The evidence for treatments for postural orthostatic tachycardia syndrome: a systematic review of randomized trials.

This systematic review looked at 21 randomized controlled trials (750 patients, 2000–2023) testing treatments for POTS and found that the evidence base is still limited and fragmented. The best-studied drugs include propranolol (a beta‑blocker), midodrine (raises blood pressure), pyridostigmine (enhances autonomic nerve signaling), and ivabradine (slows heart rate), with smaller trials of desmopressin, melatonin, atomoxetine, modafinil, sertraline, and IVIG. Some medications can improve heart rate and/or symptoms in the short term, but most studies are small, use different outcome measures, and rarely follow patients long term, so it is hard to identify a single best first‑line treatment. The review also summarizes trial evidence for non‑drug strategies such as high‑salt intake, structured exercise, compression, and device-based approaches, which generally support current guideline recommendations but, again, are based on small studies. Overall, current POTS management still relies heavily on trial‑and‑error using beta‑blockers, midodrine, and pyridostigmine plus lifestyle measures; the authors emphasize the need for larger, high‑quality trials to define optimal first‑line therapies and evidence-based treatment algorithms.