Low dose pred timing : Hi All. I've just read a... - PMRGCAuk

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Low dose pred timing

Jontie
Jontie

Hi All. I've just read a pinned post re pred timing. It explained the advantages of taking pred at night. However the last para said this might not be advisable for low doses. Could someone explain why please?

By the way, I've been on pred for 3.5 years. After many unsuccessful attempts at reducing below 5mg I've finally managed to get to 3.5 without too many adverse effects. Ironically, if it wasn't for coronovirus my consultant would have put me on methetrexate by now. I've always taken my gastro resistant (presumably slower release?) pred before I go to bed. But having read the pinned article I'm wondering if I should switch to taking it first thing in the morning?

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DorsetLady
DorsetLadyPMRGCAuk volunteer

If I were you, I’d stick to evening with your slower release meds, especially if that suits you.

I’m guessing, that some concern is that taking them at night may interfere with the normal production of cortisol, which varies throughout the day. See below -

Blood levels of cortisol vary throughout the day, but generally are higher in the morning when we wake up, and then fall throughout the day. This is called a diurnal rhythm. In people that work at night, this pattern is reversed, so the timing of cortisol release is clearly linked to daily activity patterns.

Not sure how much the evening dose will upset your system working correctly, if at all, but the last thing you want is to upset your PMR by changing medication times.

Sure someone with better medical knowledge will be along idc.

Hidden
Hidden

DorsetLady is correct. It is "recommended" to take it once in the morning. The biological clock that synchronizes with biological rhythm may be endogenous or exogenous. "Endogenous" cortisol is released in the early morning so taking "exogenous" pred at that time simulates the normal cycle.

I think you need to do what you need to do. For a long time, I didn't have any choice but to take it at 3-4 am because I would wake up in extreme pain. If I got pred "on board" by 4 am, I would be ready for work at 7 am.

However, I had another autoimmune disorder where that approach didn't work at all. In that case, inflammation inside my eye was the problem. Believe it or not, I could actually see the inflammation. It was interesting because it didn't matter how big a dose (100 mg sometimes) that I took in the morning the inflammation inside my eye would only slightly clear up by the afternoon. When I went to bed, I would wake up the next morning with even more inflammation inside my eye. That's when I discovered splitting the dose made a big difference. I usually did 2/3 of a dose in the morning and 1/3 in the evening. When I did that, whatever gain I achieved by the afternoon was maintained overnight. My ophthalmologist was amazed but said that I should keep doing it.

Jontie
Jontie in reply to Hidden

Interesting. Hadn't thought of splitting the dose. May be best of both worlds. Cheers.

Hidden
Hidden in reply to Jontie

That's not "recommended" but it worked for the inflammation in my eye and also helped the overnight pain. There is a secondary spurt of endogenous cortisol in the afternoon that is part of the normal cycle. In my opinion, the second smaller dose of pred simulates that.

PMRpro
PMRproAmbassador in reply to Jontie

Splitting the dose with e/c pred is rather more complicated - you have to allow for the considerable delay in the absorption which is anything from 4 to 7+ hours longer than with plain pred

Hidden
Hidden in reply to Jontie

Sorry, I didn't notice that you were taking the gastro resistant variety. I have never taken that kind before. So much of corticosteroids is about the timing. That is why exogenous corticosteroids can never replace the endogenous cortisol that your adrenals produce. Your body needs it when it needs it (increase stress, infections etc.) and unless you are very clever nobody really knows when that is.

Jontie
Jontie in reply to Hidden

No worries. I appreciate your input 👍

PMRpro
PMRproAmbassador

No, I wouldn't. I'd say what you are doing is perfect.

Most people would be taking plain pred and before bed at (say) 10pm. Plain prednisolone is absorbed within an hour or so, the peak in the blood will be just before midnight. e/c coated pred taken at the same time won't be absorbed until well after midnight, about 4 hours later than the plain variety so the blood level at midnight will still be low.

A low level of corticosteroid at midnight is the signal to the feedback set-up that tells the adrenal glands to produce cortisol in the early morning which is what normally happens. If the pred level at midnight is high, that signal isn't given and the adrenal glands have a sleep in and don't produce that morning peak. It doesn't matter because you are on pred - but once you get to a low daily dose of pred the hope is that the low level will allow the return of normal adrenal function. With plain pred taken at night that is less likely.

Does that make sense?

Jontie
Jontie in reply to PMRpro

Yes that's a great explanation, thanks. So because I'm on low dose e/c pred, continuing to take it at night shouldnt stop the normal adrenal system kicking back in.

PMRpro
PMRproAmbassador in reply to Jontie

Exactly

Gunflash
Gunflash in reply to PMRpro

Is it therefore better to take standard uncoated pred at bedtime?

DorsetLady
DorsetLadyPMRGCAuk volunteer in reply to Gunflash

Not necessarily - the recommendation is to take early morning - particularly at the start of treatment when Pred is higher than your body would normally produce (approx equiv 7.5mg). So your adrenals have “gone to sleep” anyway.

Plus higher doses may well affect sleeping patterns, so you don’t really want Pred to start working when you want to sleep.

PMRpro
PMRproAmbassador in reply to Gunflash

NO! At least not when you are lower doses and looking for adrenal function to return. Read what I wrote more carefully - if you take it up to a couple of hours before midnight then the blood level is at its MAXIMUM at midnight so the body won't make cortisol early next morning. It must be at a MINIMUM at midnght to flick the switch.

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