Q: What is postural orthostatic tachycardia syndrome (POTS), and are patients with the syndrome at greater risk of serious complications from COVID-19?
POTS is an autonomic nervous system disorder characterized by a rise in heart rate by at least 30 beats per minute when going from a lying to a standing position. This abnormal heart rate is usually accompanied by other symptoms, such as dizziness, lightheadedness, palpitations, headache, and nausea. No studies exist on how COVID-19 impacts patients with POTS, but there is no reason to suspect that they are at a higher risk than the general population. However, if patients also have high blood pressure, diabetes, asthma, or an autoimmune disease, they may be considered at higher risk. It’s also possible the virus may exacerbate symptoms of POTS—such as dizziness, headache, and fatigue—which may delay recovery from COVID-19. Patients with POTS could experience post-infectious fatigue, dizziness, headache or sleep problems, similar to what they may experience after other types of viral illness. Because this virus is new, the short- and long-term complications are unknown.

Q: What is the relationship between POTS and the immune system?
No studies to date suggest that POTS is associated with any immune system abnormalities, but there is a relationship between the autonomic nervous system and the immune system. A subset of patients with POTS may have some form of immune dysfunction, especially those with co-existing autoimmune disorders, such as lupus, Sjogren’s syndrome, rheumatoid arthritis, celiac disease, and anti-phospholipid syndrome.

Q: Does having POTS make you immunocompromised?
No. Most patients with POTS can handle an infection and can mount an appropriate immune response to fight it off. Those who also have lupus, Sjogren’s syndrome, and other autoimmune and inflammatory conditions and who take medications to manage these conditions should contact their neurologist or rheumatologist to discuss their specific case. 

Q: Are medications used to treat POTS considered immunosuppressive?
No. Medications such as fludrocortisone (Florinef) do not suppress the immune system. If you have a co-existing autoimmune disorder, such as Sjogren’s syndrome, lupus, rheumatoid arthritis, or anti-phospholipid syndrome, ask your doctor if medications that you take for those conditions are considered immunosuppressive. Specifically, hydroxychloroquine (Plaquenil)—an antimalarial drug used to treat autoimmune disorders that also has been used in some patients to treat COVID-19—is not considered immunosuppressive, but steroids and various biologics are.

Q: What should patients with POTS do if they develop symptoms of COVID-19?
Call your doctor first and stay home until you receive further instructions. Some patients wonder how they would recognize the symptoms and signs of COVID-19 since so many—fatigue, shortness of breath, headache, muscle and joint pain, and diarrhea—are common symptoms of POTS. The COVID-19 symptoms of fever and cough would be the main indicators of infection; a suddenly altered sense of smell or taste is another. Normally, fever and infection can cause an increase in heart rate as the body fights an infection. In patients with POTS, fever can cause an even greater increase in heart rate than in healthy people, which can lead to worsening of palpitations and other symptoms. In that case, patients can increase their daily dose of POTS medication temporarily. All patients with POTS should stay well hydrated and drink fluids high in sodium, such as Pedialyte or Gatorade, to expand blood volume, which can help increase blood pressure and reduce dehydration, a major trigger for a POTS flare-up.

Dr. Blitshteyn is the director of the Dysautonomia Clinic and clinical assistant professor of neurology at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences in New York.

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COVID-19 (Coronavirus) and Neurologic Disease Resource Center