Subsection: Medications
    •  Overview
    •  Common Meds
    •  Other Factors to Consider
    •  Full List By What They Do
   •  Hyperadrenergic POTS
   •  References

Other Factors to Consider In Selecting Medication

There are a number of medications that could be used. To find the right medication for a person, it is important to think about the person as a whole.

Severity of Symptoms: This means looking at how severe the orthostatic symptoms are. People may respond differently depending on how severe their OI is and which medication is started first.

Other Conditions: If there are other conditions present, it might affect how they respond to a medication. If a medication can work on both the orthostatic problem and the other condition, that's good. It means one less pill to take, and the chance of fewer side effects and fewer interactions between drugs.


Considering the severity of orthostatic symptoms

  • Mild orthostatic symptoms that don't improve with non-pharmacologic action and moderate orthostatic symptoms:
    • Pyridostigmine with or without fludrocortisone2
  • Severe orthostatic symptoms:
    • Midodrine with or without fludrocortisone2
    • When no other treatment has been effective:
      • Erythropoietin3 - has vasoconstrictive effect on body, increases red cell mass and increases volume
      • Octreotide3

Considering the type of POTS

  • Partial Autonomic Dysfunction
    • The goal
      • To increase fluid volume and increase peripheral vascular resistance.3
      • To increase volume - Fludrocortisone 0.1-0.2/da alternative - DDAVP.
      • Add vasoconstrictor midodrine if needed. Give first dose in the morning before the person gets out of bed.3
      • If midodrine effective but is not well-tolerated, an alternative is methylphenidate.3
    • If a person cannot tolerate these meds or they are not enough to manage symptoms, add either an SSRI or SNRI.
      • SSRIs - are more helpful in neurocardiogenic syncope3
      • SNRIs - are more helpful in POTS. 3
Back to the top

Considering Other Symptoms or Conditions

Symptom or Other Condition
Suggested medication

Systolic Blood Pressure (SBP-top number) is less than 110 mmHg

fludrocortisone1, midodrine1

Increased heart rate when lying down or when upright:


Increased salt appetite




Dysmenorrhea (menstrual cramps) or worse fatigue with menses:

Oral Contraceptive Pills (OCP)1, Depo1

Anxiety or low mood


Myalgias (muscle pain) is prominent:


Family history of ADHD



stimulant1, midodrine1


treat like Partial Dysautonomia3

*Modified from Bloomfield, Am J Cardiol 1999; 84:33Q-39Q

Back to the top
  1. Rowe, Peter. Managing Orthostatic Intolerance. Webinar. September 1, 2010. Hosted by CFIDS Association of American. Accessed June 1, 2012.  Written material.  Slides PDF.   Video.
  2. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med. 2010 May;77(5):298-306.  Abstract.  Article PDF.
  3. Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–2817. Abstract. Article PDF.
  4. Freeman, Roy. Neurogenic orthostatic hypotension.NEJM 2008;358(6):615-624. Abstract


Author: Kay E. Jewell, MD
Page Last Updated: August 11, 2012