Splitting doses
Posted , 9 users are following.
Without going through the whole tale, my 7 months on Prednisone have been equal parts pain free and painful. A cold or virus threw everything out of whack about a month ago and the Rheumy and I have struggled to get me at a dose level that keeps me pain free again.
For the last short while I've taken 20 mg of Pred each morning and that has done a good job on the pain and inflammation but seems to wear off around 2-4 am, before I take my next dose. On 1/2 to 3/4 of the mornings I'm pretty crippled by the pain/inflammation for 6 hours until the morning dose of prednisone kicks in. I'll be seeing the rheumy next Thursday and I'm sure he'll want me to split the dose (we did this before with moderate success) so I have better results over the full 24 hours. How to split the dose is where he and I differ.
I think I should take the 20 mg in the morning and then take 10 mg when I go to bed. This way I should go to sleep before the 10 mg kicks in and it should help keep the pmr down until my morning dose of 20 mg.
The rheumy literally splits the dose, having me take 10 mg at 6 am and another 10 mg at 6 pm. We did this before with moderate success but I don't think that gives me enough and also makes it difficult or impossible to sleep because the evening dose is at full effect about the time I go to bed.
Thoughts anyone? How have you split doses? I don't really care about lowering my prednisone dose at this point. I just want to try and be pain/inflammation free for more than a few days at a time. I figure once I get on a stable, effective dose I can start thinking about reducing again.
0 likes, 12 replies
EileenH TheRaven
Posted
Many people take about 2/3 in the morning and the rest at some time - it doesn't HAVE to be 12 hours later and sometimes just a few mg in the late afternoon is enough to make the difference.
HOWEVER - the 4am timing of return of pain is normal (inasmuch as anything is normal in PMR) - that is about the time the daily dose of new inflammatory substances is shed in the body and starts up the inflammation again. A study showed the optimal time to take the pred is 2am so it is ready and waiting at its peak level in the blood at 4am . The alternative to a 2am dose is taking asap after 4am - waking early, taking the dose and settling down for another couple of hours allows it to start working and the earlier you take it the less inflammation is established to be combatted.by the pred. You are saying though that you will up the dose to 30mg/day - of course it works better!
And the other "however" is - exactly what time does the pain start? And is your rheumy REALLY sure about teh PMR diagnosis? Because pain starting earlier in the night than 4am, especially about 2am, is typical of ankylosing spondylitis which is often mistaken for PMR in the early stages by rheumies looking for horses and not zebras. There are 2 or 3 people on the forums who originally had diagnoses of PMR but when it came to reducing they had problems - because while AS responds quite well to higher doses of pred there are far better drugs to manage it. Just a thought.
TheRaven EileenH
Posted
It can vary but on a bad night the pain starts usually in the 3-4 am range. I'd be surprised if I had AS - the main pain areas don't match and I see that the typical onset age is much, much younger. There's exceptions to everything but I'd doubt it was AS.
EileenH TheRaven
Posted
One of the ladies who used to be on another forum first had GCA but it wasn't diagnosed as such, "just" PMR. She never managed to get the pred dose down below about 10mg without problems. She had useless rheumies in her part of the southeast of England and eventually travelled a few hours to see one of the PMR experts in the north. She looked at everything with MRIs etc and it did look very PMR-ish. Until one day she mentioned night pain - typical of AS - and extra imaging and blood tests were done: AS. She is in her early 50s now, was late 40s at the outset. She is doing so much better on the anti-TNF drug and Arcoxia. There is one form that is very disseminated and really could well be PMR.
Unfortunately there are these received wisdoms that a few things are found in a particular age group - not always...
Michdonn EileenH
Posted
Thanks again ☺☺
Nefret TheRaven
Posted
But if, in your scenario, you are taking 20mg + 10mg, you are not splitting it are you? You're just adding another 10mg into the equation. And a total of 30mg is quite a whack.
From my own experience and from what I have gathered widely, your consultant is right. If you are going to split the dose then that is two halves of your current dose. Some patients choose to take 2/3rds of the dose in the morning and the other third at bedtime, which doesn't interfere with sleep so much. Perhaps that would suit you better.
nick67069 TheRaven
Posted
Everyone has their own internal clock. You need to experiment with timing, but keep the total dose at 20mg. maybe it was a typo, but your plan to split 20 into 20+10 is incorrect and would increase your daily dose from 20mg to 30mg.
Michdonn TheRaven
Posted
Anhaga Michdonn
Posted
Prednisone prevents calcium from doing its job. They interfere with each other. I blithely took the two together the first three months I was on pred and hence at my highest dose. Wouldn't you think the pharmacist might have mentioned prednisone is incompatible with calcium given that we are all recommended to take calcium supplements when on pred.
