Medications Used to Treat Orthostatic Intolerance

In an article titled, “Orthostatic intolerance and chronic fatigue syndrome: New light on an old problem,” Peter Rowe, MD, identifies the beginning of treating orthostatic intolerance (OI) as “education, reassurance, dietary measures, postural maneuvers to prevent blood from pooling in the limbs, the use of compression garments and avoidance of situations that provoke symptoms.” In addition to these measures, which we have addressed in the “Top 10 Tips” article in this issue, there are several types of medications which can be helpful.

If you think of the body as a series of pumps and pipes, controlling the flow of blood through it can be addressed in a variety of ways. Treatment for orthostatic intolerance must be individualized. In general, treatment can help alleviate some symptoms, but rarely leads to total recovery. Consultation with a physician should occur before starting (or stopping) any of these medications.

Fludrocortisone (Florinef):
For many years, fludrocortisone was considered the first-line for treatment of orthostatic intolerance. It is a steroid medication that has many side effects, including rapid potassium loss that must be accounted for with supplementation. Studies of fludrocortisone in CFS have yielded mixed results.

Beta blockers:
Beta blockers, also known as beta-adrenergic blocking agents, are drugs that block norepinephrine and epinephrine (adrenaline) from binding to beta receptors on nerves.

Beta blockers can have specific or generalized effects, and some of their side effects mirror CFS symptoms. They may also interact with other medications, so it may take a trial-and-error approach to find one that’s right for you. Beta blocker medications include atenolol (Tenormin) and propranolol (Inderal). Many of them are available in generic form and can be quite inexpensive.

Vasoconstrictor medications:
Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels. When blood vessels constrict, the flow of blood is restricted or decreased, thus, retaining body heat or increasing vascular resistance. This can make the skin turn paler because less blood reaches the surface.

Midodrine (ProAmitine), methylphenidate (Ritalin), dextroamphetamine (Dexedrine) and desmopressin (DDAVP) are examples of vasoconstrictor medications that have been used to reduce the symptoms of orthostatic intolerance. Caffeine is considered the most widely used (and abused) vasoconstrictor. These too have specialized effects and need to be used with care, since raising blood pressure can have some unhealthy consequences. Careful blood pressure monitoring should be part of any medication trial period.

Selective serotonin reuptake inhibitors (SSRIs):
SSRIs, a family of antidepressants, have been used with some success in patients with a specific type of orthostatic intolerance called postural orthostatic tachycardia syndrome (POTS), and one randomized trial has demonstrated the efficacy of paroxetine (Paxil) for those with recurrent fainting.

Other strategies to increase blood volume or overall fluid volume, such as erythropoietin (Epogen) and regular administration of IV saline have also shown some mixed benefits and deserve more study.

Resources:

Rowe, PC. “Orthostatic intolerance and chronic fatigue syndrome: New light on an old problem.” Journal of Pediatrics, 2002;140:387-9.
http://www.cfids.org/about-cfids/orthostatic-intolerance.asp
www.MedicineNet.com
www.wikipedia.com

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