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Study: Timing of BP Pills Might Matter

Taking a blood pressure pill at bedtime instead of in the morning might be healthier for some high-risk people.

New research suggests that simple switch may normalize patterns of blood pressure in patients at extra risk from the twin epidemics of heart and kidney disease.

Why? When it comes to blood pressure, you want to be a dipper. In healthy people, blood pressure dips at night, by 10 to 20 percent. Scientists don't know why, but suspect the drop gives arteries a little rest.

People with high blood pressure that doesn't dip at night — the non-dippers — fare worse than other hypertension sufferers, developing more serious heart disease. Moreover, heart and kidney disease fuel each other — and the 26 million Americans with chronic kidney disease seem most prone to non-dipping. In addition to heart problems, they're at extra risk of their kidney damage worsening to the point of dialysis.

Most blood pressure patients need two or three medications. So Italian researchers performed an easy test: They told 32 non-dippers with kidney disease to switch one of those drugs from a morning to a bedtime dose. In two months, nearly 90 percent of these high-risk patients had turned into dippers. Their nighttime blood pressure dropped an average of 7 points, without side effects or increase in daytime blood pressure.

Better, a key sign of kidney function improved significantly, too, Dr. Roberto Minutolo of the Second University of Naples reports this month in the American Journal of Kidney Diseases.

It's the latest research in the field of chronotherapy: How our bodies' internal rhythms make certain diseases worse at certain times of the day, and in turn affect how to time treatments.

While the Italian study is too small for proof, similar studies from Europe also back a bedtime switch for non-dippers. The work is catching the attention of U.S. hypertension specialists, and now doctors at Baltimore's Johns Hopkins University are planning a larger study to see if a bedtime switch really could give certain people healthier hearts and kidneys.

How big a problem is non-dipping?

"I think it's huge," says Hopkins' Dr. Lawrence Appel. "This is our best lead" into why black Americans with kidney disease, in particular, tend to worsen despite treatment.

Appel found 80 percent of black kidney patients in a recent study were non-dippers. Most startling, 40 percent had nighttime blood pressure that was even higher than daytime levels.

Two-thirds of chronic kidney disease patients, and at least 10 percent of the general population, are estimated to be non-dippers, says Dr. Joseph Vassalotti of the National Kidney Foundation. One theory is that their bodies have trouble excreting salt.

Yet few patients have ever heard of the problem — and few doctors know who is affected. Most people get their blood pressure checked only during the day. A 24-hour blood pressure monitor can tell but is rarely used, partly because insurance seldom pays for the extra visit to download and diagnose the readings.

And most patients who take several once-a-day pills swallow them all in the morning, meaning they all start wearing off around the same time, says Dr. Gina Lundberg of St. Joseph's Hospital in Atlanta.

"It does make good sense to take some in the morning and some in the evening," says Lundberg, a spokeswoman for the American Heart Association.

Everyone has an internal clock, determined by genes, that affects health. Many of these biological rhythms are circadian, meaning they fluctuate on a 24-hour cycle.

Consider how that can affect the timing of treatments. Some older "statin" pills fight cholesterol best if taken at bedtime; they target a liver enzyme that's most active at night. Asthma attacks are more frequent at night, and the stomach secretes more heartburn-causing acid at night, affecting some patients' dosing requirements. Researchers even are studying how to better time certain cancer chemotherapies and allergy treatments.

The best-known example: Blood pressure jumps in the early morning hours, as the awakening body produces more stress hormones. That's also why heart attacks and strokes are most common in the morning.

The nighttime dipping problem has gotten far less attention. The new Italian study marks an important advance, says Dr. Mahboob Rahman of the University Hospitals of Cleveland.

"We know now that you can change medication timing and lower blood pressure at night," he explains.

That doesn't mean everyone should switch willy-nilly to bedtime dosing. Morning may be best for people on just one drug, and no one yet knows if the switch truly gives non-dippers better overall health. "That's the million-dollar question," Rahman cautions.

Still, Lundberg says it's worth asking your doctor how to time doses, saying one at night for someone taking multiple medicines couldn't hurt.

--LAURAN NEERGAARD, AP Medical Writer

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The Role of Antibiotics and Nasal Steroids on Acute Sinusitis

This article I came across only shows that not all sinus infections are created uhm infected equal. he-he

Seriously, this British study is a known fact since a long, long time ago to most people in the medical profession.

