Note - Below are brief descriptions of some commonly used drugs for the treatment of POTS. This partial list is not a recommendation for any treatment, just the factual reporting of some of the drugs doctors most commonly prescribe. I strongly urge all POTS patients to see specialists in the field and not ask ordinary doctors for treatment with these drugs.

Beta blockers are used by many doctors to treat POTS and neurally mediated hypotension (NMH). I have heard of more bad drug reactions to beta blockers than any other drugs used for the treatment of POTS and NMH, especially for those patients who have NMH secondary to Chronic Fatigue Syndrome. In these patients beta blockers can actually cause POTS. Some patients have found beta blockers to be helpful, however, especially those patients who develop POTS because of an overly sensitive beta adrenergic system. For these sensitive patients only very low doses of beta blockers are usually required.

Florinef is a common drug for the treatment of POTS and NMH. It is used to stimulate the body’s retention of salt and water and it also has a very small alpha agonist effect (vasoconstricting effect). The list of Florinef’s known potential side effects is hair raising, but at the small doses prescribed Florinef is not unusually dangerous. Some patients have had bad reactions to Florinef, but that is true of all drugs. Florinef makes you expel potassium so you must take potassium supplements to keep in balance.

Midodrine is a useful drug for many patients and is probably the most effective alpha agonist currently available. Alpha agonists work by constricting blood vessels, thus reducing blood pooling in the lower part of the body. Sold in the United States as ProAmitine, Midodrine has the advantages of being long lasting and is most like the body’s own natural vasoconstricting hormones in effect. Midodrine is a large molecule that does not pass through the blood brain barrier, which is helpful for patients who are drug sensitive. Because you do not want your blood vessels constricted when you are supine, it is essential that alpha agonists should not be used before bedtime. Supine hypertension is not only uncomfortable, it is dangerous. Alpha agonists are usually only prescribed for those patients who are not seriously overweight, who have consistently low blood pressure, and whose main problem is vasodilation. Florinef is usually tried first and Midodrine introduced for those who do not respond sufficiently to expansion of blood volume.

Some patients have an abnormal supersensitivity to alpha agonists which can present serious problems during treatment. Supersensitivity to alpha agonists can be caused by impaired amine uptake in the nerve endings of alpha receptors (denervation supersensitivity). Abnormal sensitivity can also be produced by a prolonged lack of norepinephrine release from sympathetic nerve endings, which leads to enhanced receptor responsivity (decentralization supersensitivity). These conditions usually produce a two to five times increase in sensitivity level, but there is a small subset of patients who are hundreds of times more sensitive than normal. For these patients vasoconstricting alpha agonist drugs are dangerous to use because of their sheer potency. If your physician prescribes any alpha agonist drug, consult with him about taking a very small test dose first in order to gauge your sensitivity level.

Celexa (citalopram hydrobromide) is a selective serotonin reuptake inhibitor similar to Paxil, Zoloft, and Prozac, but with the claim of fewer side effects and less potential for negative drug interactions. Serotonin reuptake inhibitors have been used for many years to treat neurally mediated hypotension and syncope (passing out). The mechanism through which central serotonin levels effect blood pressure and heart rate has not been fully mapped out. The net effect of Celexa appears to be to increase nerve communication and stimulation of the standing vasoconstriction reflex. This limits venous blood pooling and increases orthostatic tolerance. Celexa and the other serotonin reuptake inhibitors are known to increase norepinephrine release to varying degrees.

Celexa has been used with some success in treating patients who have been unable to tolerate the other drugs used for treating POTS and NMH. Celexa is reported to have the potential for reducing the effects of central sleep apnea, which often accompanies the onset of POTS. Treatment is started at a very low dose level of 5 mg a day or less, and gradually increased over time. Taking a full dose immediately is reported to make patients even more ill while a gradual increase in dosage is often well tolerated. Please note - I have never taken Celexa and do not personally recommend any specific drug or other medical treatment. This page simply passes on general information which is received from dozens of doctors and hundreds of patients. For recommendations of treatment you must see a specialist. I myself do not take any drugs for my chronic orthostatic intolerance; just salt and short walks as exercise.

GOOD LUCK,JIM