doubling Pred dose 60 minutes prior to Dental surgery?

[mullochs]

Hello all,

I have learnt so much from reading the posts on this forum on a daily basis - 6 months from a PMR diagnosis I am beginning to get a grip on the endless complications. I would like to thank you for your patience and commitment to repeatedly answering questions from confused, anxious patients.

I have checked FAQ but cannot find a suitable answer:

I am due to have a fractured tooth extracted on Friday afternoon - my Dentist tells me the guidelines say that a patient on Prednisolone should double their current dose (up to 20mgs) 60 minutes before the procedure and maintain that level for 24 hours. Dropping back to their current dose on day 2. I am at 13mg in the weaning process.

I would very much appreciate your views/experience on this advice.

Thank you !

[SnazzyD]

Why is that? I can understand if your dose is low enough (under 10mg) that it doesn’t cover the daily need for corticosteroid and the adrenal glands have to work to make that up. One would be concerned that the stress might not be met with the corresponding increase in activity by the adrenal glands and risk adrenal crisis. 13mg is well above that so your system is still swamped with more steroid than it needs so adrenal crisis isn’t one’s first concern. To me, bumping up another 13mg seems odd and even possibly counter productive in that it increases your risk of infection and slows healing.

[PMRpro Ambassador in reply to SnazzyD]

Doesn't it mean up to a maximum of 20mg? i.e. if your dose is above 10mg it is not double but a maximum of 20mg?

[mullochs in reply to SnazzyD]

Over cautious Dentist - I am assuming it will be a local anaesthetic at this stage so should be fine? He insisted that I check with my GP before taking but thought asking the Forum would be far more reliable .

Thank you for replying

[Darkchocolate1 in reply to SnazzyD]

I am at 13 mg prednisone and just diagnosed with adrenal insufficiency. I was so sick I am back up to 13 mg and still have many horrible symptoms. My rheumatologist said you can suffer AI at any dose depends on the person. I am to see an endocrinologist in a week for treatment. I split my daily dose this week suggested by my primary GP and it had helped to not feel as bad in the evening. I still can’t do much after about 5 pm. I did not expect this until I was down to 10 mg or less. Always new surprises!

[Amkoffee in reply to Darkchocolate1]

I don't have medical degree but I do have secondary adrenal insufficiency meaning that it came from my prednisone use when I had PMR. Your body does not produce that much cortisol normally so you should not need more then 20-30mg of hydrocortisone which is roughly 5-6 mg of pred. That being said I have found it to be much more difficult to taper if I have to go on a short course of prednisone for allergies or something else. Where the average person could probably take 20 mg for 5 days and then stop I have to taper it back to my original dose of 25mg hydrocortisone. If you are feeling ill on 13 mg of prednisone I would suspect it's from something other than adrenaline's efficiency. But as I said I do not have a medical degree and I am only basing that on myself and what I've heard other people talk about in my adrenal insufficiency groups.

[Darkchocolate1 in reply to Amkoffee]

Thank you for your thoughtful reply. I am unsure what is happening but I am hopeful the endocrinologist will be able to sort it out and help me. I do know that every time when I was younger and took a short course of prednisone for poison ivy or uveitis I ended up with a horrible throat infection after the taper off. I have been on prednisone for 2 and a half years now starting at 20 mg. I once reached 10 mg on methotrexate but had to stop due to side effects and went back up to 15 mg. I do have most of the symptoms of adrenal insufficiency and have lost 13 lb. In the last month or so with no change in diet. Thank you for replying.

[DorsetLady PMRGCAuk volunteer in reply to Darkchocolate1]

My rheumatologist said you can suffer AI at any dose depends on the person.

Not sure that “any dose” is strictly correct - the normal production of cortisol does vary from person to person -but is quoted as being equivalent to between 5 to 10mg Pred.

Some people do suffer AI once they get down to 10mg, but it’s usually slightly lower.

healthunlocked.com/pmrgcauk...

Will be interested to hear what Endo says -so please report back.

[PMRpro Ambassador in reply to DorsetLady]

The problem even at higher doses is in an emergency situation when there would be a spike of cortisol to deal with the situation and it can be as much as 10 times the basal level - but when you are on higher doses the response is severely blunted because of the suppression due to the high doses.

