Treatment of postural tachycardia syndrome: a comparison of octreotide and midodrine

Abstract

We assessed the potency of octreotide and midodrine, and their combination, in the treatment of the postural tachycardia syndrome (POTS) and orthostatic intolerance (OI). Nine patients with POTS and six patients with OI stood for up to 1 hour while their HR and BP were monitored. Patients received on separate days, midodrine 10 mg 1 hour before testing, octreotide 0.9 micro g/kg 8 minutes before testing or combination therapy. Standing time in the patients with POTS was 41.2 +/- 8.4 minutes and not improved by midodrine or octreotide, but increased to 56.3 +/- 2.7 (P < 0.01) minutes following combination therapy. The standing heart rate in POTS, 114 +/- 0.7 bpm, was suppressed by midodrine 92.8 +/- 0.7 (P < 0.001), octreotide 90.6 +/- 0.78 (P < 0.001), and combination therapy 84.7 +/- 0.7 (P < 0.001). Combination therapy was better than monotherapy (P < 0.001) but only for the first 10 minutes of standing. Standing time of 36.3 +/- 3.5 minutes in the patients with OI improved with midodrine, octreotide and combination therapy (55.5 +/- 3.1, 56.5 +/- 3.5, and 56.6 +/- 3.3, respectively, P < 0.05 for each). Standing heart rate in OI was 100 +/- .76 bpm; following midodrine it was 80.3 +/- .69 (P < 0.05), following octreotide it was 84.8 +/- .86, and following combination therapy it was 71.2 +/- .9 (P < 0.01). The RR interval versus time area under the curve (The Orthostatic Index) was 21.1 +/- 4 in patients with OI. After midodrine it was 41.4 +/- 3.5 (P < 0.01), after octreotide 40.3 +/- 3.8 (P < 0.01) and after the combination it was 47.3 +/- 4.6 (P < 0.001). Midodrine and octreotide suppressed tachycardia in POTS and improved standing times in OI. The two drugs had similar potencies; combination therapy was not significantly better than monotherapy.

The location of the human volume indifferent point predicts orthostatic tolerance

“…Successful strategies focused on improving orthostatic tolerance have concentrated on reducing the volume of blood in these compliant regions (Hoeldtke et al 2006;Hoeldtke et al 2007;Melchior et al 1996;Rowell 1986). We previously found that administration of octreotide acetate, a somatostatin analog whose vascular effects are largely confined to the splanchnic circulation, improved tilt table tolerance in healthy volunteers (Jarvis et al 2006).…”

Treatment of autonomic neuropathy, postural tachycardia and orthostatic syncope with octreotide LAR

“…Although splanchnic hypervolemia during the post-prandial period is a well-recognized phenomena, it has only been recently documented that splanchnic hypervolemia occurs during orthostatic stress in patients with orthostatic syncope [12] and POTS [13]. This finding makes subcutaneous [7] and intramuscular octreotide theoretically attractive therapeutic options in patients with these conditions. We accordingly documented that octreotide LAR improved orthostatic tolerance in these patients and the hemodynamic benefits were associated with improvement in fatigue, dizziness and multiple other symptoms.…”

Takotsubo cardiomyopathy in a patient with postural tachycardia syndrome

“…Treatment is mostly symptom-oriented and includes methylphenidate, bupropion, octreotide, midodrine, and modafinil [5,7,25]. Co-occurrence of POTS and TCM falls far short of causal association.…”