Splitting low dose of prednisone?

You could even try 12.5/12.5/10 split three ways denise👍👍👍👍

Denise - do you have PMR or GCA? Splitting is generally less to be recommended in GCA as that reduces the maximum anti-inflammatory effect. 35mg is a very high dose for PMR.

The recommended way of using pred in PMR and GCA is in a single dose as early in the morning as possible - for a good reason. The new supply of cytokines, the inflammatory substances that cause the inflammation, pain and stiffness in PMR especially, is shed in the body every morning at about 4.30am. The longer you wait after that before taking the pred the more inflammation will have developed and the so longer it will take to have a good effect. The concentration of the pred in a single dose also packs more punch - the higher dose is more effective.

Pred is excreted from the body relatively quickly, most is gone in just a few hours but the antiinflammatory effect lasts from 12 to 36 hours depending in the patient so the effect lasts until the next morning for the majority of people. Some find splitting the dose to take some at night helps with the morning stiffness - as does taking the dose at 2am! There are people who do that very successfully, especially at the low doses. The longer your body has without pred present the better it is with regard to side effects and, once you are below about 7mg and your body has to start producing its own corticosteroid cortisol again, then taking all the dose in the early morning is less likely to suppress the body's production so it helps the recovery of the adrenal gland function.

Eileen,Thank you so much for your response. Yes I've been diagnosed with PMR. I started off with 20 mg and we kept upping the dose until I start with relief.  Really felt the best at 40mg and lowered it to 35-30mg. I'm also dealing with Lyme and on 3 different kinds of antibiotics. So what 'm hearing from you is that it might be better with my high dosage of pred is to be taken all at once early in am. This is all so new to me and I appreciate all of you.

IitheHi eilleenh  -just reading posts regarding split doses and i take my 7mg at 2am--but my query is that  that my pills are 5mg coated and 2mg uncoated -so  how  does that work  if they are dispersed    differently-should i be maybe taking all  of them uncoated  in1 mgs -would  be grateful for  any input .jeanb

  I would like to try my Pred at bedtime or 2:00 am but at low doses (below 5 mgs) I'm worried about adrenal suppression as our adrenals are working again......and since fatigue is my second worst symptom I want to avoid making that worse. 

Eileen, I've made a note that you mentioned some study that found that taking 5 mgs of Pred in the evening suppresses the early morning cortisol production......and I want to avoid that happening. 

Im wondering as a compromise if I could split my dose but I don't see forum entries about people trying this who are on low doses. 

I Usually take my Pred at breakfast but it takes at least 2 hours for the aches to get better.  For the past 10 days I've been taking it about 4 am but by then my shoulders are already achy and keeping me awake and I have no improvement to how I feel the next day. 

Jean b: The 2mg uncoated will be absorbed and start to work in under a couple of hours. The 5mg coated ones will take probably 5 or 6 hours at least to start to work. The uncoated are absorbed very quickly so a graph of the blood level would show a spike whereas the coated ones are absorbed much more slowly and would form a rounded curve on the graph. This theoretically makes it possible to take the coated sort before going to bed and they would still work nicely the next morning. If you wanted to stop waking in the night you could try that - it's what I do with the special coated sort I take and they are designed to do just that.

4am is a bit late to prevent the early morning aches - the optimum time for that for uncoated pred tablets is 2am. To be honest - I suspect that 4am is early enough to suppress the adrenals a bit anyway so trying it earlier probably wouldn't make much difference to what you are now.

That is a very high dose for PMR, the recommendations for management of PMR say that more 30mg/day is not to be recommended - but I suppose if you also have Lyme it might affect things. The general feeling would be that if you needed 40mg that there may be something else going on besides "just" PMR - such as an arthritis. However, some people don't absorb or respond to pred as well as others and need a higher dose simply because of that.

PS to MrsCJ - forgot to say: your adrenal glands will start to work even at 5mg whatever time you take it and you have to worry less about suppression simply because you have been on so much for so long and you are going to have to wean off slowly anyway. The study was aimed more at people on short-term pred - once you have been taking it for more than a couple of months, whatever the dose, there is adrenal suppression.  

Could weight and size have any reason for the high dosage works better?

I'm tall and now obviously overweight!

Yes, size does matter - a study in Italy found that a starting dose of 12.5mg achieved a good result within a month in about 75% of patients - it was a justification for a lower starting dose - and the patients who did best were the small and dainty women as opposed to the larger men who were in the study. In the meantime, it is being felt that a higher starting dose gets a better longterm result - some years ago they started at as much as 30mg but then they got scared about the long term accumulated dose so lowered it. Now they are going full circle ...

Thank you Eileen

Eileen my other question is that I felt some relief from 20mg but much more @ 30mg Do you think I should have stayed on 20mg and try to deal with pain?

