The People's Perspective on Medicine

When Should You Take Your BP Pills? Morning or Bedtime?

Do you want the the biggest bang for your blood pressure buck? If so, you may want to ask your doctor whether you should take your BP pills before bed.
Hypertension BP

Most people get into the habit of taking all their medications at breakfast time. It’s a routine that is hard to break. But a new study suggests bedtime might be a much better choice for some meds (European Heart Journal, Oct. 22, 2019). That’s because if you take your BP pills before bed, they appear to improve blood pressure control. More important, such a regimen reduces the risk of serious cardiovascular disease (CVD) events.

The Study:

In 2008, Spanish researchers undertook a fascinating study called the Hygia Chronotherapy Trial. It lasted a decade. The investigators recruited over 19,000 patients with hypertension in northern Spain. Half were randomly assigned to take their BP meds at bedtime. The other half took their drugs in the morning. The median patient follow-up was 6.3 years. This is one cool study!

The Results:

We always like to let researchers describe their results in their own words, if they are understandable.

Here’s what the Spanish investigators explained:

“Results establish, first, greater ABP [ambulatory blood pressure] control in patients of the bedtime treatment than in those of the awakening-treatment regimen. The main differences in ABP control were achievement with bedtime treatment of: (i) significantly lower asleep BP mean without loss of awake BP-lowering efficacy and (ii) greater sleep-time relative BP decline resulting in a significantly lower prevalence of non-dipping. These ingestion-time-dependent effects on asleep BP control were strongly associated with substantially attenuated CVD [cardiovascular disease] risk.”

OK, we admit, that’s a little technical. Here’s what they found in English. In a nutshell, taking blood pressure medicines before bed led to better blood pressure control during the night as well as during the daytime. More important, this regimen reduced morbidity and mortality. That’s doctor talk for less sickness and death.

Drilling Down!

Did you know that your blood pressure normally goes down while you sleep? It hits its nadir (lowest point) between 2 and 4 am. There is also more activity with your renin–angiotensin–aldosterone system (RAAS) during sleep. You can learn more about why this is important at this link.

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Why should you take your BP meds at bedtime if they are ACE (angiotensin converting enzyme) inhibitors like lisinopril or ARBs (angiotensin receptor blockers) such as losartan or valsartan?

The reason is that the effect is more sustained:

“enhanced reduction in asleep BP mean without compromised therapeutic effect on awake BP.”

In the Spanish study, blood pressure was lower both during the day and while people were sleeping if they took their pills at night. This group also had a significant (45%) reduced risk of experiencing a major cardiovascular disaster. Stroke risk was reduced by 49%. Heart failure was diminished by 42% and heart attacks were 34% less common in the nighttime pill takers.

It’s always nice when a biomarker such as blood pressure measurement matches up with an outcome that people really care about, namely heart attack and stroke reduction. That’s not always the case.

But Is It Safe to Take Your BP Pills at Night?

The researchers wanted to know if you take your BP pills at night would it be safe?

Here are their conclusions:

“It also demonstrates that the safety of the bedtime hypertension therapeutic scheme is similar to the more common awakening one, a finding consistent with previous publications reporting that bedtime compared with morning BP therapy significantly improves ABP reduction without any increase in adverse effects.”

Before you decide to take your BP pills at night, you must check with the prescriber. There may be instances when an older person should not take hypertension medicine at night. If the pills contain a diuretic, you may have to get up more often to go to the bathroom at night. That can disturb sleep. If the medicine causes dizziness, that could increase the risk for a fall on the way to the bathroom. Please discuss any change in regimen with a health care professional!

To make that conversation fully informed, here is a link to the article. Make sure your doctor, nurse practitioner or physician assistant reviews it carefully and considers your personal situation before giving you the green light to change your pill taking pattern.

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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    Citations
    • Hermida, R. C., et al, "Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial," European Heart Journal, Oct. 22, 2019, https://doi.org/10.1093/eurheartj/ehz754
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    I take Ramipril and Apixaban. I suffer the Ramipril cough, which is worse at night, and even worse if I try to sleep on my left side. But I can get some relief on my right side or my back. However, after trying your suggestion of taking the meds at bed-time, I found the coughing to be much worse at night, so much so that I lost most of my sleep. It’s a shame, but I am now changing back to taking the meds in the morning, as that will presumably leave me emptier of the ACE inhibitor at night. Somehow a daytime cough is easier to manage – perhaps it’s something to do with being upright. Also, as you stated, BP tends to drop by itself at night, so it would seem the ideal time to be ‘light’ on the ACE inhibition.

    Philip,

    Trying to cope with an ACE inhibitor cough is crazy. What does your doctor say? Has your doctor considered an ARB? Such drugs are less likely to cause cough. You may need something else entirely. Your doctor should work with you to help you control your blood pressure without side effects.

    “Make sure your doctor…reviews (the article) carefully … before giving you the green light to change your pill taking pattern.” And how do you suggest we do that?

    I believe there may be evidence that taking blood pressure pills later in the day may lower blood pressure too much and prevent adequate perfusion of the optic nerve exacerbating or causing glaucoma.

    I think I’ll give this a go. I take Losartan and Metoprolol plus Synthroid meds. Oddly enough, I missed my pills this morning but was already on my way to work when I realized it.

    “49% reduced risk of stroke.” I assume that is the relative risk. If so what is the absolute risk? As you know those numbers are quite different. You might want to explain the difference to readers.

