Table 2:

Pharmacological treatments for postural orthostatic tachycardia syndrome

DrugDosingQuality of evidence*Adverse effectsOther considerations
Heart rate inhibitors
Propranolol10–20 mg orally up to 4 times dailyModerateHypotension, bradycardia, bronchospasmCan worsen asthma
Ivabradine2.5–7.5 mg orally twice dailyModerateVisual disturbances, bradycardiaExpensive
Pyridostigmine30–60 mg orally up to 3 times dailyLowIncreased gastric motility and cramping
Vasoconstrictors
Midodrine2.5–15 mg orally 3 times dailyModerateHeadache, scalp tingling, supine hypertensionAvoid within 4 hr of bedtime to avoid supine hypertension
Sympatholytic drugs
Methyldopa125–250 mg orally twice dailyLowHypotension, fatigue, brain fogStart with a low dose
Clonidine0.1–0.2 mg orally 2–3 times daily or long-acting patchLowHypotension, fatigue, brain fogStart with a low dose; withdrawal can lead to rebound tachycardia and hypertension
Blood volume expanders
Fludrocortisone0.1 to 0.2 mg orally per dayLowHypokalemia, edema, headacheSerum potassium should be monitored
Desmopressin0.1 to 0.2 mg orally per day, as neededLowHyponatremia, edemaSerum 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.