Probably not - but if you struggle to get down from the higher dose I think your rheumy should have a consideration of either something else or trying a different corticosteroid. Although the top experts have again recommended up to 25mg as the starting dose, with a maximum of 30mg. The idea is to later manage the pain as well as the starting dose - if 30mg does it better than 20mg that is where you need to be to get it under control as quickly as possible even though it is then further to reduce and the side effects are more. You shouldn't need other painkillers - they rarely work in PMR - but equally not everyone gets even 90% relief of their pain. 70% improvement in symptoms is felt to be pretty good - there are other things that can appear alongside PMR and I do write about them a fair bit. Myofascial pain syndrome is just one and it can be very similar to PMR in some aspects.

Hi Eileen,  hope you are resting and recovering from you trip. 

We talked about this but I am still confused.  I am at 5mg of pred and my cortisol and ACTH levels are low (1/2 minimum).  If the adrenals kick in around 7 or 8am would they not detect the cortisol from pred taken at 2:00am and not produce any more cortisol?  If there's not enough cortisol wouldn't they be more likely to be activated?  Sorry to be so thick but I have changed to taking my dose between 8:00 and 9:00am so don't want to mess things up.  I do notice more stiffness in the morning now. 

Hugs

Diana

Hehe - catching up with hundreds of emails so "resting" in front of the computer. And being prodded to plan our next trip - to the UK this time. The weather is going to be better here though I suspect...

I'm pm'ing you a link which I think explains the dilemma quite well in layman's terms. I will also put it up in another post in the hope that the Moderator will approve it as relevant.

Basically, yes, as long as we are taking some pred the production of ACTH and cortisol isn't going to be "normal" - and testing JUST cortisol or ACTH levels is meaningless, they will be suppressed because they know there is some corticosteroid present. The ONLY helpful test is an ACTH stimulation test, the synacthen test. It will show if your adrenal glands are CAPABLE of producing more cortisol given the right conditions - it doesn't mean they will, but does at least show that there is some point in continuing to reduce very slowly in the hope they will wake up fully at some point. You will see the article suggests a month for month recovery time - we have been on pred at a level sufficient to suppress cortisol production for years. It doesn't mean it will take years to recover full adrenal function but the possibility is there. The only way to go about it is to reduce in very small steps and at adequate intervals - and possibly accept a degree of fatigue. Excessive fatigue or other symptoms of adrenal insufficiency should result in a return to a slightly higher dose and a retry.

I'm sure she won't mind me saying, Nefret on this forum was diagnosed with adrenal insufficiency some years ago and knew she would be on a low dose of pred for life as replacement therapy. Recently she has had the dose increased from 5mg to 7.5mg because of symptoms - presumably there was still some adrenal function present at first that has now fallen off so that a higher dose of pred is now required. Normally it is said that 7.5mg is the physiological dose - the amount the body produces anyway. It shouldn't be associated with side effects - it is a replacement therapy. But it is also a problem with regard to stress or trauma/infection - the body may need more corticosteroid but can't make its own, you might need a booster dose if ill or under stress.

In the meantime, while taking the pred at 8 or 9am may result in a bit better return of function - if it then becomes combined with PMR stiffness and fatigue anyway is that a benefit? Many endocrinologists switch patients to hydrocortisone - you take 2 doses a day, most in the morning and a bit in the afternoon, as it has a shorter halflife plus that mimics normal production better. I suppose you could do the same with pred - 2/3 in the early morning and the rest in the afternoon but I think that may still be enough to interfere more with cortisol production than with hydrocortisone.

So does that help? Tell me if I'm not clear.

This is the link I mentioned - I hope it is approved for general consumption!

http://www.nadf.us/adrenal-diseases/secondary-adrenal-insufficiency/

I have a quick question about the adrenal glands waking up and doing their job at the end of treatment.  Are they more sluggish and less apt to get back to work the longer you are on the prednisone?  I am a born optimist!!!  I am hoping that I can get down very low at the end of a year.  Would things go back to near normal or normal, if a person managed to do this in a year?  I am one of those who chose to do methotrexate to help things along.  I was told that I can go down to 10 by fives  because of the MTX and then it will be the slower lower dose.  I am only in the beginning of my reduction.  I am down to 15 from 20 and have no pain or stiffness.  I am hoping to be at 10 by mid August and then begin the slow taper.  I will continue with the MTX.  I have gotten a bit confused.  I look to this forum for answers, I have tried to stay away from "Google" searches as it messes with my "optimistic" personaity.  LOL  Thanks, Donna

Why aren't we all prescribed hydrocortisone instead of prednisone?

Thank you, Eileen,  I have read this very informative article and placed a bookmark on it for turther reference.  As I said in my other post, I am hoping that perhaps with the help of the MTX I might get out of this earlier.  I know that most are probably thinking I have my head in the sand.  :-)

Because it would mean two doses a day, pred is only a single daily dose. It's all to do with the halflife in the body and how long it is then effective for. The fewer doses per day the better the compliance. Otherwise there is no difference above the physiological level - too much hydrocortisone is still going to inhibit adrenal function.There is a lady on the HU forum who is on hydrocortisone because she has fewer side effects with it.

