Q: I recently started taking ramipril 5 mg once a day for high blood pressure. Is it better to take this medication in the morning or at night? I thought I once heard night was better because most heart attacks happen overnight.
Hypertension, commonly known as high blood pressure, happens when the blood flowing through our arteries applies too much pressure to the walls of the arteries. With time, this causes scarring, stiffening and weakening of our arteries, and makes our heart worker harder, which can eventually weaken it. When high blood pressure is left untreated it increases our risk of stroke, heart attack, heart disease and cardiovascular-related deaths.
For many people, a healthy blood pressure is less than 120/80mmHG. However, personal factors such as your age and medical conditions may cause your health-care provider to set a different target for you. The first number measures the pressure in your arteries when your heart is contracting and pumping blood, and the second number measures the pressure in your arteries when your heart is relaxing and filling with blood.
If your blood pressure is only slightly elevated, it can often be managed by lifestyle changes such as healthier eating habits, exercise, quitting smoking and limiting alcohol consumption. When it rises to more than 130/80mmHG we often see prescription medication started to lower your blood pressure along with lifestyle changes.
There are many different types of blood pressure medications, that work in slightly different ways to lower your blood pressure. Ramipril belongs to a class of medication called angiotensin-converting enzyme inhibitors. It works by relaxing our blood vessels which allows them to become wider and this allows blood to flow through without applying as much pressure on the artery walls. Ramipril can be taken either in the morning or in the evening, and some people who are prescribed to take it twice a day do both.
About once every other year, I have someone ask if evening dosing is more beneficial, as it is true that most heart attacks occur overnight in the early morning hours. There have been studies published that showed a benefit to evening dosing, but how these studies were performed has been criticized, and their results have been questioned by both health professionals and researchers. Recently, the American Heart Association Journals published a study that found there was no significant difference in the number of heart-related events when people took their blood pressure medication in the morning versus the evening. In Canada, we currently have two studies underway that are looking at the same thing, but the results are still years away from publication.
There can be patient-specific reasons for why your prescriber wants you to take your blood medication at night or in the morning. There can also be drug-related reasons. Diuretics are blood pressure medications that lower blood pressure by getting rid of excess sodium and water in our body which can cause us to urinate more often. We will generally tell you to take these medications in the morning so you can avoid having to get up frequently throughout the night to use the toilet.
Since ramipril doesn’t have a drug-related reason and your prescriber didn’t give you a patient-specific reason to take it at night or in the morning, I would suggest you take it at the time that is going to be easiest to remember. It is extremely important that you consistently take your blood pressure medication at the same time every day. Missing doses or abruptly stopping it may cause your blood pressure to spike and may cause headache, fast heart rate, anxiety or chest pain. Most importantly though, it can increase your risk of heart attack or stroke.
In the future, you could potentially see a second or third blood pressure medication added as hypertension can be difficult to manage for some people. It is possible that you may be able to take a second medication at the same time as your ramipril but when a third drug is added I always recommend you separate the dosing time. This is to reduce your risk of experiencing light-headedness or dizziness after taking all three medications at the same time.
If you have concerns about when or how to take your medications, book an appointment with your pharmacist for a medication review. They will look at all your prescription and over-the-counter medications and help you create a dosing schedule that works best for you.
Erin Thompson (BSc, BScPharm) is a graduate of Dalhousie University and a community pharmacist practicing at Shoppers Drug Mart in Quispamsis N.B. Her opinions expressed in this column are published for educational and informational purposes only, and are not intended as a diagnosis, treatment or as a substitute for professional medical advice, diagnosis or treatment.