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

From the Guidelines

POTS treatment should prioritize a combination of lifestyle modifications, including a formalized exercise program, salt and fluid loading, and elevation of the head of the bed, as well as pharmacological interventions such as low-dose beta-blockers, fludrocortisone, and midodrine, as supported by the 2022 ACC expert consensus decision pathway 1.

Lifestyle Modifications

Key lifestyle modifications for POTS treatment include:

• Initiating a formalized exercise program, which may be supervised by a physical therapist or conducted at home with specific instructions, to support long-term cardiovascular health 1.
• Increasing fluid intake to 3 liters of water or an electrolyte-balanced fluid per day, and liberalizing sodium intake to 5-10 grams per day to expand blood volume 1.
• Elevation of the head of the bed by 4-6 inches during sleep to reduce blood pooling in the lower extremities 1.
• Use of support stockings, waist-high, to ensure sufficient support of central blood volume 1.

Pharmacological Interventions

Pharmacological treatments for POTS may include:

• Low-dose beta-blockers, such as bisoprolol, metoprolol, nebivolol, or propranolol, to slow the heart rate and improve exercise tolerance 1.
• 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.
• Midodrine, 2.5-10 mg, to help with orthostatic intolerance, with the first dose taken in the morning and the last dose taken no later than 4 pm 1.
• Ivabradine, which may be used in patients with severe fatigue exacerbated by beta-blockers and calcium-channel blockers, as supported by a trial of 22 patients with POTS 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Approaches for Postural Orthostatic Tachycardia Syndrome (POTS)

• Lifestyle modifications are the first line of treatment for all POTS patients, including increased fluid and salt intake, compression garment use, physical reconditioning, and postural training 2, 3, 4, 5.
• There are no medications approved by the United States Food and Drug Administration (FDA) for the treatment of POTS 2, 6, 5.
• Pharmacologic therapies are used to manage specific symptoms, with the choice of medication depending on the underlying pathophysiologic mechanism 2, 3, 4.

Phenotype-Based Treatment Strategies

• Hyperadrenergic POTS: beta-blockers are an effective option to manage excessive norepinephrine production or impaired reuptake 2, 3.
• Neuropathic POTS: agents that enhance vascular tone, such as pyridostigmine and midodrine, are used to manage impaired vasoconstriction during orthostatic stress 2, 3.
• Hypovolemic POTS: volume expansion and exercise are the primary treatment strategies to manage dehydration and physical deconditioning 2, 3.

Experimental Therapies

• Supplemental therapies such as iron, vitamin D, and α-lipoic acid may be used to manage POTS symptoms 4.
• Cardiac neuromodulation is a promising experimental therapy, although more research is needed to fully understand its potential benefits 4.
• Other experimental therapies, including erythropoietin, IVIG, and desmopressin, may be considered in certain cases, but their use is more specialized and nuanced 4.