Tuesday, February 5

Timing Your Medical Treatments for Better Health: The New Science of Chronotherapy

William J. M. Hrushesky, MD

Stratton VA Medical Center

Special from Bottom Line/Health

iologists now know that almost every aspect of human physiology -- from body temperature to hormone levels to immunity -- is regulated by an internal clock.

An emerging science known as chronotherapy (or medical chronobiology) uses this fundamental knowledge to determine the best time to administer various medical treatments.

Chronotherapy researchers have made significant strides in recent years. Among their most important findings...

CHRONIC PAIN

Almost everyone with chronic pain suffers according to the same schedule. Pain levels tend to be tolerable early in the day, then rise to a peak between 3 p.m. and 10 p.m.

Problem: Few doctors take this pain cycle into account when prescribing painkilling medication to their patients. Instead, they simply put every patient on the standard two- or three-times- a-day equal dose of long-acting pain medication.

The typical result? A fog-brained "medication hangover" in the morning... and incomplete pain prevention throughout the rest of the day.

If you take daily pain medication: Ask your doctor about finding a dosage routine that takes the daily pain cycle into account. The best approach for many patients is to take one large dose of long-acting pain medication before lunch and a small dose at bedtime.

CORTICOSTEROID THERAPY

Corticosteroids work by duplicating the action of the adrenal hormone cortisol. Oral forms of these powerful anti-inflammatory drugs are used to treat arthritis, inflammatory bowel disease, asthma, emphysema and chronic bronchitis, lupus and psoriasis.

Trap: Long-term use of oral corticosteroids can cause severe side effects, including reduced immunity, osteoporosis, high blood pressure, diabetes, cataracts, weight gain, fluid retention and thin, easily bruised skin.

Side effects are especially common when patients take corticosteroids the way many doctors recommend -- in multiple equivalent doses throughout the day.* This regimen severely depresses normal adrenal function.

Solution: Ask your doctor about taking one dose of corticosteroids early in the morning. That boosts the drug's effectiveness and limits side effects, since the body ordinarily releases most cortisol around 5 a.m.

CARDIOVASCULAR DISEASE

More than 60% of all heart attacks occur between 6 a.m. and noon. Angina attacks and stroke are also more common in the morning.

A quick look at the chronobiology of the circulatory system tells the story. In the morning, blood pressure rises sharply in preparation for getting out of bed... blood clots more easily... more stress hormones pour into the bloodstream... and foam cells -- immune cells that gobble up cholesterol and turn into plaque -- are more active.

If you have high blood pressure, ask your doctor about taking one of the new "before bedtime" blood pressure drugs, Covera-HS or Verelan PM -- different formulations of the prescription medication verapamil.

If you have angina, keep a daily log of your symptoms. Ask your doctor about customizing your medication schedule to prevent episodes.

Helpful resource: Dr. Prakash C. Deedwania’s 1997 book, Circadian Rhythms of Cardiovascular Disorders (Futura Publishing).

ARTHRITIS

For most people with osteoarthritis, pain worsens as the day goes on. The usual approach to controlling the pain is to take a nonsteroidal anti-inflammatory drug (NSAID) such as aspirin or ibuprofen (Advil).

Unfortunately, these drugs are tough on the digestive tract.

To minimize the amount of medication you take: Ask your doctor about taking one dose with lunch and another late in the afternoon. This should also boost its effectiveness. Evening doses are less likely to cause digestive trouble.

With rheumatoid arthritis, joint pain and swelling tend to be worse in the morning. If your medication is a NSAID, taking a dose before bed will help diminish morning stiffness. If you’re on a corticosteroid, talk to your doctor about the dosage schedule described above.

ALLERGIES

Allergy drugs are notorious for causing problems. Conventional antihistamines often cause grogginess during the day, and nonsedating varieties are costly. Decongestants can leave you wide awake at bedtime.

To control allergies without upsetting your body clock, ask your doctor about taking your decongestant first thing in the morning. Antihistamines should generally be taken after dinner or at bedtime.

ASTHMA

Asthma attacks are 100 times more common in the early morning hours than they are at other times of the day.

To deliver antiasthma medication when you need it most, drug companies have developed long-acting versions of the airway muscle relaxant theophylline, which can be taken at bedtime. Ask a doctor which of these medicines is best for you.

MAMMOGRAPHY

Twice as many cancers are missed if the mammogram is done during the luteal phase of the menstrual cycle (days 15 through 28) than during the follicular phase (days one through 14). Redistribution of water and fat in the breast during the luteal phase makes tumors hard to find.

Better way: Schedule mammography for the first half of the menstrual cycle.

BREAST CANCER SURGERY

Premenopausal women who undergo breast biopsy, lumpectomy or mastectomy during the luteal phase have a 25% lower risk of death from metastatic breast cancer during the 10-year period following surgery than women who have the surgery earlier in their menstrual cycle.

Bottom line: Any woman facing breast cancer surgery should discuss the timing of the operation with her surgeon.

CHEMOTHERAPY

Scheduling chemotherapy at the right time of day -- what time depends on the particular drug -- can minimize the damage done to surrounding tissue by six- to eightfold. More important, it can increase the cancer-killing effectiveness up to fourfold. If you’re facing chemotherapy, make sure your oncologist is familiar with these and similar findings.

*The only reason to take corticosteroids throughout the day is if you have cancer or another life-threatening disease that has been proven to require multiple daily doses.

First Printed: July 1, 2000

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Bottom Line/Health interviewed William J. M. Hrushesky, MD, senior attending oncologist at the Stratton Department of Veterans Affairs Medical Center and a professor of medicine at the Albany Medical College, both in Albany. For more on chronotherapy, see his Web site at www.rpi.edu/˜hrushw. He is the author of Circadian Cancer Therapy (CRC Press).

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