{This is the second article in a mini-series on treatment options for POTS. Check out the first article here and the third article here.}

Admittedly, switching to metoprolol succinate was a bit rough. I don’t know that I’d go so far as to call it a train wreck, but we certainly wobbled on the tracks. While metoprolol tartrate seemed to give me increased ability (and unfortunately a few tough side effects), navigating metoprolol succinate was comprised of both worse POTS symptoms with the addition of side effects – the worse of both worlds. 

I began by switching from 12.5mg tartrate twice a day to 12.5mg succinate once a day. The difference was impressive. With light activity (walking across the house, using the restroom, standing up to grab something), I was easily breaking the 100bpm barrier for pulse. I felt more on edge and less stable. Interestingly, while the minute-by-minute experience was worse, I didn’t have the swings that came with the tartrate. Instead of 2 hours of feeling great followed by 1 hour of feeling crummy, I experienced no highs/lows, and instead hummed along at a constant “meh”. My doctor had told me I could increase the dose to 25mg once per day if I didn’t feel like the half was working well, so on the fourth day, I took her up on it. The result was a worsening of all the things. 

In general, it felt like a bad POTS flare with lightheadedness, fatigue, lower blood pressure and tachycardia. It was abundantly clear that I was unwell, and by the second day, my parents and I were all on board with getting me off of it ASAP. Interestingly, apart from the worse POTS symptoms, two other things happened. First, I had a low-level migraine for multiple days, and second, I had noticeably more heart palpitations. I recently finished a 30-day heart monitor test, and the results indicated I had had more than 7,000 extra beats, called “premature ventricular contractions” or PVCs. While not life-threatening by themselves, they can be bothersome and/or escalate, and are often treated with metoprolol. The first week of medication they were all but gone, and so I found it fascinating that they returned with a vengeance once I switched forms of the same drug. 

While there was more complexity than what I have energy to diplomatically share, we ultimately decided to return to the first medicine, metoprolol tartrate, in order to see if my body will adjust with a couple more weeks. We may also try propranolol (another beta blocker), although our main goal at this point is to do my best until I can be seen at the Mayo Clinic in Rochester in about 6 months.  

Conclusion

If I could sum up my first week of POTS treatment in one word, it would be hope. And if I had to describe the second week, I would use the word weary. Being on the fast-acting metoprolol tartrate worked. And yet in an effort to curb the relatively intense highs and lows as well as the persistent migraines, we switched to succinate which did not offer the same benefits but still had its fair share of drawbacks. As I continue to press forward in trialing these treatment options, I have a renewed determination to stay diligent with all the lifestyle adjustments that have historically helped manage my symptoms, and to give myself grace in this season as everything shifts back and forth.