[DorsetLady PMRGCAuk volunteer in reply to PMRpro]

okay -see what you mean…

[SnazzyD in reply to Darkchocolate1]

so you went down, felt ill and went back to 13mg? What are the symptoms you have now that suggest you don’t have enough corticosteroid in your body? You will have adrenal insufficiency at 13mg in that the adrenal glands will be switched off because they don’t need to work with so much Pred in your system. However, unless you are not absorbing the Pred properly you shouldn’t have symptoms of AI because the Pred is doing the job and then some for you. If you had an adrenal test now, it would likely show no activity.

[Darkchocolate1 in reply to SnazzyD]

My symptoms are stomach ache, nausea, facial flushing, tremor in one hand sometimes, reflux pain which I never had before, insomnia, 13 lb weight loss in about 6 weeks with no diet change, extremely hot and sweating day and night, increased fatigue, dizziness, confusion, worse memory, feel like fainting when I was on 23 mg prednisone, my skin prickles like fiery hot needles are sticking me when I get overly tired. My skin feels like it is on fire right now after washing dishes. I am weak, shaky and anxious, I haven’t cried much for years now I cry over nothing and everything several times a day, feel unsteady on my feet. All of this is worse when I am tired after doing any physical chore. I fall asleep briefly every time I sit down. All of these symptoms are a little less severe on 13 mg than on 12 mg. I really thought I was going to faint when I was taking 12 mg.

I am also dealing with 3 herniated discs pressing on my spinal cord causing much pain constantly and that has caused incontinence. I have appointments with two surgeons to discuss what can be done about my spinal issues. PMR seems not so bad compared to this spinal pain which runs down my entire right leg and into my foot and never quits since late January. Thank you for listening.

[SnazzyD in reply to Darkchocolate1]

Goodness, that sounds very hard to deal with all the time. Some aspects of your symptoms don’t chime with my experience of adrenal insufficiency at all but we are all different. In theory if it is adrenal insufficiency that isn’t being covered by your Pred if you raise your dose, you should feel better. Another thought, if you are really on Prednisone and not Prednisolone (sometimes people refer to them interchangeably) perhaps something is stopping the conversion in your liver. Prednisone needs an extra step of processing in the liver before it becomes available in the body. If that part is not happening you may not be getting the full dose.

How was your adrenal insufficiency that resulted in your Endo referral diagnosed?

Please report back after your Endo appointment with a separate post. I wonder what PMRpro thinks of your suite of symptoms?

[Darkchocolate1 in reply to SnazzyD]

I am taking prednisone not prednisolone and it worked fine up until about 6 weeks ago when I started feeling so poorly. My rheumatologist diagnosed AI based on my symptoms, red face and weight loss and tremor were visible to him when I saw him last. He referred me to endo saying I should get an appointment quickly. I have waited about 7 weeks. My appointment is June 22nd. I had a liver work up when I started PMR and function was fine then. I guess it could have changed. I appreciate your thoughts and knowledge. Best wishes.

[Amkoffee in reply to Darkchocolate1]

I am in the same boat. I've had chronic back pain for 17 years now. In the beginning the surgeon said I did not qualify for surgery. Then in 2019 many years later the doctor said I was too far gone for surgery. Seems unfair. My pain from my back is 10 times worse than the PMR pain I had during my time with that condition which fortunately has gone into remission. But it did leave me with adrenal insufficiency and severe osteoporosis. I've had six fractured vertebrae and a fractured sacrum. This is why they won't do surgery on me. But there is a procedure I've recently heard about that is a lot less invasive than something like a lamindectomy. It's where they basically go in and put these little spacers in between the vertebrae that are causing the problem. So instead of having your whole back open it's just one or two little slits. It's called Vertiflex.

[Darkchocolate1 in reply to Amkoffee]

Thank you for your reply. I am so sad that you are unable to get help with your back pain. I could end up in the same spot. I haven’t seen the surgeons as yet. The relentless chronic pain I am still learning to deal with. My PMR is still active my inflammatory markers are still high after 2 and a half years on prednisone. The AI is making me miserable right now and I hope there is help for that to feel better. Life isn’t always easy as we age. I try to stay positive but sometimes it is difficult to do so. Blessings to you!

