Medications for Postural Orthostatic Tachycardia Syndrome (POTS)

MedicationMost treatments for postural orthostatic tachycardia syndrome (POTS) work to alleviate symptoms of the disorder, but do not cure POTS. These medications are prescribed off-label; meaning that they were designed for other disorders but have not been approved for POTS by the FDA.  They may, however, help alleviate POTS symptoms. Here are some of the more common medications used to treat POTS symptoms that you can discuss with your physician.

Antidepressant medications: Bupropion (Wellbutrin), Paroxetine (Paxil), or Sertraline (Zoloft)

These medications can help people with POTS who are prone to fainting by raising the blood pressure and modifying the brain’s response to low blood pressure signals. They are also beneficial to those who have depression or anxiety issues.

Antidiuretics: DDAVP (Desmopressin acetate)

This medication is a synthetic version of the hormone anti-diuretic hormone, and helps retain the body retain water which can increase blood pressure.  At night when you lay flat, the kidneys eliminate excess fluid. This is why many people with POTS often feel worse in the morning. By retaining some of the fluid at night, the blood pressure is higher in the morning which translates to feeling a bit better in the morning.  This medication should be taken at bedtime.

Beta Blockers: Propranolol (Inderal)

Beta blockers decrease heart rate, force of contraction, and conduction velocity through the heart. Beta blockers are most useful in people with elevated norepinephrine levels, beta receptor supersensitivity, hyperadrenergic state and those suffering from angina, hypertension, or cardiac arrhythmias.  A low dose of propranolol blunts the pounding fast heart rate feeling without lowering the blood pressure.  Beta blockers can reduce plasma renin activity and be counterproductive in those with low blood volume, however.

Centrally acting sympatholytic drugs: Clonidine (Catepres)

These medications decrease sympathetic activity and blood pressure. Clonidine works by stimulating the inhibitory alpha-2 adrenergic receptors in a part of the brain called the medulla oblongata. This reduces activity of the sympathetic nervous system and decreases heart rate, decreases release of renin, and dilates the blood vessels which reduces blood pressure.  They can improve sleep when taken at bedtime.

Cholinesterase Inhibitors: Pyridostigmine Bromide (Mestinon)

These are reversible inhibitors of the enzyme in synapses called acetylcholinesterase. This enzyme normally breaks down acetylcholine, the neurotransmitter of the parasympathetic nervous system. When acetylcholinesterase is inhibited, however, the level of acetylcholine increases in the synapse and is available to bind its receptor for a longer duration. This type of medication is particularly helpful in patients with postviral, paraneoplastic, or autoimmune forms of POTS.

Mineralocorticoids: Fludrocortisone (Florinef)

This is the most commonly prescribed medication for POTS.  These steroids increase plasma volume and helps body retain both salt and water. They are often prescribed in tandem with salt tablets. This drug mimics aldosterone, which helps the body reabsorb sodium into the blood and secrete potassium into the urine. Florinef can deplete potassium and magnesium – supplements may be needed. Thermotabs can be helpful at supplementing both sodium and potassium when taking Florinef.  It can also reduce levels of plasma renin activity and be counterproductive in those with low blood volume. The dose should never total more than 0.4 mg daily as adrenal suppression may occur.

Stimulants: Amphetamine and Dextroamphetamine (Adderall), Methylphenidate (Concerta)

These are the same medications that can be used for individuals who have Attention Deficit Disorder. For POTS, they are used for those experiencing significant fatigue symptoms and brain fog.  Stimulants have the added benefit of raising the blood pressure by vasoconstriction.  These medications should be taken in the morning.

Modafinil (Provigil)

This medication is not a stimulant, but is used to improve wakefulness in patients with excessive sleepiness.  It stimulates the brain and may work by increasing the amount of dopamine (a neurotransmitter used by neurons for communication) in the brain by reducing the reuptake of dopamine into nerves.  This medication should be taken in the morning.

Vasoconstrictors: Midodrine (ProAmatine)

This medication tightens the blood vessels to raises the blood pressure and decrease blood pooling in the legs and abdomen.  It is short acting, however, and may need to be administered three times daily. It is best NOT to lie down to nap or sleep within four hours after taking this medication since the blood pressure can go up significantly when you are lying flat, but you can make an exception to this if you are feeling dizzy or faint. Midodrine can cause headaches and a feeling of goose-bumps which is a good indication that the medication is taking effect.

For more specific information on treatment options, visit the Dinet website and or the primary literature on the topic.