Timing of Antihypertensive Medication Administration
Antihypertensive medications should be taken at whatever time of day is most convenient for the patient—morning, lunch, or evening—as there is no cardiovascular benefit to bedtime dosing compared to morning dosing, and adherence is the priority. 1
Evidence-Based Recommendation
The European Society of Cardiology explicitly states that current evidence does not show benefit of diurnal timing of blood pressure-lowering drug administration on major cardiovascular outcomes (Class I, Level B recommendation). 1 This recommendation is strongly supported by the most recent and highest quality evidence:
The 2025 BedMed randomized clinical trial (3,357 patients, median 4.6 years follow-up) found no difference in cardiovascular events between bedtime and morning dosing, with identical event rates of 2.3-2.4 per 100 patient-years (adjusted HR 0.96,95% CI 0.77-1.19, P=0.70). 2
A 2025 systematic review and meta-analysis of 5 randomized controlled trials with 46,606 patients confirmed that evening administration did not reduce major adverse cardiovascular events compared to morning administration (HR 0.94,95% CI 0.86-1.03 when restricted to low-risk-of-bias trials). 3
The International Society of Hypertension position paper (endorsed by World Hypertension League and European Society of Hypertension) concluded that all eight published outcome studies on bedtime dosing had major methodological flaws and high risk of bias, and therefore bedtime dosing should not be routinely recommended. 4
Practical Implementation Strategy
Focus on adherence, not timing:
Patients should take medications at the same time each day in a consistent setting to ensure adherence. 1
Select a dosing time that fits the patient's daily routine and lifestyle to establish a habitual pattern. 1, 5
Use once-daily, long-acting antihypertensive medications that provide 24-hour blood pressure control. 1, 4
Consider fixed-dose single-pill combinations to improve adherence when multiple medications are needed. 1, 5
Safety Considerations
Bedtime dosing does not increase safety risks:
The BedMed trial found no difference in falls, fractures, new glaucoma diagnoses, or cognitive decline between bedtime and morning dosing groups. 2
All-cause unplanned hospitalizations and emergency department visits were equivalent between timing groups. 2
Special Populations
For patients with diabetes and hypertension, the American Diabetes Association and European Society of Cardiology do not recommend preferential bedtime dosing, though one or more medications may be considered at bedtime based on patient preference (weak recommendation). 1
Common Pitfalls to Avoid
Do not mandate bedtime dosing based on outdated studies showing benefits—these findings have not been reproduced in high-quality recent trials. 1, 5, 4
Do not prioritize chronotherapy over adherence—the most important factor is consistent daily medication taking, regardless of time. 1, 5
Do not assume morning surge requires evening dosing—use long-acting medications that provide 24-hour coverage instead. 4