Split dose tapering below 6 mg pred

[Joydeck]

I was diagnosed with PMR last October. I tried lower doses of prednisolone but ended up on 24 mg, split 17/7 taken after breakfast and tea. On just a morning dose, I had PMR pain until sunset because the pred always takes ten hours to work.

This year I have been pain free. Recently I have tapered 1.25 mg a month, split 50:50. In the past fortnight, an attempt to take my 6 mg, split 4/2 has resulted in some PMR shoulder pain. Returning a few days ago to 2/4 split, I am again pain free.

Should I phase out the morning dose entirely?

[PMRpro Ambassador]

All you can do is try it and see what happens. If your pred takes so long to work - have you tried taking it before bed?

[Joydeck in reply to PMRpro]

I take pred after breakfast and tea but these meal times and my bedtime are far from fixed. Anyway, I'm symptom free. Taking pred at bedtime is less convenient as pred shouldn't be taken on an empty stomach.

From the first, reducing my evening dose has led to PMR pain from early morning until late afternoon.

[DorsetLady PMRGCAuk volunteer]

It entirely up to you, but why alter something if it’s working.

[Joydeck in reply to DorsetLady]

I suppose I could continue the split dose down to 1 mg pred but once a day would be more convenient as I have been taking low-dose aspirin at lunch time to better protect my stomach lining.

I also wonder whether a low split dose might impair the return of my natural adrenal function.

[PMRpro Ambassador in reply to Joydeck]

You are on such a low dose I doubt the 2mg in the evening will make any difference in the split dose. The original study found 5mg at night did suppress the morning adrenal spike - so putting it all in the evening might do so.

[Joydeck in reply to PMRpro]

If I do move to an evening only dose, I guess I'll incur pred major withdrawal symptoms below 5 mg. If so, I can then move to just a morning dose without delay.

A few months back, I recall reading of someone who did taper successfully with only an evening dose. (Specialist advice is not perfect.)

[PMRpro Ambassador in reply to Joydeck]

"Specialist advice is not perfect" - er, no. You could say that ...

[SheffieldJane]

Can I ask what kind of Prednisalone you are taking? Several hours seems an awfully long time to wait for relief. Have you ever tried the 2 am method, to stop the inflammatory substance at source?

[Joydeck in reply to SheffieldJane]

I am taking uncoated prednisolone. The ten hours for PMR pain relief could be related to my very high fiber diet or to my heavy exercise regime. It has always been ten (even when I forget a tablet).

My early and brief attempt to take a single pred dose at 2 am was an abject failure.

[SheffieldJane in reply to Joydeck]

I know that I process food slowly but drugs quick quickly. Whatever you are doing seems to work well for you. I am sure that you will figure out a regime for the last lap.

[ConventCassie]

I split mine 50/50, or the greater one at night. I take it at 7:30 am and 11:00 pm.

[Joydeck in reply to ConventCassie]

A 50:50 split dose has long worked for me although I often wonder whether 30:70 would have worked better. I take pred after breakfast and tea, the times for which vary greatly. The timing of my split dose seem immaterial.

[ConventCassie in reply to Joydeck]

I’m consistent with the times. I usually have a dried prune or 2 for the morning with meds & go out & walk & stretch before breakfast. I think consistency helps?

[DorsetLady PMRGCAuk volunteer in reply to Joydeck]

Would agree with ConventCassie that consistency is probably more important. Pred doesn’t need to be taken with a big meal, it can be taken with yogurt or something lighter. You might get a better result if you stick to taking your evening dose at a regular time.

I took aspirin after breakfast along with Pred - not aware it needs to be taken at a different time.

[Joydeck in reply to DorsetLady]

Inconsistent dose times has worked well enough down to 6 mg as I have been symptom-free all year.

From Drugs,com: "Using aspirin together with prednisone may increase the risk of side effects in the gastrointestinal tract such as inflammation, bleeding, ulceration, and rarely, perforation." However, a 2012 study suggests this risk is low: "Prednisolone aspirin "Clinical Impact of Drug–Drug Interaction Between Aspirin and Prednisolone at a Cancer Center?"

[DorsetLady PMRGCAuk volunteer in reply to Joydeck]

That’s why you are given a PPI as well (Omeprazole, Lanzoprozol or similar)

[PMRpro Ambassador in reply to Joydeck]

The use of low dose aspirin is - according to Prof Dasgupta - to be removed from the recommendations for management of GCA when the new guidelines come out.

[Sandy1947]

Used to split my dose but Rheumatlogist suggested taking all at once once I got to 6. She said it was more effective. Hit some bumps reducing to 5. Starting again this week. Sounds like you’re doing what works for you.

What’s your heavy exercise regime?

[Joydeck in reply to Sandy1947]

Your dose all at once in the morning, I presume.

As for heavy exercise, every week I play 8 hours tennis, 3 hours badminton, an hour jogging, 5 hours cycling, 3 hours aerobics (Body Attack and CXWORX), 4 hours gym, an hour in-line skating, and a dozen days skiing in winter.

[Sandy1947 in reply to Joydeck]

My doctor has me take it at 5:00 am all at once to minimize side effects. I didn’t gain weight, but I’m edgy, have a few purple marks on my arm that seem to be fading, I’m hungry all the time with cereal and 2 squares of very dark chocolate being my worst food vice. I cut out all alcohol and do watch sugar intake.

You certainly maintain a serious exercise routine. It’s amazing you do all that with PMR. Pred has weakened my ability to lift 10 pound weights so I do 5-8. I do Zumba, African dance and walk 3-6 miles a week. I have had stress fractures in both feet and now I have inflammation in my left foot. Doc wants to give me a cortisone shot but I’m afraid.

[Joydeck in reply to Sandy1947]

Purple splotches is my lone side effect from pred. I'm as fit as before PMR.

I have been trying in vain to gain weight ever since I lost a few kg in my month with untreated PMR. Instead of chocolate, I crave cacao nibs. For decades, I only eaten what's good for me although I have, long ago, made serious mistakes with whole grains, which I now limit.

Cortisone shots, I think, are desperate measures. Strengthening exercises often help...eventually.

[Sandy1947 in reply to Joydeck]

I bought cacao nibs and find them to be terrible straight up! I add to cookies made from 2 bananas, 1/2 cup unsweetened coconut and those tasteless pellets you like. The cookies are just OK.

I lost weight at onset of PMR...103 pounds. Now I’m 108.

I am maintaining my exercise routine but not to intensity pre diagnosis. I feel Pred has weakened my muscles. My attention span is so short, I tend to leave a class half way through.

Today I’ll force myself to stay an hour for Zumba!

[Joydeck]

Daily, I have a light sprinkling of cacao nibs, pine nuts and cereal (usually brown rice, quinoa or oats) on unsweetened skim-milk yoghurt, chopped fresh fruit, and frozen blueberries or raspberries. Extravagant?

I tried Zumba but once.

[Sandy1947 in reply to Joydeck]

Sounds delicious! I’ll give the cocoa nibs a sprinkle on cereal!

[Joydeck]

An update. As it happens, split dosing had much less to do with my PMR pain than a tapering flare as I dipped below 6.5 mg pred.

This mild flare is is my first since tapering from 20 mg at Christmas. All last week I was back to 7.5 mg but still have an some ache in the upper arms. Thankfully, the pain has been insufficient to impact on my heavy exercise regime.

In retrospect, I should have retreated 1 mg without delay. One learns best by experience. Don't anyone say, "I told you so!"