Table 2.

Treatments for postural tachycardia syndrome.

Drug	Dosing information	Side effects	Precautions
Non-pharmacological treatments
Withdraw exacerbating medications	Stop drugs that decrease blood volume or directly increase heart rate
Increased oral water intake	Target 2–3 L/day	Frequent urination
Increased oral NaCl intake	Target 8–10 g/day	Hypertension, peripheral edema	Buffered NaCl tablets/solutions if cannot be done with diet alone
Lower body compression garments	20–40 mmHg compression; focus on abdomen +/− legs	Can be hot, tight, and itchy
Exercise training	Aerobic: 30+ min 4 days/week with some leg resistance training	Will initially feel poorly/worse for up to 6 weeks	Initial recumbent exercise (rowing, recumbent cycle or swimming)
Pharmacological treatments	0.1 to 0.2 mg daily	Hypokalemia, edema, headache	Electrolytes must be monitored
Blood volume expanders
Fludrocortisone
Desmopressin (DDAVP)	0.1 to 0.2 mg as needed	Hyponatremia, edema	Monitor electrolytes
Acute IV saline	2 L Intravenous over 2–3 h	Venous thrombosis, infection
Chronic IV saline	2 L given intravenously once weekly	Infection/thrombosis risk of central venous catheters	Avoid long-term use; avoid placement of central catheters
Erythropoietin	10,000 IU weekly	Increased risk of cardiovascular death	Monitor Hematocrit
Heart rate inhibitors
Propranolol	10–20 mg orally up to 4 times daily	Hypotension, bradycardia, bronchospasm	Can worsen asthma or exercise tolerance
Ivabradine	2.5–7.5 mg orally twice daily	headaches, palpitations, hypertension, visual disturbances
Pyridostigmine	30–60 mg orally up to 3 times daily	Abdominal cramps, diarrhea	Can worsen asthma
Vasoconstrictors
Midodrine	2.5–15 mg orally 3 times daily	Headache, scalp tingling, hypertension
Octreotide	Long-acting intramuscular injection 10–30 mg	Nausea, stomach cramps, diarrhea
Methylphenidate	10 mg orally 2–3 times a day. Last dose should be avoided before bed.	Tachycardia, insomnia, nausea, headache, dizziness
Sympatholytic drugs
Alpha-2 adrenergic agonists, such as clonidine	0.1–0.2 mg orally 2–3 times daily or long acting patch	Hypotension, fatigue, brain fog
Methyldopa	125–250 mg orally twice daily	Hypotension, fatigue, brain fog
Other
Modafinil	50–200 mg orally 1–2 times daily	Tachycardia

Modified with permission from Miller and Raj (2018).