Treatment of Postural Orthostatic Tachycardia Syndrome With Medication: A Systematic Review

Abstract

Purpose: Postural orthostatic tachycardia syndrome has been recognized for decades, but treatment is largely based on anecdotal experience and expert opinion. Pharmacologic treatment is inconsistent and unstandardized. We did a systematic review to identify controlled studies from which informed treatment decisions can be made. Method: Through a standard systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified all English-language studies of a medication treatment for postural orthostatic tachycardia syndrome that included a comparison or control group and followed outcomes for at least 1 week of treatment. Results: A total of 626 studies were identified by the search criteria, and 8, involving a total of 499 patients, met the criteria. No studies were adequately similar to allow for meta-analysis. Of the identified 8 studies, 2 were randomized controlled trials and 4 had been subjected to peer review. In individual studies, there was some favorable effect with fludrocortisone, beta blockers, midodrine, and selective serotonin reuptake inhibitors. Conclusion: There is a paucity of high-quality data about effectiveness of medication in the treatment of postural orthostatic tachycardia syndrome. Nonetheless, 2 randomized trials and 6 other reports show some favorable effects of medication.

Excessive Postural Tachycardia and Postural Orthostatic Tachycardia Syndrome in Youth: Associations With Distress, Impairment, Health Behaviors, and Medication Recommendations

“…There is a paucity of data about what medication treatments are actually effective in patients with postural orthostatic tachycardia syndrome, as well as in those with more vague symptoms of autonomic dysfunction. 10,11 There is, at the same time, reason for optimism that multidisciplinary treatment of postural orthostatic tachycardia syndrome is effective, even in markedly affected patients, 26,27 based on data from China 28 and the United States. 12 Lifestyle aspects of management should conceivably benefit youth with similar presentations of autonomic dysfunction, regardless of postural orthostatic tachycardia syndrome diagnosis.…”

“…Therapeutic decisions about medication use are sometimes based on whether or not postural tachycardia accompanies the symptoms, 9 but there is a paucity of data to actually guide medication use decisions. 10,11 More information is needed regarding how medication recommendations relate to whether postural orthostatic tachycardia syndrome has been diagnosed and, further, to how often postural tachycardia is observed on tilt table test among youth presenting for clinical evaluation of symptoms suggestive of autonomic dysfunction. Nonetheless, affected patients seem to benefit from nonpharmacologic treatment strategies, 9 and outcomes are often good.…”

Choices and Challenges With Drug Therapy in Postural Orthostatic Tachycardia Syndrome: A Systematic Review

“…Postural orthostatic tachycardia syndrome (POTS) is a chronic orthostatic intolerance that is considered to be an autonomic dysfunction characterized by the inability of the involuntary nervous system to properly control blood flow, gastrointestinal flow, and body temperature [ 1 , 2 ]. This results in postural symptoms like persistent fatigue, dizziness, lightheadedness, and palpitations, especially upon standing [ 3 ].…”

“…The disease is a complicated multi-system disorder contributing to poor quality of life [ 7 ]. Pharmacologic therapies have been explored in minimizing symptoms and increasing functional ability in POTS patients [ 2 ]. Treatment targets have focused on reducing heart rate (beta-blockers), increasing cardiac output (increase in salt intake), or increasing blood pressure (midodrine).…”

“…Treatment targets have focused on reducing heart rate (beta-blockers), increasing cardiac output (increase in salt intake), or increasing blood pressure (midodrine). The therapies are based on the hypothesis that affecting the said parameters will reduce symptom burden and are aimed at managing symptoms such as lightheadedness, dizziness, and rapid heartbeat that occur when standing up [ 2 ]. POTS patients face considerable physical, psychosocial, and financial challenges in the absence of a definitive cure [ 8 ].…”