The Dead Slow and Nearly Stop approach to pred reduction:

[PMRpro]

I have been asked by someone to post this reduction plan on this forum. It is long to try to make it understandable - those of you who use word processing will be able to copy and paste it into a file on your computers to read again and again. I have left it as it is for the PMR forum (polymyalgia rheumatica) but reducing pred is reducing pred - the slower you go the fewer problems you will have reducing if you have been on pred for a long time (more than a few months). Some bits may not apply for lupus - but I'm not very knowledgeable about lupus so I'll leave that to you.

"Reducing pred: dead slow and nearly stop"

In an attempt to make this reduction scheme available more simply to the people who request it I am posting it here where it can be found easily. I hope noone minds but I have copied and pasted it what feels like dozens of time!

"A group of us worked out reduction schemes individually that have allowed us to reduce far further than ever before but they are all basically the same - and they were based on a scheme a Swedish gentleman worked out when he simply couldn't get below 3mg without pain. Img at that level is 33%, 1/2mg is 17% - way above the 10% that has been recommended for years. So he used table to see the daily doses and took the new dose on one day, old dose for a few days and then proceeded by repeating that and then reducing the number of days of old dose - until he got to everyday new dose. It worked, he got off pred and has been off pred for at least 3 years (it could be longer). Something similar to mine is being tried by a consultant rheumatologist in the north of England and he too finds it works for every single patient he has given it to. As it did for several ladies beforehand. It is also now being used in a clinical study in the UK.

My reductions are VERY slow. I use the following pattern to reduce each 1mg:

1 day new dose, 6 days old dose

1 day new dose, 5 days old dose

1 day new dose, 4 days old dose

1 day new dose, 3 days old dose

1 day new dose, 2 days old dose

1 day new dose, 1 day old dose

1 day old dose, 2 days new dose

1 day old dose, 3 days new dose

1 day old dose, 4 days new dose

1 day old dose, 5 days new dose

1 day old dose, 6 days new dose

By that stage if I feel OK I feel safe to go all new dose. I suppose you might be OK starting and stopping at "1 day new, 4 days old" but I was terribly sensitive to steroid withdrawal pain so I err on the safe side. Once you get to the "everyday new dose" - if you feel OK you can start on the next reduction, no real need to spend a month at the new dose.

This avoids steroid withdrawal pain - which is so similar to PMR pain that you often can't tell which is which and some of us suspect that many flares are NOT the PMR returning but problems with steroid withdrawal. Using a scheme like this also means you can stop immediately if you have any problems - you might be fine at one day old dose, 2 days new (lower) dose but not at a 3 day gap - but you have dropped your dose a lot and that is the idea. It also isn't as slow as you would think - you can reduce at a rate of about 1mg/month on a continual basis.

The Bristol group start new patients with PMR with 6 weeks 15mg, 6 weeks at 12.5mg and then a year at 10mg before continuing the reduction and that achieves a far lower rate of flare (20% instead of 60%) and I suspect their flares then come below 10mg as they then do the 1mg at a time reduction. Just below 10mg is a common dose for people to get stuck at - and I (and others) believe it is because even 10% drops are too much for many patients. These patients are then labelled as "steroid resistant" or told they need methotrexate to help them reduce but we have seen this slow reduction work for those patients too. We believe that methotrexate (MTX) works for patients who have late onset rheumatoid arthritis (LORA) or LORA and PMR together. Very few patients get off pred altogether when taking the MTX - those who do are probably the mis-diagnosed LORA patients - or another arthritis that responds to MTX.

When you are at doses below 5mg it is a good idea to rest at each new dose for a month at least before trying the next reduction. At this point you risk overshooting the dose that is controlling the inflammation so waiting a short time to see if symptoms reappear is helpful. If you just continue there is a possibility that you get to very slightly below the "right dose" and inflammation will start to reappear very slowly. The blood tests will lag even further behind the dose reduction - there must be enough inflammation to increase the proteins being measured for the blood tests to rise.

Contrary to the beliefs held by many doctors it is NOT a race to reduce the pred dose. Doing that will lead to flares, needing to go back to a higher dose and starting again - and the end result is you took MORE pred than if you had reduced more slowly.

[Barnclown]

THANKS SO MUCH! INVALUABLE! Have been wanting clear concise instructions like yours! I do know several v experienced long-term patients who manage their pred similarly, but none have explained it so beautifully 🌟👏👍👌✌️🍀

[LUPUSadmin]

Thanks for sharing this PMRpro. I'm pleased that this has worked well for you. We would encourage people to talk with their doctor before attempting to reduce their dose of prednisolone.

George

[Hidden]

I used this Bristol method and got off Pred without problems after six months on it. My GP was reasonably helpful about this.

However, following a recent post about this on the RA HU I just wanted to add that a similar approach should be adopted when coming off Duloxetine/ Cymbalta. My GP told me that I could come straight off it as I was already on lowest dose. I did as he advised and all hell broke loose - it was a scary time of heart pounding anxiety, intense nausea, a terrible headache and retching constantly. In the end, at a psychiatric nurse friend's advice, I went back onto it, emptied the capsules out a little more one day and then back up the next day and so on until I finally got off after about two weeks.

[misty14]

Hi PMpro

Many thanks for posting this different steroid withdrawal plan. Very HELPFUL, as I'm struggling to get to 10 mg!. Will talk to my docs about it. Hope your well. X

[Penelope-Mary]

Need to Reread and digest slowly 👏🏼👏🏼

[Cookiecutter76]

Thank you! I'm stuck at 5mg and really needed some advice as to how to proceed. (No doctor I've asked has been this useful unfortunately!)

[PMRpro in reply to Cookiecutter76]

Very few of them have had to do it themselves have they? We have read the book, got the t-shirt and seen the film. So we know the real truth - slowly does it!