Help please, Getting flare under control

[golfnutter]

I was trending quite well, down to 2.5mgs. Caught Covid two months and was put on antivirals and managed to escape any unwanted side effects of the virus. Unfortunately I started to experience symptoms of a flare of PMR. I increased my dose to 4mgs , then 4.5 and now 5mgs. It hasn’t made any difference and the symptoms are now just as bad as ever. First thing in the morning are very classic with the stiffness and discomfort for the first couple of hours until the prednisone kicks in .

I understand the inflammation has built up quite significantly as the dose is inadequate. What dose should I go to and for how long. I’m not wanting to go down the road of of the horrible side effects again that are linked with prednisone.

Appreciate any advice please.

[PMRpro Ambassador]

We say add 5mg to the dose where the flare occurred - 7.5mg for you. That is only for up to 2 weeks and you can drop back to the last dose you were good at so shouldn't be too bad with side effects. Creeping up never works well - you are always playing catch-up.

The trouble is - this may be a real increase in disease activity so you may need more. And the time scale is also typical of Long Covid having developed so don't dismiss that.

[golfnutter in reply to PMRpro]

Many thanks for the prompt reply, just taken another 2.5mgs to add to my dose of 5mgs I took about an hour ago. Will, as you advised to remained on that dose for two weeks and drop to 4mgs as I was very settled on that dose and stay on that for two weeks and then see how I will go before reducing again to 3mgs. Does that sound ok?

[PMRpro Ambassador in reply to golfnutter]

I'd be in no hurry to drop from 4mg - be sure you are well recovered from the Covid. My younger healthier daughters took a couple of months to really recover.

And maybe 3.5 as the next step? 1mg at a time is a lot and the disease activity post Covid is an unknown

[DorsetLady PMRGCAuk volunteer]

This link/post contains advice for dealing with a flare -

and I’d be inclined to go up to 7.5mg -follow the advice therein -probably drop back down to 3mg rather than 2.5mg

healthunlocked.com/pmrgcauk...

[golfnutter]

Thank you for the prompt reply. Yes, PM Pro advised the same. I have just increased my dose to 2.5mgs now on 7.5mgs which I will take for two weeks to get the inflammation under control again and then drop to the 4mgs. Fingers crossed it does the trick.

[PMR_sufferer1]

It may be worth taking your pred in the evening as an experiment..Sadly the body processes pred out of your bloodstrem after about 20 hours so morning pred doses have no effect on PMR in the morning. Just an idea ! 😃

[golfnutter]

I am always looking for ways to improve my quality of life around PMR. Will give it a go and see what happens 👍

[Darcy2000]

I think I must be an anomaly as I have never had serious side effects from Pred. I realize that internally maybe bones are being affected but so far so good. That being said it gave ne great energy and granted sleep was a bit sketchy I generally felt very well.

[PMRnewbie2017]

As you were down to 2.5mg prior to getting Covid I'd like to caution you about the suggestion to take your Pred at night. ( I am assuming you are taking the plain tablets not coated or modified release?)

Whilst increasing your dose to 7.5mg is necessary to counteract a flare you should take your dose in the morning and as early in the morning as you can after about 2am. There are sound pharmacological reasons for doing this and studies have even shown that it is possible to take a slightly lower dose if early morning regimes are followed. Taking Pred later in the day does cause more HPA axis suppression and since you were down to 2.5mg (well done!) you really don't want to undo all your effort by switching to the evening.

Can I also add that the Biological Half-life of Prednisolone is quoted as between 18 and 36 hours with most patients being in the mid range. Thus after let's say 24 hours, there will be 50% of the dose left, not zero. Hence the reason for dosing with Predisolone once a day, rather than Hydrocortisone which is given up to three times a day because it has a much shorter biological half-life. If you happen to be a very fast or slow metaboliser then you will be at either end of the range.

[PMRpro Ambassador in reply to PMRnewbie2017]

The biological half life of prednisone is 2 to 3.5 hours - effectively all out of the system in about 20 hours, The antiinflammatory effect of pred lasts 12-36 hours - the effect persists long beyond the elimination of the pred.

[PMRnewbie2017 in reply to PMRpro]

Hmm. I was particularly careful to use the terminology quoted on pharmacokinetic sites. Three said, plasma half life 2.1 to 3.5 hrs. Biological/elimination half life 18 to 36hrs. Peak plasma conc 1-2 hrs after oral admin. ???????

[PMRpro Ambassador in reply to PMRnewbie2017]

ncbi.nlm.nih.gov/pmc/articl...

"Biological half-life of prednisolone is in the range of 2.1 to 3.5 hours.18 In the present study, we found the mean elimination half-life of prednisolone 3.30 hours for test formulation and 3.16 hours for reference formulation which are slightly longer than observed in a previous study17 but are comparable with the data reported by other studies."

are the figures I have always been taught.

[golfnutter in reply to PMRnewbie2017]

Thank you for your excellent informative explanation , it all makes good sense.I really appreciate the wisdom and expertise from everyone and I’m taking everything on board. One question,Would taking the prednisone the prednisone so early in the morning cause its own problems , For example, sleep disturbances ( elevated levels of prednisone causing an overactive mind.)Also I realise it needs to be taken with food which I would find hard to do at such an early time in the morning . Any tips please 😊

[PMRpro Ambassador in reply to golfnutter]

A glass of milk or a couple of spoons of yoghurt is often enough.

[golfnutter in reply to PMRpro]

Perfect, I will give it a go , should I take the Omeprazole at the same time too?

[PMRpro Ambassador in reply to golfnutter]

Do you take it regularly? The effect lasts more than 24 hours once it is a regular dose. The peak effect is after a few hours - take if before bed,

[golfnutter]

I do, 10mg dose alongside the prednisone each day. (3.5 years )Although I’m now wondering wether I need to take it that often now, perhaps every other day as I’m not wanting the good old long term side effects of this drug.

[PMRpro Ambassador in reply to golfnutter]

Can only find out by trying.

[golfnutter]

Thank you. I will give it a go.