In fact, this was harped on us over and over again by our professors in the Best Medical School along Aurora Boulevard in the Philippines years back when I was a young med student.

Since most acute sinus infections are caused by viruses which are self- limiting ergo no amount of antibiotics and nasal steroids can help cure them of the infection but still a lot of medical practitioners give them for reasons that they only know--

--is it because of trying to please their patients; that they will be satisfied that their doctor have given them something for their troubles rather than the “normal” advice in this particular case of just drinking plenty of fluids, rest and steam inhalations?

Or are they just beholden to the drug companies that give them some percentage of their sales, finance their travels for medical seminars or what have you?

Anyway this study published by HealthDay News is nothing but a re-affirmation of that belief that in most cases of sinus infections, antibiotics and nasal steroids actually doesn’t work.

Here’s the rest of the news…

TUESDAY, Dec. 4 (HealthDay News) -- Antibiotics and nasal steroids work no better than a placebo in combating sinus infections, a new British study shows

"Antibiotics are probably not as effective as have been previously believed, particularly for the majority of cases of acute sinusitis," said study author Dr. Ian Williamson, a senior lecturer in primary medical care at the University of Southampton. "Patients should turn more to symptomatic remedies like analgesics while the body heals itself, usually over a period of three days to three weeks. Topical steroids have little overall effect, but may be beneficial, particularly in milder cases of acute sinusitis."

"For sinusitis, however it is being diagnosed in the primary-care setting, many of these cases do not require treatment, and a more cautious and conservative approach would seem to be warranted," added Dr. Reginald F. Baugh, vice chairman of Texas A&M Health Science Center College of Medicine and director of the division of otolaryngology at Scott & White, in Temple, Texas.

But other experts say the study, published in the Dec. 5 issue of the Journal of the American Medical Association, is no reason to scrap antibiotics altogether in this scenario.
"This is a helpful and useful study, and we shouldn't condemn antibiotics in those people who need them," said Dr. Michael Stewart, chairman of the department of otolaryngology at New York Presbyterian-Weill Cornell Medical Center, in New York City.

But, he added, only a minority of sinus infections are bacterial and will respond to antibiotics. The majority are viral infections, which won't respond to antibiotics.

According to an accompanying editorial, sinus problems account for 25 million doctor's office visits in the United States each year. Antibiotics are used to treat sinus infections 85 percent to 98 percent of the time in the United States.

Overuse of antibiotics not only won't help a patient with a viral infection get better, it will contribute to the growing problem of antibiotic resistance, experts have noted.

"Antibiotic resistance is rising dramatically, and there is no question about that," Baugh said.
For this study, 240 adults with sinus infections were randomized to one of four treatment groups: 500 milligrams of the antibiotic amoxicillin three times a day for seven days plus 200 micrograms of the nasal steroid budesonide once a day for 10 days; a placebo in place of the antibiotic plus budesonide; amoxicillin plus a placebo in place of budesonide; or two placebos.

In the amoxicillin group, 29 percent of patients had symptoms lasting at least 10 days, and 33.6 percent of those not receiving amoxicillin had the same symptom length of time.

In both the budesonide and no-budesonide groups, exactly 31.4 percent of patients had symptoms lasting at least 10 days.

The nasal steroids seemed to be more effective in individuals who had less severe symptoms.

As the editorial pointed out, most patients with acute sinusitis will get better on their own. Unfortunately, there's no good way to determine who has viral sinusitis and who has bacterial sinusitis.

"It's difficult to make a distinction in a primary-care setting," Baugh said.

If the symptoms are worse, treatment might be warranted, he added. "But for the bulk, I would assume it would be more of a wait-and-see approach. The bugs are winning," he said.

While researchers investigate possible new treatments, sinus infections sufferers might look to analgesics or brief use of steam inhalations, Williamson said.

Dr. William Morris, chairman and director of the department of osteopathic manipulative medicine at Touro College of Osteopathic Medicine in New York City, recommends an alternative approach: manual pressure to the bottom of the head and beginning of the neck, to allow better drainage from the head.

"One of the problems with sinusitis is that the sinuses tend to get closed up," he said. "If you don't drain properly, bacteria is just happy as a clam. If you can increase drainage and improve flow through the sinuses, you're going to be facilitating the process."