Dr. Kendal Stewart on a 'hypo-adrenergic' variant of POTS, genetics and novel treatments

Dr. Kendal Stewart describes POTS as a neuroimmune syndrome with common comorbid inflammation, MCAS, methylation issues, and sometimes hypermobility/EDS. He proposes a “hypo-adrenergic” POTS subgroup he frequently sees, linked to variants in dopamine beta-hydroxylase (DBH) that limit conversion of dopamine to norepinephrine, leading to low NE, low blood pressure, and intolerance of beta blockers. He often uses targeted nutrigenomic testing (including MTHFR/methylation pathways and histamine genes AOC1/DAO and HNMT) to individualize care and to distinguish MCAS-driven POTS (histamine-mediated vasodilation) from catecholamine-related forms. For hypo-adrenergic patients, he reports benefit with solriamfetol (Sunosi; a DA/NE reuptake inhibitor) plus foundational measures like hydration; for MCAS he uses combined strategies such as a DAO-containing supplement (for dietary histamine) and peptides like BPC-157 for mast-cell reactivity. He emphasizes calming chronic inflammation and microglial activation using layered, longer-term tools: vitamin D and bioidentical hormones (e.g., progesterone in women, testosterone support in men), low-dose naltrexone, selected peptides (thymosin alpha‑1, thymosin beta‑4, BPC‑157, gonadorelin as needed), CBD (variable response via CB2), and, when appropriate and affordable, IV amniotic-derived exosomes to rapidly downshift inflammation and support repair. He notes symptom flares around menses and after infections (e.g., EBV), highlights hypervigilance/anxiety as part of a glutamate‑driven “microglial activation” pattern, and underscores that addressing the individual’s genetics and immune balance is key to improving dysautonomia rather than only suppressing tachycardia. He offers in‑person care and upcoming consumer nutrigenomic panels/education (Helix Revolution), while advising that complex POTS/MCAS cases still require knowledgeable clinical oversight.