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

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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

Considering Other Symptoms or Conditions

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