Timing is Everything

By Peter J. Rice, PharmD, PhD, BCPS, FAPhA ~

Telling a good joke.  The perfectly cooked steak.  Getting along with the spouse. Al-dente pasta. Taking your medicine.  In so many important areas of life, timing matters. 

 It is always interesting to talk with patients. Our Denver 9News channel hosts the Pharmacist 9Line each month and surprisingly, there is often a theme that reveals itself to the pharmacists during the phone-in. This month, the answers to several questions related to the best time to take medications. 

One interesting patient with high blood pressure is taking two common medications – atenolol and lisinopril – once a day.  Concerned about how best to take them, she takes the atenolol in the morning and the lisinopril at bedtime.  

Another patient with GI problems was taking ranitidine (a histamine H2 blocker) when he experienced indigestion after meals, until ranitidine and related drugs were pulled from the market because of contamination.  He tried omeprazole (a proton pump inhibitor, or PPI), but it did not work as well.   

It does matter when you take your medications, and as pharmacists we will make patient-specific recommendations that are influenced by the patient, medication, disease state and goal of therapy. 

In general, the highest blood level for a medication occurs within an hour or two of taking it, and the lowest blood level occurs around the time of the next dose.  Medications typically produce their greatest effects but also their side effects when blood levels are highest. This can help us understand why pharmacists recommend when it’s best to take your medications.

Here are some general principles to help you decide when to take your medications:

• When a disease state is more active at a particular time of day, take your medicine to maximize its effect when you need it.  Cholesterol is formed at night, so many cholesterol medications that block cholesterol formation are more effective when taken at bedtime; this is particularly true for some older statin medications which rapidly exit the body. Blood pressure and acid reflux are two diseases that can be worse for some patients during the night; if you are one of those patients, then taking your blood pressure medication or antacid medication at bedtime may work better for you.
• If you know when your symptoms will be most severe, you can time the medication by taking it one to three hours before this.  If you are allergic to dogs or cats and visiting someone with a pet, take your antihistamine about two hours beforehand so you have the greatest antihistamine effect during your visit. If you expect indigestion, you can pre-emptively take an H2 blocker an hour before eating. In each case, your highest medication blood level and greatest drug activity will occur when you most need it. Patients with joint pain that worsens during the day should take their anti-inflammatory drug a few hours before their pain develops.
• If you are expecting or experience troublesome adverse effects from your medication but still need to take it, you can sometimes minimize the impact by choosing when you take it.  Some antidepressant medications pep you up just after you take them; good meds for morning, bad timing if you take them before bedtime. Other meds can be different; if your once daily medication makes you feel tired or foggy, why not take it at bedtime.
• When adverse effects bother patients, pharmacists can suggest some other strategies that might help.  Taking medication with or after a meal can slow its absorption, decreasing peak blood levels and sometimes decreasing adverse effects.  Another strategy can be to take the medication at bedtime so that you’re sleeping during the adverse effect.
• Medications taken for symptomatic relief are supposed to make you feel better. So, take your medications when you feel they are providing the best symptom relief. 

But for many diseases, medications don’t necessarily make you feel any different; they just prolong your life. Blood pressure medications are like this. 

• Pharmacists love talking about medications and helping patients.  If you have questions about your medications, or when it’s best to take them, stop by and speak with your community pharmacist. Pharmacists are the drug experts and can help you take good care of yourself.

Take your medicines when you can remember to take your medicines.  Most of us do best when we can leave our medicines next to the toothpaste or the coffee maker to remind us when to take them. Often, prescribers will choose “each morning” dosing simply because most people can successfully remember to take their medicines in the morning.  Bedtime is also good. During the day can be difficult for busy people to remember, although smartphones and other apps can help you remember.