BedMed RCT – Bedtime Antihypertensive Dosing

Written by Peter Liu 

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In the BedMed RCT, there was no difference in outcomes between bedtime versus morning administration of once-daily antihypertensive medications.

For timing, convenience and adherence remain the priority
Over the past decade, a Spanish research group (Hermida et al.) has published the MAPEC and Hygia RCTs, showing that administration of at least one daily antihypertensive medication at bedtime resulted in a 40-60% decrease in cardiovascular events. However, these findings have not yet been replicated outside of this research group, so nighttime administration of once-daily antihypertensives is not mainstream.

BedMed is a recent multicenter RCT in Canada that attempted to replicate the findings of MAPEC and Hygia with negative results. BedMed assessed whether bedtime versus morning administration of once-daily antihypertensive medications reduced major cardiovascular events or death among 3,357 Canadian primary care patients with hypertension. Over a median 4.6-year follow-up, the primary composite outcome rate was 2.3 vs 2.4 per 100 patient-years in the bedtime and morning groups, respectively (adjusted HR, 0.96; 95%CI 0.77–1.19; P = .70). No significant differences were observed across individual cardiovascular events or safety outcomes. Notably, adherence rates were lower with bedtime administration compared to morning administration. For example, 6-month adherence of morning administration was 94.2%, compared to 83.5% for bedtime administration (p-value not reported).

Taken alongside the similar TIME RCT, another negative trial that failed to reproduce the results from MAPEC and Hygia, the results from BedMed suggest that there remains no clearly optimal time to take daily antihypertensive medications.

How does this change my practice?
The findings of BedMed give me some reassurance that my own current nonchalance with antihypertensive timing is OK.  By default, I write daily antihypertensives to be taken in the morning, but I’m very flexible about when patients actually take them. There is only one common situation where I am particular about nighttime dosing of antihypertensives: supine hypertension in the setting of dysautonomia. For such patients, supine positioning at night can often lead to hypertensive diuresis, and nighttime administration of short-acting antihypertensives can be a key part of management.

Source
Antihypertensive Medication Timing and Cardiovascular Events and Death: The BedMed Randomized Clinical Trial. JAMA. 2025 Jun 17;333(23):2061-2072. doi: 10.1001/jama.2025.4390. PMID: 40354045