Postural orthostatic tachycardia syndrome (POTS) is a complex disorder of autonomic dysfunction characterized by orthostatic intolerance, tachycardia, lightheadedness, fatigue, and often significant gastrointestinal symptoms. Although the etiology of POTS is multifactorial—ranging from hypovolemia to neuropathic and hyperadrenergic mechanisms—recent evidence suggests that gluten-related disorders may play a role for a subset of patients.
Celiac Disease Prevalence Is Higher in POTS Patients
A study in the European Journal of Gastroenterology & Hepatology (2016;28(12):1383–1387) evaluated 100 patients with confirmed POTS for celiac disease and compared them with two large control groups (n=1200 and n=400). Several important findings emerged:
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4% of POTS patients had biopsy-confirmed celiac disease, compared to the 1% prevalence found in the control groups and in the general population.
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42% of POTS patients self-reported gluten sensitivity, compared with 19% of age- and sex-matched controls.
This marked elevation suggests that gluten-related disorders—both immune-mediated (celiac) and non-celiac gluten sensitivity—may contribute to symptoms in a meaningful subset. The authors concluded that this possible association warrants further investigation, particularly because gluten exposure is modifiable.
Does a Gluten-Free Diet Improve POTS Symptoms?
A more recent retrospective study (Chronic Illness, 2022;19(2):409–417) evaluated the effects of a gluten-free diet (GFD) in 20 patients with POTS who did not have celiac disease but voluntarily adopted a GFD for ≥4 weeks.
Key findings:
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Average COMPASS-31 symptom scores decreased from 57.8 to 38.2 (p < 0.00001).
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The greatest improvements occurred in:
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Orthostatic intolerance
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Vasomotor symptoms
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Gastrointestinal symptoms
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Mean symptom reduction was 33.9%, with patients reporting ~50% subjective improvement.
This suggests that a GFD may reduce symptom burden for some POTS patients—even in the absence of celiac disease—possibly through mechanisms involving gut permeability, immune activation, microbiome changes, or autonomic reactivity.
Why Might Gluten Affect POTS?
Emerging hypotheses include:
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Immune activation: Gluten can increase zonulin and intestinal permeability even in non-celiac individuals, which may amplify systemic inflammation.
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Autonomic nervous system effects: GI inflammation can influence vagal tone and sympathetic activity.
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Overlap with comorbidities: Many POTS patients in the study also had mast cell activation syndrome or hypermobile Ehlers-Danlos syndrome—both of which have known GI vulnerabilities.
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Malabsorption and micronutrient deficiencies (e.g., iron, B12, folate), common in undiagnosed celiac disease, can exacerbate orthostatic intolerance.
Clinical Considerations for Practitioners
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Consider celiac screening in POTS patients with significant GI symptoms, iron deficiency, malabsorption, autoimmune history, or unexplained inflammation.
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A trial gluten-free diet may be appropriate for select patients after standard evaluation—especially those reporting post-prandial worsening, bloating, diarrhea/constipation, or brain fog.
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Work with patients to ensure nutritional adequacy if a GFD is implemented.
