Critical appraisal of recent translational chronopharmacology and chronotherapeutic reviews, meta-analyses, and pragmatic patient trials discloses significant deficiencies of design and conduct and suspect findings

Figures & data

Table 1. ISC/AAMCC recommendations for design and conduct of prospective hypertension chronopharmacology and chronotherapy trials plus scoring system for rating such reports.

Protocol item	Statement of procedure	Score
Specific chronopharmacology and chronotherapy trial criteria
1. Inclusion criteria for patient recruitment	Reliance on wake-time OBPM or wake-time HBPM to certify subjects as arterial hypertensive	−0.5
	Recruitment primarily of properly controlled treated patients according to diagnostic thresholds for hypertension	−0.5
	Failure to require as inclusion criterion that participants have a confirmed similar activity/sleep routine	0
	Recruitment of hypertensive patients according to ABPM diagnostic thresholds (0.5), all with similar activity/sleep routine (0.5)	1
2. Tested treatment times	Arbitrary clock-time or spans of the 24 h (e.g. 08:00 h vs. 20:00 h, morning vs. evening, etc.)	0
	Surrogate markers of endogenous biologic-time (e.g. upon awakening vs. at bedtime of sleep/wake routine)	1
Specific BP measurement criteria
3. Primary BP measurement method	Wake-time OBPM	0
	Wake-time HBPM	0
	Around-the-clock ABPM by a validated and calibrated device	1
4. Primary ambulatory BP and other endpoints	24 h mean or daytime/awake BP mean	0
	Nighttime/asleep BP mean and/or sleep-time relative decline calculated using fixed common clock-time span across all subjects	0
	Dipping based on sleep-time relative decline derived from MAP or DBP, instead of only SBP	0
	Asleep SBP/DBP means calculated using the individualized activity/rest cycle per subject and SBP dipping (only if sleep-time relative SBP decline properly calculated from awake/asleep SBP means)	1
5. Intended ABPM duration	<48 h	0
	≥48 h	0.5
6. Calculation of ABPM-based mean values	Unadjusted (arithmetic mean) procedure	0
	Adjusted procedure	0.5
General criteria applicable to any clinical trial
7. Sample size calculation	Not done or mistakenly done	0
	Properly calculated	1
8. Study design	Non-randomized or crossover open-label without washout period	0
	Crossover (with sufficient washout period of ≥2 weeks) or randomized (PROBE or double-blind)	1

AAMCC: American Association for Medical Chronobiology and Chronotherapeutics. ABPM: Ambulatory blood pressure monitoring. BP: Blood pressure. HBPM: Home blood pressure measurement. ISC: International Society for Chronobiology. MAP: Mean arterial pressure. OBPM: Office blood pressure measurement. PROBE: Prospective, randomized, open-label, blinded endpoint trial. Sleep-time relative SBP decline, index of BP dipping, defined as percent decrease in mean SBP during the sleep span relative to mean SBP during the activity span, calculated as: ([awake SBP mean – asleep SBP mean]/awake SBP mean) x 100; participants are designated as dipper if the sleep-time relative SBP decline is ≥ 10%, and as non-dipper otherwise (Hermida et al. 2013b). The total score, utilized either to evaluate appropriateness of any given trial or to compare quality among trials, is calculated as the addition of the rating obtained for each of the eight listed protocol items (Hermida et al. 2021f).

Table 2. Comparison of patient sample size, quality of trial design and conduct, and rate of significant treatment-time dependent reduction of asleep SBP mean reported in ABPM-based efficacy studies categorized by location of coordinating institution.

