CONSULT ROUNDS: An approach to orthostatic hypotension with supine hypertension

This is not uncommon; but can happen in the elderly. The cause is usually autonomic failure.
These patients can have supine BP of 200 systolic and decrease to 70 systolic upon standing.
Goals of therapy are to prevent the supine HTN and decrease the drop in SBP while they are standing up.
1-non-medicinal interventions:
So basically increase salt intake to decrease the hypotensive episodes, standing up slowly to mitigate the hypotensive symptoms and prevent sycope and falls, High Ted stocking and has to be high up to groin to increase venous return and increase CO and BP upon standing, crossing legs while standing for the same reason. and finally sleeping in 30-40 degree angle; avoiding warm drinks and meals : these above measures decreases renal flow and activates renin-angiotension system and mitigate hypotension upon standing.
2-Nitropaste at night and to be removed in AM may be helpful.  Acytelcholinsterase inhibitors and there are thought to work through catacholamine surge(norepinephrine usually) and pressors activity and increase in BP during standing; and the advantage is that there no hypertensive sides effects.
Erythropoietin has been tried but hypertensive side effects do limit its use.
Clonidine may be helpful(case reports and series only); my personal experince it worked 2/3 patients. it increases upright BP through the postsynaptic effects on alpha 1 receptors agonist. and it decrease supine BP through the alpha2 receptors cenrtaly; the fact that these patients have discoordination between their central and peripheral nervous systems due to the autonomic failure, clonidine is able to perform both functions and actually narrows the orthostatic gap.