I’ve developed a system for myself in the selection of the medications.
While taking into account the many factors that make an individual unique (such as presence of underlying reactive airways disease making beta blockers a less desirable choice), as well as taking into account the most likely form of dysautonomia present, much of the selection is based on the top-rated symptoms the patient has ranked at each visit.
Each visit, the patient either verbally or, on the worksheet, completes a ranking of their symptoms based on most impactful in their life for the past week. They then rank each symptom on a scale of 0 to 100% where 0 is as bad as ever (allowing for them to sink into negative numbers as needed should symptoms become even worse) to 100% which is defined as completely resolved. These can then be summarized from the worksheet as given below.
Usually only a single medication is adjusted at each visit with the exception of support medications such as Ondansetron and pain relief medications. The medication selected is intended to work on improving one of more of the top rated symptoms. Adjustments are usually allowed to take affect and be monitored over a two week period with occasional fast-tracking to once weekly if a patient is particularly struggling.
The 3 most common medications trialed first are fludrocortisones, midodrine and metoprolol as dizziness, fatigue and orthostatic symptoms are often at the top of the list. I have found that the success rate with midodrine in relieving fa- tigue and orthostatic symptoms is higher than fludrocortisones which is higher than metoprolol. But midodrine must be given at least three times daily and often four times daily and this schedule is not often tolerated by patients. See details of these medication separately. Fludrocortisone is given at a starting dose of 0.1mg per day and can be doubled to achieve full effect. Occasionally, fluid retention limits the dose to 0.1mg daily.
If palpitations or migraine headache is near the top of the list, I often select metoprolol as the first or second medication so long as asthma is not a significant part of the history. If there is doubt or if chest pain and shortness of breath are included in their symptom list, I will exercise test patients while performing PFTs to rule out significant asthma before initiating the beta-blocker.
If foggy thinking or attention deficit is near the top of the list, I will select guanfacine as a second or third choice. I would only select this medication first in the cases of hyperadrenergic POTS with documented hypertension as its vasodilatory effects would not be well tolerated in classic POTS patients without first developing a solid pharmacologic base with pressor medications such as midodrine or vascular expander medications such as fludrocortisones. I included Adderall and Concerta on the list as they are used commonly in POTS but I try to minimize their use given the potential for interfer- ing with sleep/wake cycle, their potential for anorexia and even their tendency to reduce physical activity (they are after all used to quell hyperactivity). Finally, they are addictive.
Patients that have concomitant depression may benefit doubly from the vascular and neuropsychiatric benefits of Wellbutrin, Celexa, or Effexor. Of the 3, I believe I have had the most success with Wellbutrin.
As joint pain, extremity paresthesias, face, chest and abdomi- nal pain move up the list, I will often add gabipentin or pre- gabalin to manage these symptoms.
In a few patients with POTS who seem to have mood adjustment issues and/or erratic cycles, I have found that initiation of oral contraceptives relieves POTS symptoms alone.
Because many of these patients have GI disturbances and this may interfere with the good nutrition plan so basic in their therapy, I liberally prescribe ondansetron.
Once a combination of medications is found that produce improvement scores to near 100%, they are usually left alone for a full year before trying a person off the medication again to see if the symptoms return.