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

A reader got better blood pressure control if he took his pills at night instead of in the morning. Should you take your BP pills before bed?
When Should You Take Your BP Pills? Morning or Bedtime?
Hypertension BP

When do you swallow your pills? If you are like most people, you get into the habit of taking all your medications and supplements at breakfast time. It’s a routine that is hard to break. One 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.

One Reader Shares his Story:

Sometimes an anecdote reveals the science:

Q. I want to thank you for your story about whether to take blood pressure medications in the morning or at bedtime. I’ve been taking BP meds for about 20 years.

In January I visited my doctor about another problem, and he became concerned about my blood pressure. He wanted me to monitor it every day for a month and check back in.

During that month, I read your article. I’d been taking my meds with breakfast and I decided to change that.

The effect was quite remarkable. My systolic pressure dropped from about 145 to 135. (Those are averages of about 70 readings before the switch and 21 readings after the switch, measured both before breakfast and before supper.)

I’ve had serious side effects from BP meds in the past and I was apprehensive that my doctor would change my meds. Lately, I’ve been on amlodipine and HCTZ and the side effects seem minimal. Yesterday, my doctor decided to not to make any changes and I want to thank you for that.

A. We are glad to hear that this is working for you. Research shows that people taking their blood pressure pills in the evening had better BP control and were less likely to have heart attacks or strokes (Sleep Medicine Reviews, Jan. 23, 2021).

A Study on When to Take Your BP Pills:

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.

2021 Updates on When to Take Your BP Pills:

An analysis of 153 studies carried out over 45 years confirmed the Spanish research results (Advanced Drug Delivery Reviews, Jan. 22, 2021). The researchers reported that when hypertension medications were taken at bedtime/evening rather than upon-waking/morning there were fewer adverse drug reactions and better kidney function.

A recent review of 155 randomized controlled trials compared people taking their medicines in the morning or in the evening (Chronobiology International, Oct. 2021).  A significant majority of these trials found better blood pressure control when people took their pills at bedtime. None of them found that taking the pills in the morning worked better.

Diuretics could be an exception, though. Taking such water pills in the evening might lead to excessive urination during the night. In addition, people with glaucoma must take their blood pressure pills in the morning. Keep reading to learn more.

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.”

Do NOT Take BP Pills at Night if You Have Glaucoma!

When we suggested nighttime BP pill taking we were notified in no uncertain terms that this would be a big mistake for people with glaucoma. To read more about this problem, here is a link

Glaucoma Patients Should Not Take Blood Pressure Pills at Bedtime
If blood pressure drops too low overnight, it can aggravate optic nerve damage. That is the last thing glaucoma patients need!

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!

Learn More:

To make that conversation fully informed, here is a link to the original Spanish research. And here is a link to the recent systematic review. Make sure your doctor, nurse practitioner or physician assistant reviews them carefully and considers your personal situation before giving you the green light to change your pill taking pattern.

Should you wish to read about the proper way to take blood pressure readings at home, here is a link to our eGuide to Blood Pressure Treatment. It describes many nondrug ways to help control hypertension. 

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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.” .
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
  • Hermida, R.C., et al, "Ingestion-time differences in the pharmacodynamics of hypertension medications: Systematic review of human chronopharmacology trials," Advanced Drug Delivery Reviews, Jan. 22, 2021, DOI: 10.1016/j.addr.2021.01.013
  • Hermida RC et al, "Systematic review and quality evaluation of published human ingestion-time trials of blood pressure-lowering medications and their combinations." Chronobiology International, Oct. 2021. DOI: 10.1080/07420528.2021.1931280
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