Core IM: Mind the Gap on Prescribing Meds Day vs. Night Part 1

May 12, 2019


For a transcript of the podcast and show notes: https://www.coreimpodcast.com/2019/05/08/medications-daytime-vs-nighttime-part-1/

Time Stamps

  • Why do we dose warfarin at night? (2:45)
  • Back to the basics – what are the pharmacodynamics of warfarin and how does vitamin K intake matter? (4:28)
  • Practical matters – so what should we tell patients (6:14)
  • Dippers and non-dippers – what happens to blood pressure at night? (9:32)
  • The surprising link between dipping and cardiovascular outcomes (11:15)
  • Timing is everything… or is it? The evidence behind taking BP meds at night (11:58)
  • Review of teaching points (15:58)

Thank you to Dr. Matthew Sparks, Nephrologist at Duke and Tania Ahuja, pharmacist at NYU Langone Health for peer-reviewing this episode!

References

  • Hirsh J, Fuster V, Ansell J, Halperin JL; American Heart Association; American College of Cardiology Foundation. AHA/ACCF guide to warfarin therapy. Circulation. 2003 Apr 1;107(12):1692-711.
  • https://my.clevelandclinic.org/health/drugs/4713-anticoagulant-medication-warfarin-coumadin
  • Heran BS et al. Effect of medication timing on anticoagulation stability in users of warfarin (the INRange RCT): study protocol for a randomized controlled trial. Trials. 2016 Aug 4;17(1):391.Pushpinderddep K et al. Warfarin dosing and time required to reach therapeutic international normalized ratio in patients with hypercoagulable conditions. Turk J of Hematol. 2016 Dec; 33(4)4:299-303.
  • FDA. Coumadin Tablets Insert. Oct 2011. Accessed at <https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/009218s107lbl.pdf>
  • LR Barker. “Hypertension.” Principles of Ambulatory Medicine 6th Edition Lippincott Williams & Wilkins. 2003 p987
  • Millar-Craig MW, Bishop N, Raftery EB. Circadian Variation of Blood Pressure. The Lancet April 15, 1978; 795.
  • O’Brien E, Sheridan J, O’Malley K. Dippers and non-dippers. The Lancet Aug 13, 1988. Pp 397
  • O’Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. Journal of Hypertension 31(9), September 20113, p 1731-1768,
  • Cuspidi C, Facchetti R, Bombelli M, Sala C, Tadic M, Grassi G, Mancia G. Night-time heart rate nondipping: clinical and prognostic significance in the general population. J Hypertens. 2018 Jun;36(6):1311-1317.
  • Delaney A et al. Pitfalls in the measurement of the nocturnal blood pressure dip in adolescents with type 1 diabetes. Diabetes Care 32: 165-168, 2009.
  • Boggia J, Li Y, Thijs L, Hansen TW, Kikuya M, Björklund-Bodegård K, Richart T, Ohkubo T, Kuznetsova T, Torp-Pedersen C, Lind L, Ibsen H, Imai Y, Wang J, Sandoya E, O’Brien E, Staessen JA; International Database on Ambulatory blood pressure monitoring in relation to Cardiovascular Outcomes (IDACO) investigators. Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet. 2007 Oct 6;370(9594):1219-29.
  • Cuspidi C et al. Clinical and prognostic significance of a reverse dipping pattern on ambulatory monitoring: an updated review. J Clin Hypertens. 2017;19:713-721.
  • Hermida RC, Ayala DE, Mojón A, Fernández JR. Influence of circadian time of hypertension treatment on cardiovascular risk: results of the MAPEC study. Chronobiol Int. 2010 Sep;27(8):1629-51.
  • ACC cardiotool
  • Laffin LJ, Barkis GL. Has the sun set on nighttime dosing in uncomplicated hypertension? Hypertension. 2018 October; 72(4): 836-838.
  • Poulter et al. Randomized Crossover Trial of the Impact of Morning or Evening Dosing of Antihypertensive Agents on 24-Hour Ambulatory Blood Pressure. Hypertension. 2018 Oct;72(4):870-873.
  • Rogers et al. Protocol for assessment of sleep quality and duration in the Treatment In Morning versus Evening (TIME) study: a randomised controlled trial using online patient-reported outcome measures. BMJ Open. 2018 Jun 7;8(6):e021890.

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