Splitting doses

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.

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.

I take 1/2 of the dose very late at night, just before going to bed ( for me that is ~1AM) and second half when I wake up , 8 or 9 AM... From my experience, late night dose kicks in on time to prevent ( reduce) morning stiffness/pain.

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.

Hi​ TheRaven, funny your history much like mine. First flare up after sore throat and head cold, was doing great till that point. Had to go up 30 mg to get the pain under control. This is what is working for me 20 mg after breakfast, 10 mg just before bed. Split my Calcium and my Magnesium hours apart. I was taking Calcium at the same time, but EileenH, stated that the Calcium interferes with Predinisone being absorbed. Stopped taking together, feel much better, thank God. Good luck, hang in there!

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.

Someone mentioned that Calcium and Predinisone, interact. Yes, they do. I split my Predinisone 20 mg after breakfast. First Calcium 600 mg mid morning 2-3 hours after the Predinisone, second Calcium 600 mg after dinner. Before bed light snack, second Predinisone 10 mg. This is what currently is working for me. The sad thing is I have been on Phedinsone for 10 months, been to two doctors, an Endocrinologist and a Rheumatologist, both asked if I was taking Calcium, neither told me to not take the two pills together. If I had not come on this forum, I would be still taking them together.

SAD

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.