
  • Exercise training 3
  • Pharmacotherapy (fludrocortisone, midodrine, β-blockers, and/or pyridostigmine) 3
  • Behavioral-cognitive therapy 3
• Experimental therapies for POTS are being explored, including:
  • Cardiac neuromodulation 4
  • Supplemental therapies such as iron, vitamin D, and α lipoic acid 4
  • Erythropoietin, IVIG, and desmopressin 4
• A systematic review of medication treatments for POTS found some favorable effects with:
  • Fludrocortisone 5
  • Beta blockers 5
  • Midodrine 5
  • Selective serotonin reuptake inhibitors 5