A Â鶹ÊÓƵ-led study has put to rest a long-standing controversy about the best time of day to take blood pressure medications — and in the process created a powerful research network of family doctors to answer important primary care questions.
The and studies reported this week in high-profile online JAMA network journals, finding that medications to control high blood pressure work just as well when they are taken in the morning as when they are taken at bedtime.
The question had been pressing since 2010, when the first of reported a 61 per cent lower risk of heart attack, stroke, heart failure and death when the meds were taken in the evening.
“It seemed too good to be true because hardly anything gives you that kind of a risk reduction,” explains BedMed principal investigator , professor of family medicine and director of the .
A also tried to reproduce those results and showed no difference in outcomes based on the time of medication usage.
“In a sense, we’re the tiebreaker of ‘does it matter or not,’ and our findings are that it doesn’t make any difference,” says Garrison. “The risks are not any different. The benefits are not any different.”
Statistics Canada reports that , the top risk factor for stroke and a major contributor to heart disease according to the .
“Our findings support the patient being the one who decides when they want to take their blood pressure medication,” Garrison says.
“If something sounds too good to be true, it is probably not true,” writes , professor of medicine at the Mayo Clinic, in an . “At the end of the day, timing of medications doesn’t matter as much as consistency in taking them. Regular dosing and use of long-acting medications should be emphasized and may better address concerns related to blood pressure variability.”
BedMed was the largest randomized trial ever carried out in a Canadian primary care setting, following 3,357 patients with high blood pressure for five years and involving 436 primary care providers (429 family physicians and seven nurse practitioners) from Alberta, British Columbia, Saskatchewan, Manitoba and Ontario participating.
Garrison explains that most clinical trials aim to determine the safety and efficacy of new drugs compared with placebo under ideal conditions, whereas pragmatic trials compare outcomes from treatments already offered in the real world.
The group is now pursuing further research questions including whether higher blood pressure is better for people in continuing care () and whether reducing the dosage and total number of medications can improve health outcomes for those over the age of 80 ().
“We’re pursuing questions that otherwise don’t get asked — questions that are often overlooked but are important to our patients,” says Garrison.
Fostering a “learning health-care system”
Garrison was determined to carry out the BedMed trial for frail patients in care as well as in the general population, because most clinical trials focus on younger, healthier patients and then the results are extrapolated to older patients. Nearly 800 patients in 13 Alberta continuing care facilities were followed for six months.
Since everyone’s blood pressure is naturally lower at night, the fear was that taking medication at bedtime could lead to an increase in falls, glaucoma or cognitive decline in care home residents. But the study found medication timing made no difference to these factors.
Garrison began his career as a family physician in British Columbia and then did a PhD in experimental medicine so that he could pursue research and foster a “learning health-care system.”
He first pitched his idea of a family physician research network at a doctors’ conference in 2011. About a sixth of the physicians in the audience signed up immediately.
Primary care physicians are uniquely positioned to carry out this type of study because they see so many patients. But they are very busy people, Garrison explains.
“I understand their workflow, and I explained how easy it could be to work with us,” Garrison remembers. “We’re pretty much the only group in Canada that has been able to get the family physicians to engage in such a robust way.”
All the doctors involved with the research collaborative are volunteers. When they sign up to participate, the research team helps the doctors invite their eligible patients to join a study, then randomizes them to receive the different interventions. The doctors follow their own patients on each treatment, and the research team analyzes the resulting data.
The BedMed study was carried out in partnership with the and was funded by and the .
