Expert Q&A: Researcher Urges Autonomic Assessment for Patients With Long COVID

Nearly 6 in 10 patients with long COVID in a small Australian study had been unable to return to work after their infection, according to findings published in the Journal of the American Heart Association. Compared with healthy controls, participants with long COVID and those with postural orthostatic tachycardia syndrome (POTS) reported greater fatigue, orthostatic intolerance, and autonomic symptom burden, along with reduced health-related quality of life.^1,2

The investigators found substantial overlap between the 2 conditions. On active stand testing, heart rate rose by a mean of 34.6 beats per minute (bpm) in participants with long COVID and 46.3 bpm in those with POTS, compared with 12.7 bpm in controls. The study also identified group-level differences in inflammatory markers, including lower IL-2 and higher IL-8 levels in patients with POTS, but these measures could not reliably predict a POTS diagnosis in individual patients.^1,2

In an interview with Pharmacy Times, lead author Marie-Claire Seeley, RN, MNurs, PhD, senior research fellow at Adelaide University and chief executive officer of The Australian POTS Foundation, discussed which symptoms should prompt evaluation for POTS, what pharmacists should watch for when reviewing medications in patients with long COVID, and what the inflammatory findings may mean for future treatment.

Pharmacy Times: What should prompt evaluation for POTS, and how simple is the standing test?

Marie-Claire Seeley, RN, MNurs, PhD: The important clue is the orthostatic pattern: a racing heart and other symptoms that worsen on standing and improve on lying down. In an individual with long COVID, that pattern should prompt formal assessment for POTS. An active standing test is relatively simple. Heart rate and blood pressure are measured after resting lying down and at intervals over 10 minutes of standing. A sustained heart rate rise of at least 30 beats per minute in an adult raises suspicion, but the result needs clinical interpretation alongside symptoms, blood pressure, and other possible causes. In our study, 62.5% of participants with long COVID met POTS criteria.

Pharmacy Times: What should pharmacists keep in mind when reviewing medicines?

Seeley: Off-label medicines can be an important part of POTS management. Equally, medicines prescribed for other conditions may contribute to worsening orthostatic symptoms. A patient who was previously treated for hypertension, for example, may develop autonomic dysfunction after COVID-19 and find that their existing regimen now affects their ability to tolerate standing.

Pharmacists are well placed to recognize that change, document the timing of symptoms, and bring the medication history to the prescribing clinician’s attention. Assessment of lying and standing heart rate and blood pressure may help the clinician decide whether a dose adjustment or deprescribing is appropriate. Those decisions need to account for the original reason for treatment and the patient’s current clinical picture.

Pharmacy Times: What might the inflammatory findings mean for future treatment?

Seeley: Our findings add to a growing body of research investigating immune and inflammatory mechanisms in long COVID and post-viral conditions such as POTS. Other studies and clinical trials are also exploring these pathways. Inflammation may affect blood vessel function, including dilation, and could contribute to orthostatic symptoms in some patients.

POTS is likely to involve several mechanisms, which may differ between patients. We do not yet know which inflammatory changes are driving symptoms, which are consequences of illness, or who might benefit from a treatment targeting a particular pathway. Our study found group-level differences, but the markers did not reliably identify individuals with POTS.

In the meantime, new allergy-like symptoms in long COVID and POTS should be assessed and managed on their own merits. A treating clinician may consider whether an H1 antihistamine or, where appropriate, an H2 blocker is warranted for those symptoms. Our study did not test these treatments, so it cannot tell us whether they improve POTS itself.

REFERENCES

1. Seeley MC, Gallagher C, Wilson G, et al. Comparative analysis of circulating cytokines and adrenergic autoantibodies in postural orthostatic tachycardia syndrome, postacute sequelae of SARS-CoV-2, and healthy controls. J Am Heart Assoc. 2026;15(11):e048615. doi:10.1161/JAHA.125.048615

2. Ferruggia K. Nearly two-thirds of patients with long COVID meet diagnostic criteria for POTS. Pharmacy Times. September 25, 2026. Accessed September 29, 2026. https://www.pharmacytimes.com/view/nearly-two-thirds-of-patients-with-long-covid-meet-diagnostic-criteria-for-pots