Pharmacologic treatments for postural tachycardia syndrome

TherapyDosagePathologic mechanism addressedPotential drawbacksComments
Blood volume expanders
Fludrocortisone0.05–0.1 mg
twice daily
HypovolemiaHypokalemia, hypertension, fatigue, headache, fluid retention, edema
Desmopressin0.1–0.2 mg
3 times daily
HypovolemiaHyponatremia, headache, edemaOnly for occasional use; must monitor blood sodium
Erythropoietin2,000–3,000 IU subcutaneously
1–3 times per week
HypovolemiaHigh cost, requires injection, risk of vascular complicationsReserved for patients with symptoms refractory to more common treatments
Heart rate-lowering agents
Propranolol10–20 mg
3–4 times daily
AllHypotension, fatigue, drowsiness, wheezingNot well tolerated at higher dosages
Ivabradine5–7.5 mg
twice daily
AllPalpitations, headache, dizziness, constipation
Central nervous system sympatholytics
Clonidine0.05–0.2 mg
twice daily
HyperadrenergicMental clouding, fatigue, drowsiness, constipationCan be associated with rebound hypertension and tachycardia
Methyldopa125 mg
once or twice daily
HyperadrenergicHypotension, fatigue, headache, drowsiness, constipationRare lupus-like syndrome reported
Other drugs
Midodrine5–15 mg
every 4 hours, 3 times daily only
NeuropathicHypertension, goose bumps, urinary retentionNot recommended for use within 4-5 hours of sleep
Pyridostigmine30–60 mg
3 times daily
AllAbdominal cramping, diarrhea, increased sweatingMay increase gastrointestinal motility
Droxidopa100–600 mg
3 times daily
AllNausea, palpitations, urinary symptomsMay worsen tachycardia
Modafinil100–200 mg
twice daily
“Brain fog”Headache, dizziness, anxiety, insomniaMay improve cognitive symptoms