Pharmacological treatments for postural orthostatic tachycardia syndrome
| Drug | Dosing | Quality of evidence* | Adverse effects | Other considerations |
|---|---|---|---|---|
| Heart rate inhibitors | ||||
| Propranolol | 10–20 mg orally up to 4 times daily | Moderate | Hypotension, bradycardia, bronchospasm | Can worsen asthma |
| Ivabradine | 2.5–7.5 mg orally twice daily | Moderate | Visual disturbances, bradycardia | Expensive |
| Pyridostigmine | 30–60 mg orally up to 3 times daily | Low | Increased gastric motility and cramping | |
| Vasoconstrictors | ||||
| Midodrine | 2.5–15 mg orally 3 times daily | Moderate | Headache, scalp tingling, supine hypertension | Avoid within 4 hr of bedtime to avoid supine hypertension |
| Sympatholytic drugs | ||||
| Methyldopa | 125–250 mg orally twice daily | Low | Hypotension, fatigue, brain fog | Start with a low dose |
| Clonidine | 0.1–0.2 mg orally 2–3 times daily or long-acting patch | Low | Hypotension, fatigue, brain fog | Start with a low dose; withdrawal can lead to rebound tachycardia and hypertension |
| Blood volume expanders | ||||
| Fludrocortisone | 0.1 to 0.2 mg orally per day | Low | Hypokalemia, edema, headache | Serum potassium should be monitored |
| Desmopressin | 0.1 to 0.2 mg orally per day, as needed | Low | Hyponatremia, edema | Serum sodium should be monitored if used chronically |
↵* We critically appraised the literature using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.44 We rated the quality of the evidence as high, moderate, low or very low based on the likelihood that further research would change confidence in the estimate of effect.