Recommended Sodium Intake for POTS
Adults with POTS who have no hypertension or chronic kidney disease should consume a high-sodium diet of 6-10 grams of salt per day (approximately 2,400-4,000 mg of sodium), which is substantially higher than general population recommendations. 1, 2
Evidence-Based Rationale
The recommendation for high sodium intake in POTS is supported by direct mechanistic evidence demonstrating that high dietary sodium (300 mEq/day, equivalent to approximately 7 grams of salt) significantly improves the pathophysiology of POTS compared to low sodium intake 1:
- Increases plasma volume, which directly addresses the hypovolemia characteristic of POTS 1, 2
- Reduces standing heart rate and the excessive orthostatic tachycardia that defines the condition 1
- Lowers standing plasma norepinephrine levels, addressing the sympathetic overactivity seen in POTS 1
- Improves orthostatic tolerance by increasing the time to provoke symptoms during tilt-table testing 2
Practical Implementation
Target intake: 6-10 grams of salt daily (2,400-4,000 mg sodium) 2, 3
This translates to:
- Approximately 2.5-4 teaspoons of table salt per day 2
- Substantially more than the 5 grams (approximately 2,000 mg sodium) recommended for hypertensive patients 4
Important Safety Considerations
This high-sodium recommendation applies ONLY to POTS patients without:
- Hypertension (as specified in your question) 2
- Chronic kidney disease (as specified in your question) 2
- Heart failure 3
- Supine hypertension (common in autonomic disorders) 3
Monitor for:
- Development of elevated supine blood pressure, which can occur with high salt intake 2, 3
- Symptom improvement in orthostatic intolerance (standing heart rate, dizziness, presyncope) 1, 2
- Baseline urinary sodium excretion—patients with baseline sodium excretion <170 mmol/day show the most pronounced benefit 2
Duration and Monitoring
- Short-term use (approximately 3 months) has demonstrated efficacy for reducing syncope and presyncope episodes 2
- Endothelial function is not negatively affected by high-sodium intake for at least 6 days in POTS patients, unlike concerns in other populations 5
- Regular monitoring of blood pressure (both supine and standing) and symptom burden should guide continuation 2
Clinical Context
This recommendation directly contradicts general cardiovascular guidelines that recommend sodium restriction to approximately 2 grams per day for most adults 4, 6. However, POTS represents a specific pathophysiologic state where hypovolemia and excessive sympathetic activation require volume expansion through sodium loading 1. The 2021 study in the Journal of the American College of Cardiology provides the highest-quality mechanistic evidence supporting this approach 1.