Expert: David Richardson - 7/9/2009

Question
My 18 year old daughter has been diagnosed with POTS in March.  She had to drop out of college and has been severely debilitated  She was an active healthy high acheiver until last fall.  She's on beta blockers, florenif, high sodium diet, and just recently added midodrine.  Can you offer any suggestions or advice?  I so appreciate your time and expertise.

Answer
Dear Lisa,

Doesn't POTS stand for postural orthostatic tachycardia syndrome?  I judge from her meds that she has orthostatic hypotension, that is her blood pressure gets too low when she stands up.  If so, right much fluorinef is needed and can cause low blood potassium.  I'd increase the dose of midodrine first, try adding some salt tablets, and add physostigmine if necessary, The following is the summary of a study about physostigmine.  Maybe consult Dr. Singer.

Pyridostigmine is effective in treating neurogenic orthostatic hypotension (OH)
without worsening supine hypertension, according to the results of a randomized, double-blind
study published in the February 13 Early Release issue of the Archives of Neurology.
"Midodrine hydrochloride is the only drug demonstrated in a placebo-controlled treatment trial to
improve orthostatic hypotension (OH) but it significantly worsens supine hypertension," write
Wolfgang Singer, MD, from Mayo Medical Center in Rochester, Minnesota, and colleagues. "By
enhancing ganglionic transmission, pyridostigmine bromide can potentially ameliorate OH without
worsening supine hypertension."
In this 4-way cross-over study, 58 patients with neurogenic OH had baseline measurements for
1 day. In random order on successive days, they were then given 4 treatments (3 active
treatments [60 mg of pyridostigmine; 60 mg of pyridostigmine and 2.5 mg of midodrine; 60 mg of
pyridostigmine and 5 mg of midodrine] and a placebo). Supine and standing blood pressure (BP)
and heart rate were measured immediately before treatment and hourly for 6 hours after
treatment.
There were no significant differences in supine BP, either systolic (P = .36) or diastolic (P = .85).
In contrast, treatment was associated with significant reduction in the primary end point of the
decrease in standing diastolic BP (P = .02). Pairwise comparison showed significant reduction
with pyridostigmine alone (BP decrease of 27.6 vs 34.0 mm Hg with placebo; P = .04), and with pyridostigmine and 5 mg of midodrine (BP decrease of 27.2 vs 34.0 mm Hg with placebo; P =
.002). Improvement in standing BP was significantly associated with improvement in OH
symptoms.
"Pyridostigmine significantly improves standing BP in patients with OH without worsening supine
hypertension," the authors write. "The greatest effect is on diastolic BP, suggesting that the
improvement is due to increased total peripheral resistance.... Pyridostigmine provides the
physician with an alternative therapeutic approach that minimizes the biggest problem with
pressor agents in patients with impaired baroreflexes.

Please write back if this note doesn't answer all your questions.  I'm very sorry she has this problem, or any problem.  I'll be grateful if you let me know what happens.

David Richardson