A growing number of health experts believe the time you have your medication can have a significant impact
What’s the best time to take your pills? From heartburn to heart disease, swallow your medicine at the wrong time of day and it may not work
By DAVID HURST
UPDATED: 22:25 GMT, 27 February 2012
While millions of us take medicine daily, few pay much attention to the time of day we take it.Yet a growing number of health experts say this is much more important than patients think — indeed when it comes to conditions such as arthritis, osteoporosis and heartburn, the time you have your medication can have a significant impact on its effectiveness and how well it protects you.
New U.S. research, published last week, seems to support this. A study of mice, published in the journal Nature, identified why heart rhythm problems are more common in the morning.
Experts believe this understanding means patients who are on anticoagulants to prevent heart attacks and strokes could maximise the effect by taking the pills when they wake up.
It’s thought the key is the circadian rhythm, our 24-hour internal body clock driven by the brain’s hypothalamus gland. This controls not only the immune system but also blood pressure, body temperature, hormone production, bowel movements and tiredness.
So what’s the best time to take your medication? We asked the experts…
HIGH BLOOD PRESSURE
Taking blood-pressure tablets at night may better control hypertension and greatly reduce the risk of heart attack and stroke, research published last year suggests.
While millions of us take medicine daily, few pay much attention to the time of day we take it
The results of the five-year Spanish study highlighted the importance of reducing blood pressure at night. In healthy people blood pressure dips at night between 10 to 20 per cent — those whose blood pressure doesn’t fall as it should are more likely to suffer from heart attack and stroke, the researchers said.
In the study of 2,156 men and women with high blood pressure, those who routinely took at least one of their blood-pressure medicines at night had a 33 per cent lower risk of angina, stroke and heart attack than those who took all their blood-pressure pills in the morning.
‘This study confirms sleep-time blood pressure as the most relevant predictor of cardiovascular risk,’ says lead researcher Ramon Hermida of the University of Vigo. ‘Sleep-time blood pressure is best reduced when medication is taken at bedtime.’
However, those who now take their pills in the morning should not begin taking them at night without speaking with their doctor, says Hermida. ‘There’s a risk for nocturnal hypotension (abnormally low blood pressure) which could increase the risk of stroke,’ he adds.
It is now recommended that cholesterol medicines be taken at bedtime instead of first thing in the morning. Studies at the University of Sunderland found that when patients taking simvastatin, one of the most commonly prescribed statins, switched from evening to morning, there was a significant increase in ‘bad’ LDL cholesterol.
Another study published in the International Journal of Clinical Practice in 2008 revealed that taking another commonly prescribed statin, atorvastatin (brand name Lipitor), in the evening was better than taking it in the morning — it was associated with fewer heart attacks, blockage of the arteries as well as greater improvements in total ‘good’ cholesterol and better blood vessel function.Experts think this may be because most cholesterol is produced at night, while we are not eating.
For some time it’s been known that heart attacks and strokes are three times more likely to happen in the morning than any other time, but until now it’s not been clear why. But research published last week by Case Western Reserve University School of Medicine in Ohio has identified a protein called KLF15 that is crucial in regulating the heart’s rhythm.
The researchers found levels of the protein rise and fall in a 24-hour cycle. The heart’s electrical impulses are slowest from 6am to noon. ‘As the duration between impulses slow down, this makes the heart more likely to go out of rhythm, to short circuit or for electrical storms to occur,’ says Professor Mukesh Jain, who led the research.
This increases the risk of a heart attack — which means that the best time to take heart medication is first thing in the morning.
‘This realisation will be one of the most important innovations in medicine in the next 20 years,’ says Professor Russell Foster, a circadian rhythms specialist at the University of Oxford. ‘Certainly, if I was taking anti-stroke medication I know at what time of the day I’d take it. It should be delivered before you properly wake up. You should lie there calmly and take it, then get up.’
The general advice is to take proton-pump inhibitors (PPIs, drugs which suppress acid production) 30 minutes before the first meal of the day.
However, a recent study by the University of Kansas found the drugs were more effective against acid reflux when taken in the evening. More than 70 per cent of patients with gastro-oesophageal reflux disease who took a commonly prescribed PPI, rabeprazole, in the afternoon or evening found their symptoms were eased, compared with 42 per cent who took it in the morning.
They suggested this could be because the drug will act throughout the night, when heartburn can be exacerbated by lying down. They concluded that before the evening meal would be the preferred time for patients to take their medication, particularly those who suffer at night. However, Marcus Harbord, gastroenterologist at the Chelsea and Westminster Hospital, suggests splitting the daily dose, providing half in the morning then half in the evening, to keep symptoms at bay at all times.
The most commonly prescribed drugs for osteoporosis are bisphosphonates, which prevent the loss of bone mass.
‘The key thing with bisphosphonates is that they are poorly absorbed,’ says Sarah Leyland, senior nurse at the National Osteoporosis Society. This is because they do not dissolve well, especially in oils and fats. ‘So you need to take your pill first thing in the morning with water on an empty stomach after a night of not eating. Then patients must wait up to hour to eat or drink.’
Many osteoporosis patients have to take calcium and vitamin D but these too can disrupt absorption, so patients should also wait at least an hour after taking their bisphosphonates, she adds.
‘If you eat or drink something other than water, or take another medication, it could mean you won’t get any benefit from it, so it could be a total waste of time taking it.’
Osteoarthritis patients are likely to find their joint pain is worst in the afternoon, according to a recent Texas Tech University study. The researchers concluded that the optimal time for taking a non-steroidal anti-inflammatory drug such as ibuprofen would be around noon to mid-afternoon, so that it takes effect as symptoms begin to build up.
They also found that rheumatoid arthritis patients generally experience the greatest pain in the mornings, so taking painkillers just after their evening meal may be the most effective way to prevent pain developing overnight.
As many as three million people in Britain are said to suffer from an underactive thyroid — the majority of them women. Most thyroid medicines contain levothyroxine, a synthetic version of the thyroid hormone T4.
The T4 hormone needs to be first converted to the active form of thyroid hormone T3 for it to be effective. This takes a long time to occur inside the body.
Traditionally, many doctors suggest that taking thyroid medication first thing in the morning is best. But two recent Dutch studies have found that taking medication at bedtime rather than the morning results in ‘higher thyroid hormone concentrations’. The researchers suggested that as the bowel is slower at night, it takes longer for the levothyroxine tablet to move through the intestinal system.
This results in longer exposure to the intestinal wall, and so better absorption of the medication. Other studies have shown that the key is taking thyroid medication consistently at the same time each day. To ensure quick absorption, doctors also advise avoiding calcium and iron supplements, high fibre foods, antacids and antidepressants for at least two hours after taking a thyroid pill.