You may or may not be able to successfully reduce by 5mg at a time because of the MTX - it all depends and it works for some and not for others. Even with MTX you may not get very low, in a year or any other time before the autoimmune part of PMR goes into remission. The MTX doesn't replace the pred, it just sometimes improves the result you get from a given dose and hopefully allows you to manage with less. There are no guarantees though - people try with MTX and then have a big flare. You need what you need, with or without MTX, and no-one can forecast what it will be. Not even a rheumy - whatever they may claim.

Yes, the longer you are on higher doses of pred the longer it is likely to take the adrenal function to return to normal but again it depends on the person. Some are on pred for years, reduce in tiny steps at the end and are fine. On average about half of people need pred for some 5 years, plus or minus a bit. About a quarter get off pred in under 2 years, well under sometimes, but they are more likely to have a relapse at some later date. A relapse is always on the cards - autoimmune disease is rarely cured, it just goes to sleep and you have no symptoms for a time but there is the potential for it to wake up, like Sleeping Beauty! 

If it's generally kinder to the body, I'd have thought it should be the med of choice.  Shouldn't we be offered it?  Some of us may have busy lives and not want the inconvenience.  Others, like me, don't have a life....

It isn't - the potential side effects are the same. It is a fairly specific problem the lady I mentioned has and hydrocortisone works for her. Another lady is on injections - because she has particular problems. 

You could ASK if you could switch to hydrocortisone, the dose is a bigger number to get the equivalent amount. No idea what the cost implications are. Many endocrinologists would use it below 5mg of pred as they feel it is easier to wean off and a few rheumatologists do so as well. I have seen the recommendation to switch to HC at that stage - but I'm not sure where I'm afraid.

Well if the side effects are the same there seems no reason to change, then.  I think I thought it was a less strong drug, which is why you'd need more to be effective, but by the same token it might do less damage to the rest of the body.  I really feel pred has been doing a number on me this past year.  It's been a fulltime job mitigating the side effects as I was determined not to need other medications.  Sigh.

Thanks, I willl continue to let my body tell me what it needs.  So far the split dose has really made my life so much easier.  I have been pain free for three weeks not since I started doing that.  It may not work for others, but it has been a miracle for me.  I noticed in your reply to Anhaga that you said that prednisone is is only a single dose med.  When I took the single dose, I was sore from about 4:00 a.m. until about 10:00 a.m. every single day.  Now with the split dose, never even a twinge.  I was a bit afraid to go down to 15, but still pain free.  I take ten in the morning and 5 at dinner.  I think that all of us react differently to these meds, sort of like some people are hightly allergice to penicillen.  I am just letting my body tell me how to handle this.  I am still able to take really long walks everyday and take care of keeping up my house.  I just came in from a two mile walk.   I would have walked further, but it is getting to be a rather hot day here.  I love alll of the info on here, thanks, Donna

yes, thank you  Will talk to rhuemy about hydrocortisone but I think I'll stay at 5mg of pred till I have the ACTH Stim test.  I'm really concerned about having another flare so want to make sure there is some activity there.   As always, patience, patience, patience

A lot of people find a split dose is better than a single one - the antiinflammatory effect lasts from 12 - 36 hours. If you are closer to being a 12 hour person your mornings will be uncomfortable until the pred works so a split dose makes sense. But until you try you don't know.

Thanks, that is what I found.  I began prednisone on May 2, it was only three weeks ago that I started splitting the dose and the change was immediate.  So, for my body, that is what works.  I actually take the doses about 9 hours apart.  This is because I take my thyroid med immediatly upon waklng.  I am not to eat for 1/2 to one hour after the throid.  So, by the time I am able to have my breakfast a bit of time has elapsed.  If it weren't for the thyroid med, I would have been able to eat as soon as I got up.  If a person chooses to take the thryoid at a different time, it must be two hours after a meal, so I have just found that I take that the second I open my eyes.  I have been on thyroid for 13 years, so that is a habit.  It really runs in my family from my mom, to me, my brother, and two of my children.  Until 13 years ago pretty much the only thing I ever took would have been my vitamins.   Thanks again, Donna

Thanks for this......i will worry less about my adrenals and focus on the best time(s) to take my Pred to minimize my symptoms. 

An observation:  I've always taken my Pred at breakfast and my aches start up about 4 am enough to wake me up. That fits in with lots of forum info about the cytokines at taking Pred at 2 am. 

For the last 4-5 days I've been taking my Pred at bedtime, about 11 pm. My day aches are significantly better but I've noticed I'm a little more achy in the evening. So maybe my Pred only lasts about 18-20 hours at my current 4 mg dose.  I'm looking forward to trying s split dose....easy to try and I'll know pretty quickly if it isn't for me.