Patients whose POTS symptoms are due to B12 deficiency need pharmacological doses of B12 for repletion of tissues.
Several classes of drugs often provide symptom control and relief for POTS patients. Treatments must be carefully tested due to medication sensitivity often associated with POTS patients, and each patient will respond to different therapies in different ways.
The first drug of choice for symptomatic relief of POTS is usually fludrocortisone, or Florinef, a mineralcorticoid used to increase sodium retention and thus increase blood volume and blood pressure. An increase in sodium and water intake must coincide with fludrocortisone therapy for effective treatment.
Dietary increases in sodium and sodium supplements are often used.
Beta blockers such as atenolol, metoprolol and propanolol are often prescribed to treat POTS. These medications slow down the excessive heart rate response (tachycardia) that POTS patients experience. They also work by blocking the effects of epinephrine and norepinephrine released by the Autonomic Nervous System. In addition, beta blockers reduce Sympathetic Nervous System activity by blocking Sympathetic impulses. For some patients, Beta blockers increase POTS symptoms (e.g., lowering blood pressure, increasing fatigue, which is why they are often prescribed in conjunction with Midodrine). Beta blockers may be dangerous to individuals with asthma or allergies.
Midodrine (Proamatine), is approved by the U.S. Food and Drug Administration (FDA) to treat orthostatic hypotension, a condition related to POTS. It is a stimulant that causes vasoconstriction and thereby increases blood pressure and allows more blood to return to the upper parts of the body. Use of midodrine is often discontinued due to intolerable side-effects, and it is known to cause supine hypertension (high blood pressure when lying down). Some doctors prefer to start patients on Midodrine without the concomitant use of Beta blockers and then add Beta blockers once the dose of Midodrine has been properly adjusted. This gives the Midodrine time to start raising the patient's blood pressure which often helps avoid the hypotension that is a common side effect of Beta blockers. Obviously lowering the blood pressure of a POTS patient would exacerbate any existing orthostatic hypotension.
Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and paroxetine (Paxil), can be extremely effective in re-regulating the autonomic nervous system and raising blood pressure. Some studies indicate that serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor) and duloxetine (Cymbalta) are even more effective. Tricyclic antidepressants, tetracyclic antidepressants, and monoamine oxidase inhibitors are also occasionally, but rarely, prescribed. A combination of two antidepressants, usually an SSRI or SNRI with bupropion (Wellbutrin) or mirtazapine (Remeron), is also shown to be very effective.
Medications used to treat attention deficit disorder and attention deficit hyperactivity disorder such as methylphenidate (Ritalin) and Adderall effectively increase norepinehprine and dopamine levels, thereby increasing vasoconstriction and blood pressure. Central Net inhibition can reduce sympathetic outflow through stimulation of A2 adrenoreceptors.
In some cases, when increasing oral fluids and salt intake is not enough, intravenous saline is used to help increase blood volume, as many POTS patients suffer from hypovolemia. Increasing blood volume can decrease POTS symptoms caused or worsened by low blood volume such as tachycardia, low blood pressure, fatigue, and syncope. Infusions can be taken on an as-needed basis in an Emergency Room, or on a regularly scheduled manner at an infusion center or at home with the assistance of a home-care nurse. Many patients report a profound though short-lived improvement in their symptoms from saline infusions.
In the UK, Ivabradine has been used to treat patients with POTS symptoms with good effect. Ivabradine acts by reducing the heart rate in a mechanism different from that of beta blockers and calcium channel blockers, two commonly prescribed antianginal drugs. It is classified as a cardiotonic agent.
- Anti-anxiety medications, such as alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin), can be used to combat imbalances of adrenaline usually seen with POTS patients.
- Angiotensin converting enzyme inhibitors, or ACE inhibitors, are used to increase vascular capacity, cardiac output, and sodium and water excretion.
- Clonidine can work in patients with reduced sympathetic activity. Clonidine lowers catecholamine(epinephrine and norepinephrine) production. This appears paradoxical, as Clonindine is normally associated with reduced sympathetic drive through a2 adrenoreceptor stimulation.
- Disopyramide (Norpace) is an antiarrhythmic medication that inhibits the release of epinephrine and norepinephrine.
- Erythropoietin, used to treat anemia via intravenous infusion, is very effective at increasing blood volume. It is seldom used, however, due to the dangers of increasing the hematocrit, the inconvenience of intravenous infusion, and its prohibitively expensive cost.
- Pregabalin (Lyrica), an anticonvulsant drug, has been shown to be especially effective in treating neuropathic pain associated with POTS. In fact, Lyrica was the first and, for its first year on the market, the only prescription drug approved by the FDA to treat fibromyalgia. Some POTS patients also report improvement in concentration and energy while on Lyrica.
- Pseudoephedrine and phenylephrine, over-the-counter decongestants, increase vasoconstriction by promoting the release of norepinephrine.
- Pyridostigmine (Mestinon), inhibits the breakdown of acetylcholine, promoting autonomic nervous system activity. It is especially effective in patients exhibiting symptoms of excessive sympathetic activity.
- Theophylline, a drug used to treat respiratory diseases such as COPD and asthma, is occasionally prescribed at low doses for POTS patients. Theophylline increases cardiac output, increases blood pressure, and stimulates epinephrine and norepinephrine production. Due to its very narrow therapeutic index, Theophylline is known to cause a wide variety of side-effects and even toxicity.
- Women who report a worsening of symptoms during menstruation will often use combined (containing both estrogen and progestin) forms of hormonal contraception to prevent hormonal changes and an aggravation of their condition.
- IVIG (Intravenous Immunoglobulin) infusions may be helpful for patients whose POTS is caused by autonomic neuropathy associated with Guillain Barre Syndrome, Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), Sjogren's Syndrome or other autoimmune diseases.
- Dihydroergotamine or DHE may be useful in some patients as a selective venoconstrictor through serotoninic receptor agonism.
Recently it has become a popular belief that medical marijuana may have positive effects on POTS patients. However, there is little evidence supporting its efficacy, and the active constituents of marijuana are often associated with postural hypotension.
There are anecdotal reports of benefit being derived from Horse Chestnut seed extract (Aescin), Rehmannia glutinosa, Licorice root, and Ruscus aculeatus (Butcher Broom) however there is currently no research to support the efficacy of these herbal remedies that is specific to POTS.
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