TheRaven Michdonn
Posted
Yes, it sure does sound like our pmr history is similar! Interestingly, I had sent the rheumy an email this morning (our health system has a nice "mychart" program that lets you access lab results and send messages to your doctor anytime. Nice when running into issues between appointments) giving him an update on how things had been going since he blasted me with 30 mg on the 12th and then dropped me to 20 mg on the 17th. He responded a bit ago, saying to stick with 20 mg in the morning but add 10 mg evening. He didn't explain but I'm thinking he's of the same mind - knock the pain out even if going up to 30 mg again and then take a fresh look at the appointment next Thursday. Won't get an argument from me. Glad to see you and others mention about calcium timing - I'd been taking mine the same time as the pred. I'll do the same and kick the calcium a few hours down the road before taking.
maid_mariane TheRaven
Posted
Hi there
I've split my dose since day one but i take my afternoon dose at 3pm.
My runi says your afternoon dose should be no more than 1/2 your morning dose.
I'm at 13mg take 9mg am and 4 mg at 3pm. When at 20mg took 15mg am and 5mg 3pm. So as you can see dropping my morning dose when tappering.
Hope this helps.
Michdonn TheRaven
Posted
SAD
artfingers TheRaven
Posted
As I'm sure Eileen will tell you in much more accurate detail. But I found for me it is useful to split it by taking half the dose at 10pm (after a light snack) if you can get the coated pred (called Rayos in the U.S.) not sure what it is called where you are. That way it starts to kick in by 2am when the cytokenes (sp?) kick in. Then I take the other half which is just regular prednisone when I wake up in the morning with breakfast. I take mine when I wake up around 8 or 9am, depending on the day. Works well for me. Below is what I copied from another post from Eileen that has info on this. Private Message me if you want more info I have copied from previous posts on this that Eileen has posted. They are quite detailed and helpful on split doses. I think we should have a way to sort all these posts by category - easier to find in a "search". My two cents.
Anyway, here is what Eileen wrote on a previous post:
·
o The release of the Rayos is dependent on the gut conditions - you take it within 3 hours of food or with a snack at 10pm. The cytokines don't peak a certain time INTO sleep time, they peak in the morning along with the circadian rhythms. Circadian rhythms are physical, mental and behavioral changes and they follow a roughly 24-hour cycle mainly influenced by light and darkness in an organism's environment. That is one of the problems with jet lag and shift work - which can quite severely affect the body both in the short and long term. If you want to change them then it requires far more than a change in what time you go to bed or how long you sleep.
There are dozens of different cytokines (one study alone looked at 42) - the ones the pred appears to have an effect on are the ones that cause morning stiffness in RA and PMR and they happen to be released about 4.30am. One thought likely to be involved in PMR/GCA is also released in response to surgery or trauma - which possibly accounts for flares in those situations. It also is "knocked out" by tocilizumab - so possibly the mechanism for that working in GCA (if it turns out to do so). But the real mechanism isn't known - these cytokines have only been identified since the 1980s - and to some extent the management is a case of trial and error. It is known though that pred works and works reliably at the right dose.
If you are on pred then actually it is a medical reason NOT to be made to work night shifts because of the effects on the body. One lady on the forums who had GCA in her late 40s/early 50s has been told she will never be expected to work more than a couple of night shifts in a row because of the stress this puts on her body and the risk with regard to GCA.
With ordinary pred, the blood level peaks about 2 hours after you take it, irrespective of whether you are awake or asleep. Then it is excreted from the body over the next few hours. So 2am is the ideal time to take pred for this early morning dose of cytokine activity - and that was why Lodotra was developed, to save patients waking to take the ordinary stuff. Lodotra has a coating that disintegrates all at once after 4 hours in the right conditions, dumping the entire dose in the gut, in a similar way to ordinary pred, though further down the gut so I assume that is also taken into consideration. There is also enteric coated pred in the UK - an acid resistant coating that ensures the pill passes through the stomach before being absorbed - the profile in the blood with that is not a peak which rises quickly and then falls off slowly, it is a more gentle rise and fall spreading the blood level over a longer period - which can be an advantage or disadvantage depending on what it is being used for. Theoretically, you could use that in a similar way - and there was an intention to see how that worked compared to Lodotra - but the company wouldn't agree to provide the samples. Which does make one a bit suspicious that they know there isn't going to be much difference! And enteric-coated pred is pretty cheap - not significantly more expensive than ordinary white pred.