Some ‘nondippers’ experience nocturnal hypertension

DEAR DR. ROACH» My blood pressure goes up when I sleep. In addition, I’m resistant to medication; I’ve tried 21 different kinds. All give me terrible side effects and don’t bring my blood pressure down. The only one that works is clonidine. The side effects are terrible — sleepiness and no motivation.

Recently clonidine stopped working, and I went from 0.1 mg per day up to 0.4 mg per day in a matter of six weeks after being on it for two to three years. A month ago, I was put on a 0.4 mg weekly patch. This has been much better, as it’s removed about 50% of the sleepiness.

I’m 69 and a nationally ranked senior singles tennis player. I have a good diet and am in good shape. My blood pressure usually spikes between 1:30 to 3:30 at night. It even goes up when I take a 40-minute nap. Have you ever heard of this?

ANSWER» The blood pressure normally goes down 10% to 15% on average when a person is asleep, a phenomenon called “dipping.” This is found by measuring someone’s blood pressure very frequently over 24 hours with a blood pressure monitor. There are people who do not dip, called appropriately enough, “nondippers.” Some people experience a blood pressure increase at night, called nocturnal hypertension. There have been studies showing worse outcomes, including a higher risk for heart disease and stroke, in both nondippers and those with nocturnal hypertension.

It is not always clear what is causing people to have this condition. Kidney disease and previous heart problems are associated with dipping. That’s why you were tested for those. The recent dramatic increase in blood pressure medication need is concerning, and a comprehensive look for any unusual causes was indicated.

Treatment for nondippers often includes giving blood pressure medication at nighttime. This is not available for you, since a clonidine patch gives medication at a continuous level night and day throughout the week. Melatonin has also been tried to alleviate nondipping, although there has not been any clear benefit to this approach.

Clonidine works at the level of the brainstem, so it is ideal for blood pressure that is mediated by brain issues. One potential cause is obstructive sleep apnea, where people stop breathing at night for a few seconds. Sleep apnea often causes difficult-to-manage high blood pressure, and may cause nocturnal hypertension or nondipping. The most effective drug is often clonidine. Physicians sometimes forget even healthy athletes can have OSA, so your physicians should consider it. Sleepiness during the day is a cardinal symptom of obstructive sleep apnea.

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Keith Roach