Medication is only used after a trial of non-pharmalogical (without medication) treatment such as increased fluids, salts, compression and exercise.
Firstly, all medicines that worsen symptoms need to be stopped. At this moment there are no approved medicines for the treatment of PoTS and therefore are prescribed “off licence”. The aim of medication is to help control symptoms so that general fitness can be improved. Treatments must be tailored to each patient taking into account the cause of their PoTS as the same medicines can have very different effects on different individuals*. PoTS patients tend to be very sensitive to medicines and therefore commenced on tiny doses (even children’s doses)*. Side effects should be monitored very closely. It is often a cause of very deep frustration to sufferers who might need to try many different drugs before finding the right combination*.
Drugs which slow down heart rate
Beta Blockers – bisoprolol, propranolol , labetalol, metoprolol
The aim of an alpha agonist is to narrow blood vessels to help return the blood back to the heart.
Selective Serotonin Reuptake Inhibitor (SSRI)
sertraline, escitalopram, citalopram, paroxetine
SSRIs are usually prescribed to treat depression and anxiety disorders, but recently, some evidence has emerged showing that serotonin plays a part in the control of both heart rate and blood pressure and may therefore be useful in treating PoTS.
Serotonin-Noradrenaline Reuptake Inhibitor (SNRI)
bupropion, venlafaxine, duloxetine
SNRIs may worsen tachycardia in patients with PoTS.
Medications that Increase Blood Volume
This is a synthetic steroid that retains salt and produces an increase in the volume of blood within the blood vessels. . It does not have all the same side effects as other steroids (e.g. prednisolone) that often worry patients. Blood potassium levels need to be monitored.
This is a hormone that reduces urine production, promotes fluid retention and therefore decreases heart rate, improving symptoms of PoTS
This hormone increases the production of red blood cells and subsequently increases blood volume. Erythropoietin causes blood vessels to narrow.
These lower the heart rate and may reduce blood pressure by working directly on the brain.
Narrows blood vessels in the abdominal cavity. Daily injections can be a drawback, but a long-acting form that can last weeks has been developed.
Acts at the nervous system "autonomic ganglia" to increase vagal tone, which can reduce heart rate. Side effects may include stomach pain, nausea diarrhoea which can be troublesome for some patients.
This is a stimulant normally used in some sleep disorders, and may improve alertness and decrease mental clouding in those with PoTS. Modafinil may increase tachycardia in some patients but this effect is not very severe .
Specialists have their favourite choice of drugs and may tailor their choice according to the symptoms of the patients or co-existing medical conditions. Fludrocortisone, midodrine, beta blocker or ivabradine tend to be used initially*. Sometimes a combination of drugs is necessary.
*No evidence, but usually recommended by specialists