TREATMENT IN MORNING VS EVENING DR AMY ROGERS MRCGP CLINICAL RESEARCH FELLOW MEDICINES MONITORING UNIT UNIVERSITY OF DUNDEE 1

ETHOS Challenge assumptions – Why do we prescribe tablets in the morning? Use IT and data technology – web-based study record linkage Can we improve outcomes without increasing drug exposure? 2 "Social Network Analysis Visualization" by MartinGrandjean - Own work : Licensed under CC BY-SA 3.0 via Wikimedia Commons -

CIRCADIAN VARIABILITY 3 White coat hypertension

PREVIOUS RESEARCH 3 Spanish studies by Hermida et al. Patients taking >1 blood pressure medication at night had a reduction in cardiovascular outcomes of almost 65%. 4 Chronobiol Int 2010;27:

CONT. MAPEC trial results (Hermida et al) Chronobiol Int 2010;27:

POSSIBLE EXPLANATIONS Correction of non-dipping pattern Delayed onset of action Duration of action less then 24 hours 6

PROBLEMS WITH MAPEC Randomisation was unclear Very high event rate – unrepresentative population? poor validation of outcomes? Too good to be true? 7

AIM to compare evening versus morning dosing of antihypertensive drugs 8

METHOD Participants sign up online Randomised follow-up Record linkage 9

OUTCOMES Primary APTC events: vascular death hospitalized MI hospitalized stroke SecondaryAdherence Patient reported outcomes eg falls, fractures 10

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SUB-STUDIES Home Blood Pressure Monitoring Cognitive Function 12 "Microlife WatchBP Home A" by Tennancening - Own work. Licensed under CC BY-SA 4.0 via Wikimedia Commons -

WHY THIS STUDY? Outcomes matter But, money does too: large study no pharma funding 13

NUMBERS Pilot study: 308 patients 0.84%/yr cardiovascular risk Need to randomise 10,269 people 14

RECRUITMENT Secondary care hypertension clinics BHS research network Primary careletter sent by GP advertising study 15

TIMELINE 16

CURRENT STATUS 17

QUESTIONS? 18