Item	Galicia, Spain	Other locations	P between groups
Short-term ABPM-based efficacy trials	19	43
No. total patients, No.	3067	3008
No. patients per trial, mean±SD	161.4 ± 53.7	69.9 ± 125.7	0.003
Quality evaluation: Trials designed and conducted in keeping with ISC/AAMCC recommendations,* No. (%)
Patient inclusion criteria	19 (100)	20 (46.5)	<0.001
Tested treatment times	19 (100)	10 (23.3)	<0.001
Primary endpoints	19 (100)	22 (51.2)	<0.001
ABPM duration	19 (100)	3 (7.0)	<0.001
Calculation of ABPM parameters	19 (100)	4 (9.3)	<0.001
Sample size	15 (78.9)	4 (9.3)	<0.001
Study design	19 (100)	24 (55.8)	<0.001
Quality score per trial, mean±SD (−1=lowest; 7=highest)	6.79 ± 0.42	2.89 ± 1.25	<0.001
Trial categorization by sample size and/or quality score in keeping with ISC/AAMCC recommendations,* No. (%)
Higher quality trials score ≥ 4	19 (100)	14 (32.6)	<0.001
Trials with > 50 patients	19 (100)	15 (34.9)	<0.001
Trials with > 50 patients and score ≥ 4	19 (100)	7 (16.3)	<0.001
Trials reporting significantly greater asleep SBP reduction and/or increased dipping with bedtime dosing, No. (%)
All trials	17 (89.5)	24 (57.2)	0.006
Trials with quality score ≥ 4	17 (89.5)	12 (85.1)	0.832
Trials with > 50 patients	17 (89.5)	13 (86.7)	0.801
Trials with > 50 patients and score ≥ 4	17 (89.5)	7 (100)	0.949

*ISC (International Society for Chronobiology) and AAMCC (American Association for Medical Chronobiology and Chronotherapeutics) recommendations for the design and conduct of ingestion-time trials of hypertension medication (Hermida et al. 2021f) are listed in Table 1 of this article.

Table 3. Hygia Chronotherapy Trial vs. TIME study: Comparison of trial design, study methods, follow-up, and evaluation of results.

