Visit to endocrinologist and Prednisone at wee hours.

[Karenjaninaz]

I visit my, very helpful, endocrinologist every three months. Yesterday we were discussing my medication and I was telling her that I was taking prednisone at around 2-4 am in the morning -when I got up . She asked me why take it at night? Well, I had a garbled expression as to how we think about it. Then she explains that lowest cortisol level is at midnight, and the body puts out cortisol at 4 AM. After she said that, I thought what’s the point of taking prednisone in the middle the night? Wouldn’t that be counterproductive to Stimulating the adrenals? In other words if cortisol is put out at 4 AM, then taking prednisone, during the night, would diminish adrenal stimulation.

My doctor, a woman by the way, was trained, at a very prestigious, adrenal center in New York City. She’s been immensely helpful with my other issue: reactive hypoglycemia. Hypoglycemia, by the way, often goes along with adrenal insufficiency. Helped greatly by low carb diet. We also discussed a DEXA scan. This has been three years since I had one.

Who came up with the idea of wee early morning prednisone?

[PMRpro Ambassador]

The low level at midnight is what triggers the adrenals produce early morning cortisol - taking pred at 2-3am does not affect that at all because it is after the switch has been flicked and the peak level in the blood is not until 4am or thereabout. But what it does in the case of PMR and RA is have the peak level of pred in the blood at the time the inflammatory cytokines are shed in the body so it minimises the inflammatory effect in the body and improves symptoms in the early morning. They are 2 totally separate events.

The 2am dose of prednisone was determined as part of a study undertaken in Germany and as a result a modified release formulation was developed. John Kirwan writes about it here

academic.oup.com/rheumatolo...

It has been discussed and explained many times on the forum.

[Karenjaninaz in reply to PMRpro]

Thanks for the correction. Excuse my 81 yr old confusion. Right now, since I am pain free for years already, I never think about the inflammatory cytokines. My endo is treating me for secondary adrenal insufficiency and reactive hypoglycemia. We did talk about my taking it at night to feel better in the morning . She is very supportive with my tapering protocols. I think now, though, I am stopping forcing myself up at night to take the pred. I cannot always get back to sleep and I’m a mess. I thought, in error, that taking it at night improved my chances of adrenal wake up.🙃

[PMRCanada in reply to Karenjaninaz]

You can stuff uncoated pred into empty enteric capsules which delays the medication being on board by 3 hours or so. In Canada there is no coated pred available so I do what I’ve described above and take my dose at 11pm…much easier than getting up at 2am.

[Hidden in reply to PMRCanada]

What a good idea! I tried the enteric coated prednisolone and didn't get on with all the ingredients in them. I going to look for some today. Thank you!!

[PMRpro Ambassador in reply to Karenjaninaz]

Taking it well after midnight but very early probably does help, it has longer to get out of the system before midnight so will be at its lowest possible level by then, But if you have no pain it suggests even if you need the pred, the antiinflammatory effect is lasting the full 24 hours, which is what matters. And you can take the tablets when suits YOU best - which is when you first wake up in the morning probably.

[Bungalows in reply to PMRpro]

Thanks for posting the link PMRpro. Interestingly the paper does also mention the possibility of improving the HPA response by using the 2am steroid dose … except that the sample numbers were too small to be significant.

Perhaps some subsequent (to this 2012 paper) work has evaluated this further?

[PMRpro Ambassador in reply to Bungalows]

No idea to be honest - but the theory is as good as anything ekle they tell us!

[DorsetLady PMRGCAuk volunteer]

I think you might have got your wires crossed… when we suggest taking Pred around 2am it’s to combat the shedding of cytokines around 4am - which are the substances that cause the inflammation/pain. Taking the Pred at that time means it’s in system ready to deal with the inflammation.

[Karenjaninaz in reply to DorsetLady]

My endocrinologist says cortisol rises at 4am.

[DorsetLady PMRGCAuk volunteer in reply to Karenjaninaz]

So it might - but that’s not why we advise patients take Pred at 2am. That’s what I was saying,,

[Karenjaninaz in reply to DorsetLady]

Thanks. 🤔

[PMRpro Ambassador in reply to Karenjaninaz]

It does - but it isn't enough to sort out the cytokines - if it were, we wouldn't need the pred!!!

[Karenjaninaz in reply to DorsetLady]

You’re right - wires not only crossed but tangled. Thanks.

[SheffieldJane in reply to Karenjaninaz]

I had a bit of difficulty with conflicting advice from my excellent Rheumatologist and my impressive Endocrinologist. They are coming from different places as regards our illness. I followed my Rheumatologist because my disease symptoms needed to be controlled before I could begin work on repairing my Adrenal function. It was confusing to say the least. I hope this makes sense as the conflicting advice has been well explained I think.

[Digory]

But if your adrenals have been shut down by the Pred it would seem to make sense - maybe less so if you are tapering down to wake them up.