POTS Treatment: Activity, Lifestyle Changes, Medication

Postural orthostatic tachycardia syndrome (POTS) is a form of autonomic dysfunction. Your autonomic nervous system regulates involuntary functions such as breathing, heart rate, blood pressure, and digestion.

The autonomic nervous system doesn’t respond appropriately in people with POTS, so actions like standing and exercising are more challenging and may be accompanied by high heart rate, dizziness, or fainting. You may also experience exercise intolerance, fatigue, digestive problems, and trouble sleeping. 

POTS is a chronic (long-term) condition that is relapsing and remitting, meaning you may have periods of worse symptoms and periods of relatively few symptoms. There is no cure for POTS, but symptoms can be managed through physical therapy, lifestyle modifications, and sometimes medicine.

Physical therapy or exercise training may help improve your POTS symptoms. While these therapies may seem counterintuitive given that POTS can cause exercise intolerance, POTS symptoms can actually worsen with physical deconditioning (physical decline due to inactivity). Specialized exercise protocols, such as the Levine Protocol, have been developed to help with symptom management.

The Levine Protocol involves mild to moderate intensity endurance training, first performed in a semi-reclined position and progressing into an upright position over three months.

Several lifestyle modifications may improve or manage symptoms. You can try the following: 

• Maintain an active lifestyle: POTS can worsen with deconditioning. Staying as active as possible, whether through swimming, rowing, biking, or walking, can help manage POTS symptoms. 
• Wear compression garments: These specialized socks, pantyhose, or abdominal binders can help prevent blood from pooling and help blood return to your heart more easily when standing. 
• Increase fluid intake: If you have low blood volume, drinking more fluids can help maintain blood pressure in POTS. 
• Increase sodium intake: Consuming salty foods and snacks such as pretzels, pickles, and soy sauce can increase your sodium intake and help stabilize your blood pressure.

Prescription medications are not the go-to when treating POTS. They may instead be reserved for cases where symptoms are severe or continue to return. When used, the goal of the drug is to get your symptoms under control enough so that you can continue with the physical activity portion of treatment.

Medications help manage POTS by targeting specific symptoms like a high heart rate, fatigue, dizziness, and fainting. Many medications can be tried under the guidance of a healthcare professional to help improve symptoms; the most common are listed below.

These medications are drugs that increase blood volume and blood pressure or that reduce heart rate. There are currently no medications for POTS approved by the United States Food and Drug Administration (FDA), and these medications are all used off-label for the condition.

Blood Volume and Blood Pressure Medications

If you stand up or exercise with POTS, you may experience dizziness, lightheadedness, blood pooling in the lower hands and feet, and, in some cases, fainting. Healthcare providers may address these symptoms by prescribing medications that help raise your blood volume or stabilize blood pressure.

Midodrine, sold under brand names like Orvaten and ProAmatine, is a prescription medication that targets certain receptors in your blood vessels and causes them to constrict. Midodrine is indicated for symptomatic low blood pressure but is used off-label for POTS. Side effects may include high blood pressure (especially when lying down), scalp tingling, and headache. 

Florinef (fludrocortisone acetate) is a steroid that works by helping expand your blood volume, which may be low in some people with POTS. Side effects of the drug may include swelling, headache, and abnormal electrolyte balance. 

Heart Rate Medications

To be diagnosed with POTS, your heart rate must increase by at least 30 beats per minute within 10 minutes after you stand. A high heart rate can be challenging, so your healthcare provider may prescribe medications to help lower it. These include:

• Inderal (propranolol): This beta blocker targets specific receptors in your heart to help lower heart rate and blood pressure. Propanolol is indicated for several health conditions, such as chest pain, migraine, and high blood pressure (hypertension). It may be also be used to reduce heart rate in POTS (typically at low doses). Side effects include low blood pressure, low heart rate, worsening exercise tolerance, and worsening asthma. 
• Corlanor (ivabradine): This prescription medication targets a unique ion channel that is involved in maintaining your heart rate. Ivabradine is indicated for certain people with heart failure but has been used off-label to lower heart rate in POTS without also lowering blood pressure. Side effects may include atrial fibrillation (a type of irregular heart rhythm) and low heart rate.
• Mestinon (pyridostigmine): This prescription medication increases the concentration of the neurotransmitter acetylcholine in your body, which can lower your heart rate and help with muscle fatigue. Pyridostigmine is indicated for an autoimmune condition called myasthenia gravis but has been used off-label for POTS. Side effects include stomach discomfort, diarrhea, and worsened asthma.

Although there is no cure for POTS and managing symptoms can be challenging, the condition does not limit life expectancy. It is estimated that people with POTS can have a quality of life similar to those with heart failure.

One study showed that approximately 30% of the 42 participants were unable to work or study due to their POTS symptoms, meaning that most people were able to go about their daily lives.

POTS symptoms can fluctuate, leading to periods where lifestyle modifications are sufficient but other times when medications are needed to manage symptoms. POTS symptoms typically improve over time.

Living with POTS can be challenging, but there are actions people can take to make life with the condition easier to manage:

• Use mobility devices like rollators (a walker with a seat) so a seat is always available to you
• Request accommodations at work or school 
• Pace your work to conserve energy 
• Use a stool to sit on while completing tasks such as cooking
• Invest in cooling vests to help with worsening symptoms when hot
• Eat frequent small meals rather than larger meals to avoid worsening of symptoms after eating
• Perform counter-maneuvers such as calf raises when you feel dizzy while standing

About 90% of people with POTS are women, and many of them are initially misdiagnosed with anxiety as the primary cause of their symptoms. POTS symptoms are varied, leading many people with the condition to consult multiple medical specialties to receive a diagnosis and treatment, which can take several years. Building a strong support system can help some individuals navigate a POTS diagnosis.