Dr,. Geoff Maly

Well not everything, but it turns out that timing in medicine is an important piece of the therapeutic puzzle. I was reminded of this concept when reading a study about the timing of antihypertensive medication administration.

The study looked at whether taking antihypertensive medication in the morning compared to nighttime had any effect on cardiovascular disease. The study followed more than 19,000 adults taking blood pressure medication over six years. Taking the medication at bedtime reduced the risk of dying from heart attack, stroke or heart failure by 50%. Viewed through another lens, over 10 years, for every 14 patients who switched from morning to evening medication administration, one death would be prevented. Obviously, death is an important outcome and this is a simple intervention without additional cost. So, I would say this is big news! I will take a minute to reflect on this finding.

High blood pressure is exceedingly common, with one in three adults in the U.S. having afflicted. First-line treatment for high blood pressure should always be lifestyle modification, like eating healthy and getting regular exercise. However, many people end up needing medication to bring their blood pressure down. If making a simple change in timing of medication administration could have a profound effect on how well the medication works, we should consider making that change.

There are many theories about why this works, and the jury is still out on the pathophysiology. However, it does appear that the evidence is pretty remarkable. Therefore, if you are on medication to lower your blood pressure, I recommend consulting with your primary care provider or local pharmacist about taking the medication at night. One caveat is that if you are on a diuretic medication, you may not want to take it at night as it could increase your nighttime waking up to go to the bathroom. And poor sleep, it turns out, will increase your blood pressure.

Other medications similarly are more or less effective if taken at certain times of the day. Most statin medications, which lower cholesterol, are best taken at night. This is because the liver makes most of its cholesterol at nighttime, so taking the medication prior to bed has the most effect on cholesterol synthesis. Atorvastatin (Lipitor) is an exception and can be taken in the morning or night. H-2 blockers, like famotidine or cimetidine, are best taken prior to dinner. Taking the medication at this time will decrease stomach acid production after the meal and during the night, when acid secretion in the stomach is the highest.

If you are on an inhaled steroid (like fluticasone) for asthma, taking this in the early afternoon makes the medication most effective. That is because asthma symptoms generally peak early in the morning, and taking steroid inhalers in the afternoon makes them do most of their work during the night to prevent this morning peak. However, keep in mind that trying to remember to take something in the afternoon (as opposed to the morning or nighttime) can be difficult and may not be worth the trouble. Similarly, taking antihistamines like loratidine at bedtime makes these medications most effective. That is because allergic symptoms also peak in the morning hours and 24-hour allergy medications have their maximal effect approximately 12 hours after administration.

Levothyroxine, the most common medication to treat hypothyroidism, should be taken first thing in the morning at least 30 minutes before a meal. That is because some foods, as well as drugs taken with food such as calcium and iron, can impair levothyroxine absorption thus decreasing its effect and potentially putting you at risk of being under-supplemented with your thyroid medication.

Similar to medication administration, healthy lifestyle changes may be more or less effective if done with regard to timing. Findings on the timings of meals has been conflicting. Earlier research had suggested that eating before bed increased risk of obesity, but more recent research has not shown that. Most recommendations focus on what you are eating compared to when you are eating it. However, it should be noted that eating before bed can exacerbate acid reflux disease, especially if items consumed contain alcohol or chocolate. Snacking throughout the day has been linked to weight gain, with the theory that snacking does not allow your body recovery time to properly digest the food. Therefore, eating spaced out meals seems to be better.

So, if you find yourself on medication for a chronic condition, consider checking to see if there is an optimal time to take the medication. Many times this will be listed on your medication bottle from the pharmacy. If not, consider asking your pharmacist or primary care physician about medication administration timing.

Mountain Medicine is edited by Ron Polk, in collaboration with Wallowa County medical practitioners.

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