Dosing Blood Pressure Medications At Bedtime: Improve Outcomes?

Citation: Hermida RC, Ayala DE, Mojon A, and Fernandez JR. Influence of Time of Day of Blood Pressure- Lowering Treatment on Cardiovascular Risk in Hypertensive Patients with Type 2 Diabetes. Diabetes Care. 2011; 34: 1270-76.
Category: Diabetes, Hypertension
Original commentary found in, written by: Joshua W. Fleming, Pharm.D. and Patricia A. Ross, Pharm.D., BCPS

Commentary Written By: Livia Macedo, PharmD

This study commented how dosing blood pressure medications at bedtime might reduce risk of cardiovascular events, specifically in patients who are “non-dippers”. I learned that the term non-dippers is used when referred to patients who don’t normally have a 10% drop in blood pressure overnight. This non-dipping blood pressure pattern has been associated with a higher risk of cardiovascular events. The authors from the original study claim that by moving 1 or more blood pressure medication to bedtime will not only decrease nocturnal blood pressure, but will also decrease cardiovascular events and increase event free survival. However, Fleming, et al. points out several limitations associated with this study. The study is not specific with regards to what classes of blood pressure medications should be moved to bedtime. Dose adjustments and baseline blood pressure medication are not reported. In addition, this study was conducted only in one center in Spain, and may not be generalizable in locations with a more diverse population. These factors make it challenging to replicate this study in other settings. Although, this study has limitations, I think it can still be applicable in practice as an alternative option for patients who are non-dippers with uncontrolled nocturnal and awakening blood pressure, and are consistently adherent to their medications. In this situations, I think it would be okay to recommend to take one of their blood pressure medications at bedtime (definitely not a diuretic though, due to inconvenience for the patient), and monitor for improvement in their nocturnal and morning blood pressure. Definitely encourage adherence as most important. I don’t think it would be a good idea to ask patients who are currently non-adherent to their medication to take one blood pressure medication at bedtime, because that would make their medication regimen more complex, and increase likelihood of them missing doses, which could potentially worsen their clinical outcome. What are your thoughts? Would you consider recommending  a blood pressure medications at bedtime? If so, which class of blood pressure medications?

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