Misunderstandings Surrounding POTS
Dr. Adler made note of a conundrum that exists in the medical community: POTS is reasonably common and clearly results in debilitating symptoms for patients, yet we know so little about the condition. How could this be?
Dr. Adler believes this is due, in part, to the tortured history of the condition. For years, POTS was thought to be due to deconditioning, and there was the belief that patients could exercise their way out of POTS. Patients with POTS also frequently encounter what Dr. Adler called medical gaslighting—a majority of patients with the condition are told their symptoms are all in their head or due to anxiety.
However, the COVID-19 pandemic forced medical providers to re-evaluate. In a study from Lee et al., more than half of nearly 300 patients with long COVID were found to experience orthostatic intolerance symptoms during National Aeronautics and Space Administration Lean Testing (NLT). Also, more than one in 10 study patients met criteria for either POTS or orthostatic hypotension.4
Diagnosis & Disease Management
It’s particularly important for rheumatologists to think about and help diagnose the condition because it can mimic symptoms sometimes associated with autoimmune disease, such as Raynaud’s, acrocyanosis, erythromelalgia and facial flushing in a malar distribution.
Once correctly identified, a range of treatments may be helpful in dealing with the vasomotor and sympathetic dysfunction seen in patients. Volume expansion and medications, such as midodrine, fludrocortisone and pyridostigmine can be beneficial.
Beta blockers serve to reduce compensatory tachycardia and can help some patients, although others may feel worse with this class of medication. When such medications are used, Dr. Adler recommends that clinicians employ non-selective beta blockers, such as propranolol over selective beta blockers like metoprolol. She also pointed out that ivabradine, which blocks the channel responsible for the cardiac pacemaker current and thereby lowers heart rate, is often better tolerated than beta blocker therapy.
Dr. Adler urged physicians to think about gastrointestinal (GI) symptoms in patients with POTS. Patients may experience issues from gastroparesis or rapid gastric emptying, as well as small bowel and colonic dysmotility. In patients with isolated upper GI tract dysmotility, treatments may include acid suppressants, dopamine-2 receptor antagonists and motilin agonists, such as erythromycin. If there is lower GI tract dysmotility, then bulking agents, osmotic and stimulant laxatives, secretagogues and somatostatin analogues may be beneficial. If there is global GI tract dysmotility, then mirtazapine, pyridostigmine and serotonin type 4 (5-HT4) receptor agonists may be of help.