[PMRpro Ambassador]

"a patient on Prednisolone should double their current dose (up to 20mgs) 60 minutes before the procedure and maintain that level for 24 hours"

Never heard it put like that ever anywhere - and I have had 2 teeth extracted, one fractured, and root treatments, I have never taken that much pred before the dentist. Taking prednisone 60min before the procedure is probably a bit late - it takes that long at least to get into the system.

Since it is just a one-off I suppose it will do no harm ...

[PMRpro Ambassador in reply to PMRpro]

As a PS

This

nature.com/articles/s41415-...

suggests there are no such guidelines as yet!!

This

ugr.es/~jagil/gibson_steroi...

says "Patients with primary Addison's disease are most at risk of acute adrenal insufficiency. The risk of clinically significant adrenal insufficiency is low in patients taking long-term steroid medication. For this latter group of patients, performance of routine dentistry including minor surgical procedures under local anaesthesia does not require supplementary steroids. For patients undergoing surgery under general anaesthesia, provision of supplemental glucocorticoids needs to be balanced against the dose and duration of treatment with steroid drugs and the severity of the planned surgery.!

A fractured tooth was possibly a bit harder because the root mightn't come out a require a second stab at it - but it really wasn't a big deal .

[mullochs in reply to PMRpro]

thank you for the useful papers which are quite clear that an increased (or doubled) Prednisolone dose prior to a local anaesthetic dental procedure in long term Pred patients should not be necessary. Different story for general anaesthetic of course.

Yes - I did assume the dentist meant double your dose up to a maximum of 20mg.

I may take an extra 5mg Friday morning which as you say can do no harm and might avoid any hypotension issues post procedure .

Thank you for that info !

[PMRpro Ambassador in reply to mullochs]

Like MrsNails below, I find most problems are avoided by requesting an adrenaline-free local anaesthetic. Once a dentist told me about that some 30+ years ago I was able to have pain-free dentistry instead of not having an LA!

[mullochs in reply to PMRpro]

thank you - I will make sure that is what I get!

[MrsNails]

Hi - l’m in a similar situation at the moment - l’m on a fairly fast taper - 8mg atm (for other reasons) but my new dentist wanted to send me to the Dental Hospital!

Anyway - l took an extra 10mg a good couple of hours before to get it into my system. The big difference for me was she used a Local Anaesthetic WITHOUT Adrenaline & the difference it made to me was incredible, as l usually feel dreadful afterwards but l felt like l hadn’t had anything done & they were very deep fillings. The big one is in July removing a Crown & it’s ongoing treatment……

Good Luck 🍀

[mullochs in reply to MrsNails]

thank you - yes a similar situation. It appears there really isn’t any need for extra Pred before local anaesthetic dental surgery. Not so General Anaesthetic…

I will be looking at a crown too eventually - hope yours goes perfectly in July !

[TheMoaningViolet]

My dentist wants to wait for me to be off Prednisolone completely before he replaces my crown. He does not want the steroids to interfere with the healing process. So I can't see him suggesting that I double my dose for anything.

[PMRpro Ambassador in reply to TheMoaningViolet]

Well it takes up to a year for the adrenals to recover fully even after stopping pred altogether, However - a crown procedure should be minimally invasive so very little healing involved - he sounds like one of the growing number of UK dentists who are totally risk averse. I was on nearly 20mg pred when I had a tooth with a fractured root removed and on anticoagulant medication, no bleeding, no problems, healed beautifully in a couple of weeks

[TheMoaningViolet in reply to PMRpro]

I agree, but it suits me to postpone this to the autumn, so I am not arguing with him.

[mullochs in reply to PMRpro]

exactly - my first thoughts - over cautious/risk averse. Thanks.

[mullochs in reply to TheMoaningViolet]

Thank you - the slow healing aspect is useful info. I have gone with no increase in Pred today with an adrenaline free LA - learnt from PMRpro!

[sidra1968]

That is odd to me, I had the exact same thing done recently and was fine..the numbness of the novocaine was the only weird feeling. I just stayed on all my meds. I am not dentist though, so...keep us updated!

[mullochs in reply to sidra1968]

Thank you for that - GP & Rheumatologist both say unnecessary to double the dose for LA dental work - so going with that. Important to have adrenaline free LA I have learnt from PMRpro & Mrs Nails - got that organised 🤞