Quick question re strategy to promote adrenals

[BiteyDelano]

After tapering at 0.5 per month for what seems ages, I've arrived this week at 4.5 mg pred.

I recently read about an interesting strategy designed to encourage the adrenal glands to kick back into what adrenal glands should do naturally.

Here's the strategy - instead of 4.5mg every day take 0mg first day and 8mg the next and repeat.

When it's time to reduce to 4mg/day the pattern is continued i.e 0mg first day and 8mg on the second etc.

Repeat until one reaches the sunny uplands (or should that be 'lowlands') when with both Adrenal glands pumping out natural cortisol, and Prednisolone is finally shown the door ...

This strategy seems kind of logical to me (not to mention easier to handle dose-wise).

I'd welcome your thoughts/advice/experience ...

[DorsetLady PMRGCAuk volunteer]

It may well be advantageous for your adrenals, but not convinced your PMR will like it….there’s an awfully big difference between 8mg and zero on alternate days…

[PMRpro Ambassador]

I think most people would find it hard. Your body often does struggle a bit with such swings.

It is a recognised approach to taking pred for some conditions and it is thought to preserve some degree of adrenal function better than taking the same dose every day. However it isn't recommended for PMR because the antiinflammatory effect of pred lasts for 12-36 hours - many patients already have a return of symptoms in the 24 hours before the next day's dose is due. So if you were unlucky you would have a very good day and a poor day alternating. I used it for a time as my antiinflammatory effects lasts well over 24 hours and it was OK but had some GCA-type symptoms and the rheumy said I must be more stable with the dose.

[SheffieldJane]

I think my Endocrinologist was trying to attempt a similar effect by the use of Hydrocortisone rather than Prednisalone when I was at 5 mgs and my Synacthen Test results were poor. I subsequently received a second diagnosis of GCA/LVV to add to my PMR, so I don’t really know if this would have worked. My Adrenals were performing normally at 3 mgs ( without changing from Prednisalone to Hydrocortisone) but I had to increase to 40 mgs, so game over. Hydrocortisone behaves more like our natural cortisol production, it is weaker than Prednisalone and you take it ( if I remember correctly) 4 times a day, it wears off between doses. In an Adrenaline Crisis your are given a Hydrocortisone injection kit as an emergency measure. I still have mine.I don’t think it does much for the symptoms of PMR.

[fmkkm]

Hi Bitey, Sounds interesting on paper, but I would worry about starting a flare going. It seems once I give this “beast” a toe in the door that’s all it takes. However, I have recently been pretty erratic about when I take the day’s 3.5 dose of prednisone, it is anywhere between 8 a.m. and 3 p.m.. I have noticed things going a bit easier now. In the past a difference of an hour would be very noticed. Is it stressing my adrenals more or a final disappearance of this thing. 🤷‍♀️

I’m very interested in how it goes if you try it, but I would probably attempt a less severe trial, maybe one day 3, next day 5? Best to you!

[PMRpro Ambassador in reply to fmkkm]

That wouldn't work I don;t think - it is the periods of total absence of pred that are important. But where this ADT (alternate day therapy) approach is usually used is for younger patients requiring pred for other chronic conditions such as MS where they found that it wasn't a good idea

"The frequency of side effects was not significantly different for alternate-day therapy compared with daily therapy. We conclude that alternate-day prednisone therapy effectively increases strength but does not sustain the improvement to the same extent as daily therapy or mitigate side effects"

jamanetwork.com/journals/ja....

[fmkkm in reply to PMRpro]

Thanks, all good to know. Thanks for the link!

[HeronNS in reply to PMRpro]

Look what I just found :

patient.info/forums/discuss...

😁

[PMRpro Ambassador in reply to HeronNS]

Those were the days!!!!

In case anyone is interested - what I said 6 years ago:

"If you are able to take your pred all in one go and manage for the full 24 hours that is really best in terms of reducing side effects since it allows the ongest time without any pred being present in the body.

Dose skipping I really wouldn't advise until you are down to 1mg and trying to finally get off pred. I'm sure that it is fine if you are a person for whom the anti-inflammatory effects lasts closer to the maximum which is felt to be about 36 hours and you are still well above the minimum dose you need the antiinflammatory efect lasts from 12 to 36 hours depending on the person).

One way of using pred is double the dose on alternate days - it isn't really recommended for PMR/GCA but I did use it for some time and it worked quite well although reducing was difficult. If you are someone for whom that works OK then you will probably be fine missing doses every so often - but if you are a 12-24 hour person then the second day will probably end in tears!

The "Dead slow and nearly stop" approach is a version of that - but one that doesn't expose the body to such a shock. You can use it with 2.5mg, 1mg or 0.5mg steps - some people will manage the 2.5mg steps, others will still struggle with 0.5mg drops. If you can do 2.5mg drops you will still reduce 2.5mg in a month - which most people would feel is pretty impressive.

It doesn't matter how you choose to reduce - if you try to reduce too far or have too big variations in the doses from one day to the next you will very likely have problems. And in the end it isn't slower - because you run the risk of having to go back to the previous dose and start again and if you are really unlucky you will need a MUCH higher dose to control the flare you have set off. And you may well miss the dose you need long term - for example, 10mg could be fine, 7.5mg isn't - but was the right dose 9.5mg or 8mg? There's a considerable difference and believe me, 1/2mg can be the difference!"

[piglette]

My gosh, whoever thought up that bright idea? Having been stupid enough to forget to take my pred twice, there is no way I am going to try it again..

[HeronNS]

I don't think you should worry about your adrenals. Not at this stage anyway. Somewhere, quite a long time ago, on an internet medical site I read that alternating days is not recommended for PMR.*** We need the ongoing effect of pred continuously in order to control our pain. I have been on pred since 2015 and a few months ago had an early morning cortisol test. Although I'd had to increase my dose a bit last year because of a resurgence of PMR, I still tested normal for cortisol production after nearly 60 hours without pred before the test. Which I think indicates that sensible taperiing and patience are really all that is usually needed to encourage adrenals to wake up. Unlike SheffieldJane I never had a synacthen test so I don't know what my result might have been if I'd been tested when I first got to lower levels of pred, but I've been under 5 mg (usually close to 2 mg) for most (not all) of my time on pred since the initial taper to 5 in the first half of 2016.

*** emedicine.medscape.com/arti... : "In contrast to other rheumatic diseases, alternate-day administration of corticosteroids in PMR has largely been unsuccessful."

[Exflex]

I’m transitioning from 4.5 to 4mg, not too dissimilar to your situation, but I wouldn’t dream of alternative days. Out walking yesterday afternoon at 4pm and the dreaded fatigue kicked in. I was about 1 mile from home and felt every step as I made my way back. Even my GP said it’s important to go slowly on the reduction, even though he would like to stop prescribing Pred I’m sure.