Schiweck et al. (2025)
- Authors: Nicole Schiweck, Katharina Langer, Andrea Maier, Daniel Vilser, Juliane Spiegler
- Institutes: Department of Pediatrics, Universitätsklinikum Würzburg, Würzburg, Germany; MRI Munich Chronic Fatigue Center for Young People (MCFC), Technical University of Munich, Munich, Germany; Department of Neurology, University Clinic RWTH Aachen, Aachen, Germany; Clinic for Pediatrics, Neuburg an Der Donau, Germany
- Publisher: Clinical Autonomic Research
- Link: DOI
Summary
This review confirms the significant lack of high-quality evidence for POTS treatments, a gap strongly felt by patients. It systematically organizes the existing, low-level evidence, identifying non-drug approaches like compression garments and salt supplementation as reasonable first-line steps. The most critical finding for the ME/CFS community is the complete absence of studies specifically addressing POTS treatment in the context of ME/CFS. The authors explicitly note that standard physical training, a common POTS recommendation, may be unrealistic or harmful for ME/CFS patients due to the risk of post-exertional malaise (PEM). This review validates the need for research that focuses on this specific patient subgroup.
What was researched?
This systematic review was conducted to present the current knowledge on non-pharmacological and pharmacological treatment approaches for Postural Orthostatic Tachycardia Syndrome (POTS). The review had a special focus on finding therapeutic options for children and for people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).
Why was it researched?
POTS is a common co-occurring condition in adults and children who have ME/CFS. Despite this, therapeutic recommendations for POTS are rare in clinical practice, and there is a significant lack of evidence to guide treatment. This review aimed to collate all existing evidence to address this knowledge gap.
How was it researched?
This was a systematic literature review that followed PRISMA guidelines. The authors searched multiple scientific databases like PubMed, Cochrane, and Embase, screening an initial 3,853 studies. They ultimately included 45 studies in their final analysis, which consisted of 18 randomized controlled trials (RCTs) and 27 non-randomized trials (non-RCTs).
What has been found?
The review found that overall evidence for POTS therapy is rare, and large-scale randomized controlled trials (RCTs) are urgently needed. Among non-pharmacological options, compression garments, physical training, salt supplementation, and transdermal vagal nerve stimulation were identified as possible first-line treatments. For pharmaceuticals, studies showed significant effects from ivabradine 💊 and β-adrenergic blocking agents 💊. Single studies also suggested that midodrine 💊 (hydrochloride) and pyridostigmine 💊 may have beneficial effects. Despite one of its main goals, the review found no studies that specifically addressed the treatment of POTS in patients with ME/CFS.
Discussion
The authors state the review followed high-quality Cochrane methodological standards. However, the primary limitation is the quality of the available data; the certainty of evidence for most interventions was rated as “low or very low”. This was because most studies had a small number of participants and a “substantial risk of bias”. The authors also note that studies often failed to differentiate between adult and pediatric patients or between different subtypes of POTS.
Conclusion & Future Work
The authors conclude that non-pharmacological options like compression garments, physical training, and salt supplementation should be the first-line therapeutic approach. If these are insufficient, β-adrenergic blocking agents and ivabradine can be considered , with pyridostigmine and midodrine as potential add-on therapies. The authors stress that future research must consist of larger, long-term studies and that “studies which specifically address therapeutic options in patients with POTS and ME/CFS are essential”.