Methodology item	Hygia Chronotherapy Trial		TIME study
Design and timeline*	Trial design: PROBE Median follow-up: 6.3 years Recruitment: 09/01/2008–06/14/2017 Estimated completion date: 12/31/2020 Actual completion date: 06/30/2018		Trial design: PROBE Median follow-up: 5.2 years Recruitment: 12/17/2011–06/05/2018 Estimated completion date: 2021 Actual completion date: 03/31/2021
Sample size*	Calculated based on reported incidence of CVD events in the general hypertensive population (n = 10,700) and in participants complicated with either diabetes (n = 3,800) or CKD (n = 3,800) Participants:  Total required: >18,300  Referred by participating primary-care investigators: 22,654  Protocol-correct, with required > 1-year follow-up: 19,084  Used for final analyses: 19,084		Adjusted upward from 10 269 to > 20,000 participants to “achieve the necessary number of events needed.” Expected event-rate unreported Participants:  Total required: >20,000  Self-registered by internet: 24,610  Randomized to treatment-time: 21,104  Protocol-correct Participants: 11329 (see “drop-outs” below)  Used for final analyses: 21,104
Main patient characteristics and CVD risk factors upon recruitment†	Age, years:	60.3	Age, years:	65.1
	Men, %:	55.6	Men, %:	57.5
	Diabetes, %:	23.9	Diabetes, %:	13.1
	CKD, %:	29.4	CKD, %:	3.2
	Previous major CVD event, %:	10.4	Previous major CVD event, %:	7.0
	BP non-dipper/riser pattern, %:	49.3	BP non-dipper/riser pattern, %:	Unknown
	Current smoker, %	15.2	Current smoker, %	4.2
	Obesity, %	43.0	Obesity, %	Unknown
	Source of the information: Electronic medical history.		Source of the information: Self-reported by participants.
	Participants providing all information, including ABPM and therapeutic scheme, %	100	Participants providing all information, including office BP and therapeutic scheme, %	<37
Investigated treatment times	Individualized awakening vs. bedtime as surrogate markers of circadian time		Broad clock-time spans (06:00–10:00 vs. 20:00–00:00), unrepresentative of circadian time
Patient recruitment	By managing and prescribing primary care physicians, all comprehensively trained in ABPM procedures and registered investigators of the trial		Patient self-recruitment by internet. Prescribing physicians were not investigators and, by protocol, unaware of treatment-time allocation
Method of diagnosing hypertension for recruitment	48 h ABPM		Current antihypertensive treatment, based on daytime office BP, thus leading to inclusion of those with low-risk white-coat hypertension (masked normotension) and exclusion of those with high-risk masked hypertension mainly associated with sleep-time hypertension and non-dipping 24 h pattern
Hypertension treatment status upon recruitment	42.6% untreated, 57.4% treated Treatment scheme registered and thus known by the investigators for all recruited participants at baseline and during follow-up		100% treated Treatment scheme self-reported, only at baseline, by 7,856 (37.2%) of the randomized participants
BP status upon recruitment	Inclusion criteria required elevated ambulatory BP (49.3% of the participants had non-dipper/riser 48 h BP pattern); average daytime office SBP/DBP 149/86 mmHg, much higher than that of the TIME study		No protocol-specified BP measurement, ABPM never conducted. Most participants had already controlled daytime office BP (self-reported by only 46.7% of the participants; average SBP/DBP 135/79 mmHg) giving rise to high risk of misleading findings
Follow-up design	Centralized, with periodic (at least annual; more frequent in ABPM-based lack of BP control and high-risk participants) clinical visits with the patient´s primary care physician/investigator		Decentralized, with participants contacted only by email and study personnel/investigators unknown to them
Follow-up BP measurement	Periodic (at least annual) office BP plus 48 h ABPM assessment		None. Only a small proportion (36.3%) of the participants provided at least one home BP assessment
Other clinically relevant variables assessed during follow-up	Clinical laboratory testing of blood and urine, plus review of therapeutic scheme (medications, doses, and ingestion-time), clinical characteristics, and CVD risk factors and events at each clinical visit for 48 h ABPM		None
Antihypertensive therapeutic recommendations	No division of medications for ingestion as split doses. Multiple therapies prescribed, when available, as single-tablet fixed medication combinations to achieve higher adherence		Participants in the evening-treatment group ingesting a diuretic should take it at 18:00 h; if nocturia, ingest it in the morning. This compromises compliance and assessment of findings, as well as preventing use of single-tablet fixed medication combinations in the evening treatment group
Antihypertensive therapeutic adjustments during follow-up	Prescribed, if needed, by the participating primary care investigators, based entirely on findings of each of the 48 h ABPM assessments during follow-up		No described in the protocol. Assumingly, prescribed, if needed, based on daytime office BP, by the participants´ treating physicians, who were not investigators and, by protocol design, unaware of their treatment-time allocation
Antihypertensive medications and dosages during follow-up	Reported and registered at every clinic visit		Unknown, unreported
Adherence assessment	Morisky-Green test at each clinic visit for 48 h ABPM assessment to assess adherence to all prescribed medications and dosages according to the allocated treatment-time		Online questionnaire only for assigned treatment-time, not for actual intake of prescribed medications and dosages. Compliance with reporting and recall unknown. Reporting subject to bias
Safety assessment	Adverse events registered when reported by patient and/or revealed through non-direct questioning and physical examination by primary care physician		Patient reporting (compliance during follow-up unknown) by email. Extremely high adverse event rate (~70%); possible relation specifically to hypertension therapy and ingestion-time, unknown. Reporting subject to bias
CVD outcome reporting	By the primary care investigators, by scheduled periodic (at least annual) review of the complete electronic medical record of each patient		Mostly self-reported by the participants; linked to anonymized National Health Service records. Reporting subject to bias
CVD outcome adjudication	Independent events committee, masked to medical records, ABPM findings, therapeutic scheme, and treatment-time allocation		Independent endpoint committee, masked to dosing time allocation
Drop-outs and protocol violation	607 participants with invalid baseline 48 h ABPM and 84 participants without required >1 year follow-up at study closing; all excluded from analysis		A total of 46.3% of the recruited participants: 847 participants withdrew full consent, 2453 withdrew from follow-up, and 6475 reported non-adherence to dosing-time; nonetheless, the data of all these participants were included in the final analyses
Primary outcome comparison	By intention-to-treat for those with required > 1-year follow-up		By intention-to-treat, despite known up to 40% non-adherence to allocated (morning vs. evening) dosing time
Statistical analyses of primary and secondary outcome variables	Cox proportional-hazards model adjusted by significant confounders		Unadjusted Cox proportional-hazards model
Reported event-rates for composite outcome of CVD death, myocardial infarction, and stroke	3.3% for bedtime treatment 6.5% for upon-awakening treatment		3.4% for evening (20:00 h–00:00 h) treatment 3.7% for morning (06:00 h–10:00 h) treatment
Main trial conclusions	“Hypertension” (preferably, altered ambulatory BP, i.e., elevated asleep SBP and/or non-dipping) must be diagnosed only by 48 h ABPM. In patients with so-defined altered ambulatory BP, bedtime treatment improves BP control, particularly of asleep BP (strongest predictor of CVD risk), and reduces CVD risk		Further research is needed to advise on dosing-time of BP-lowering medications for patients with nocturnal hypertension or non-dipper 24 h BP pattern. No data and conclusions on effect of evening, compared to morning, treatment on asleep BP control and dipping pattern (ABPM was not incorporated into trial)
Other conclusions	No treatment-time difference in adverse effects, including hypotension assessed by 48 h ABPM. Excellent adherence and compliance to prescribed circadian dosing time (utilizing awakening and bedtime as surrogate markers)		Fewer participants in the evening dosing group reported adverse events. As expected, lower compliance with dosing at evening (20:00–00:00) vs. morning (06:00 h–10:00 h)