    Quite right. That is a relative risk reduction. There were a total of 345 strokes amongst all the volunteers (19,084) in six-plus years, so as you can see the absolute risk is quite low. The scientists did not provide that figure in their tables and I am loath to extrapolate it.

    There’s another reason why one might not want to take one’s blood pressure medication before bed: The beta blocker metoprolol succinate (generic of Toprol XL), for instance, instructs the user to take it with or after a meal. So, one should always read the instructions that come with one’s medication.

    I don’t like prescription pills for myself. My BP went down 26 points after 6 months of steadily working out on machines at my gym, about 6 hours a week. Also one garlic pill a day, in the morning. I’m 71, eat a fair amount of salt, and I know I’m lucky to find a solution that doesn’t involve endless trips to the doctor. I do love People’s Pharmacy.

    Yes, based on my mom’s behavior, I’m guessing a lot of BP meds are actually being used as a sleeping pill. In my mom’s case, maybe 2 would be better than one. She has ended up in the Emergency Room a few times for extremely low BP. No one could figure it out.

    I take 2 blood pressure medications: Losartan-HCTZ. 100-25 MG. ALSO AMLODIPINE 10 MG. Take the Losartan-HCTZ in the mornings and the other at night. So far seems to be working for me.

    My wife takes 4 blood pressure medications, 2 in the morning (nifedipine + coreg),2 in the evening (telmisartan + coreg). When she switched Primary care physicians this year the new doctor wanted her to take all in the morning (except second Coreg in the evening). She complied. Within a few weeks we rushed her to emergency room with
    very low blood pressure. In my opinion, if you take a few medications for high blood pressure you should never take all at the same time.

    I’ve been taking 5mg Quinapril 2x’s daily for at least 5 years, usually a pill in the morning with b’fast, 0800-ish, and usually one at dinner between 1800-1900ish. I check my pressure twice daily, and now it seems to be normal, somewhere between 120-130 over 65-80. On some days I don’t even need a pill, so I’ll need to talk to my Doc about that. I’ve been on BP meds since at least 1990, started with 10mg daily of Accupril, than on to generic Quinapril, but because 10mg was dropping my pressure to fast, my Doc said to try 5mg twice daily.

    Me: 68 y/o male, retired, bicycle 20 miles 3x’s weekly, walk 5 miles 3x’s weekly 5’9, 155lbs, do some weight training, but not much, other than BP problems, my health is very good.
    Thanks

    I changed my time from morning to evening and noticed in a few days that the slight swelling in my lower legs is totally gone. I will continue at evenings and monitor that change. It might be that dosing in evenings and then lying flat that the body does not have as hard a time fighting gravity to return blood flow back to upper body. Whereas, taking in mornings, the fluid builds up slowly during day, so that by evening swelling is apparent. This is just personal one-person observation but if it turns out to be a benefit of an evening dose, I believe people will be pleased.

    That’s odd. Just yesterday I read quite the opposite. I read that I should NOT take my BP meds at night, but I may be a peculiar case, an exception to the rule due to having had an ‘eye stroke’ [specifically a non-arteritic ischemic optical neuropathy [NAION ] within the last 2 years):

    “If patients with nonarteritic ION are taking blood pressure medication, Dr. Shindler recommends that they take the medication in the morning. “Many people’s blood pressure naturally drops at night, and we don’t want it to drop too low,” he explains.

    “Any treatment for nonarteritic anterior ION is controversial,” Dr. Miller says. “Most people would say there is no treatment.”

    This is definitely a situation in which you should follow the advice for your particular (somewhat unusual) condition.

    Excellent article. It brought up issues that I didn’t even know were issues! Coincidentally I have a doc appt today and will definitely bring this subject up.

    I would not want to take one of two BP meds at night primarily because it does have a diuretic compound. I have found that if I fail to take it in morning and take it towards evening I have interrupted sleep because of the need to go to the bathroom several times at night. It tires me out. I will talk to doctor about taking the other one at night, though.

    Would this apply to hydrochlorothiazide as well?

    Presumably it would. We’ll be on the lookout for more research.

    My BP runs with different numbers throughout the day, therefore I take my meds 3-4 times a day to keep my daytime home monitored BP in check.

    If BP is lowest 2-4am naturally, is taking BP meds at night not dangerous by lowering it even more with pills? With more and more BP meds being recalled that are manufactured in third world countries, I would want to be awake to be
    aware of symptoms. Perhaps the Spanish study used brand name products! I would alter life-style and diet before resorting to meds. It takes discipline and foregoing a lot of tempting junk food but at 80 yrs, I am not, and never have been on meds, but spend money on vitamins,minerals, herbs and plain natural foods and have never been more than 120 pounds at 5’4.

    I take my BP medication at bedtime, 12.5 mg carvedilol(wish my insurance plan covered Coreg) and have taken this med for years. It’s the only prescription I take since an MI and a stent event 12 years ago. Oddly, my daytime BP readings are perfect but I awake once or twice during the night (including during a sleep lab study) with head pressure and elevated BP and elevated cortisol which results in hot flashes. I’m way past menopause. Both my PC and my cardiologist don’t have an answer. My heart rate remains fine, in the 60’s. Understanding heart health is puzzling, at least that is my experience. There is still much to learn.

    I cannot recall the source but recently published conflicting research suggests splitting the daily milligram dose into a morning and evening dose for better BP control. What’s a patient (retired MD) to do?

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