ABPM: ambulatory blood pressure monitoring. BP: blood pressure. CKD: Chronic kidney disease. CVD: cardiovascular disease. DBP: diastolic blood pressure. SBP: systolic blood pressure. TIME: Treatment in Morning versus Evening.

*Reported timeline and sample size information for the TIME study is markedly inconsistent in different published reports by the same main investigators. For example, Rorie et al. (2017) – in a paper submitted on June 16, 2017 – reported 31,695 self-registered individuals, 21,116 of whom were randomized, and recruitment ending on March, 2017. On the contrary, Mackenzie et al. (2022) reported 24,610 registered and 21,104 randomized individuals and dated end of recruitment on June 5, 2018.

^†(i) In the Hygia Chronotherapy Trial (HCT), all information extracted from the electronic medical record of each recruited participant; CKD defined as: either estimated glomerular filtration rate <60 ml/min/1.73 m², albuminuria (albumin/creatinine [Cr] ratio ≥30 mg/g_Cr), or both, on at least two occasions ≥3 months apart. (ii) In the TIME study, all information self-reported by the participants through internet and/or e-mail; CKD reported as unspecific “impaired kidney function”. (iii) Previous major CVD events of the HCT include: myocardial infarction, ischemic stroke, hemorrhagic stroke, coronary revascularization, and heart failure, the latter two not reported in TIME.

Hermida RC, Smolensky MH, Ayala DE, Portaluppi F, Crespo JJ, Fabbian F, Haus E, Manfredini R, Mojón A, Moyá A, et al. 2013b. 2013 ambulatory blood pressure monitoring recommendations for the diagnosis of adult hypertension, assessment of cardiovascular and other hypertension-associated risk, and attainment of therapeutic goals. Joint recommendations from the international society for chronobiology (ISC), American association of medical chronobiology and chronotherapeutics (AAMCC), Spanish society of applied chronobiology, chronotherapy, and vascular risk (SECAC), Spanish society of aAtherosclerosis (SEA), and Romanian Society of internal medicine (RSIM). Chronobiol Int. 30:355–410. doi:10.3109/07420528.2013.750490.

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Hermida RC, Smolensky MH, Balan H, Castriotta RJ, Crespo JJ, Dagan Y, El-Toukhy S, Fernández JR, FitzGerald GA, Fujimura A, et al. 2021f. Guidelines for the design and conduct of human clinical trials on ingestion-time differences – chronopharmacology and chronotherapy – of hypertension medications. Chronobiol Int. 38:1–26. doi:10.1080/07420528.2020.1850468.

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Rorie DA, Flynn RWV, Mackenzie IS, MacDonald TM, Rogers A. 2017. The treatment in morning versus evening (TIME) study: analysis of recruitment, follow-up and retention rates port-recruitment. Trials. 18:557. doi:10.1186/s13063-017-2318-4.

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Mackenzie IS, Rogers A, Poulter NR, Williams B, Brown MJ, Webb DJ, Ford I, Rorie DA, Guthrie G, Grieve JWK, et al. 2022. Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomized, open-label, blinded-endpoint clinical trial. Lancet. 400:1417–1425. doi:10.1016/S0140-6736(22)01786-X.

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