Taking pred with food

[Temoral]

Hi Everyone. I think I may have an absorption issue. Perhaps I am taking pred too close to breakfast. Is it best to take pred before food, during, or after. I have omeprazole about half an hour before the drug anyway and sometimes kefir. Any advice welcome. I am on 3.5mg.Thank you.

[Koalajane]

have my prednisolone after my first bite of toast usually.

Why do you say you may have an absorption issue?

[Temoral in reply to Koalajane]

It feels like I have dropped by more than a very gradual .25mg...and I have had more frequent trips to the loo...just wondering if pred is being 'lost' too quickly. Very fatigued and dizzy headaches...adrenals stuttering probably...

[DorsetLady PMRGCAuk volunteer in reply to Temoral]

Definitely adrenals…classic symptoms.

[DorsetLady PMRGCAuk volunteer]

Why after over 3 years on Pred, and presumably taking your tablets at similar time through that period, do you think you have an absorption issue now?

Would say the issue is probably too low a dose, rather than anything else.

[Temoral in reply to DorsetLady]

Started pred Sept 20 21. I sometimes take before food and sometimes later...just wondered if it made any difference...

[DorsetLady PMRGCAuk volunteer in reply to Temoral]

The recommendation is to take with water and before or after food, but that’s to protect stomach as much as anything.

When you say later, how much later? Minutes or hours?

[Temoral in reply to DorsetLady]

About 15 mins

[DorsetLady PMRGCAuk volunteer in reply to Temoral]

Okay- that’s not an issues then, so will return back to original thought, too low a dose for your PMR - not helped by adrenals stuttering.

And re your Rheumy’s comment in your reply to PMRpro - has he told your PMR it’s near it’s end!

[DorsetLady PMRGCAuk volunteer in reply to Temoral]

Okay, less than 3 years then… so even more likely to be too low a dose.

[PMRpro Ambassador]

The problem of an absorption issue is taken care of by the tapering of the dose, looking for the oral dose that works for YOU, If you feel you aren't getting enough all of a sudden it is more likely you have reduced a bit too far.

[Temoral in reply to PMRpro]

Yes Thank you. Pressure as always from Rheumy to reduce faster . He suggested that so near 'the end' I could go alternate days on 3 then 2.5.....I don't think I will be attempting that method.

[PMRpro Ambassador in reply to Temoral]

I have just had to take a VERY deep breath! The lower - the SLOWER!

When will they understand that this is not "nearly the end" - even 1/2mg pred can be enough to hold PMR inflammation at bay but far more important is to allow the adrenal function to recover and that takes time. 3mg is loads to replace the lack of cortisol and suppress adrenal function. The least uncomfortable way is in small steps with plenty of time between them.

[Temoral in reply to PMRpro]

Thanks PMRpro... he does annoy me! But I hold my breath and politely thank him for his opinion, but I would rather take it slowly and enjoy a quality of life on the journey. He agrees eventually, but why do we keep on having to repeat this to these Rheumys...

[PMRpro Ambassador in reply to Temoral]

Must all have ADD!!!

"Attention Deficit Disorder (ADD) is a term used for people who have excessive difficulties with concentration without the presence of other ADHD symptoms such as excessive impulsiveness or hyperactivity. The official term from the Diagnostic and Statistical Manual IV is “ADHD of the predominantly inattentive type.”"

Except when it comes to tapering, they seem to suffer from excessive impulsiveness too ...

[ImC_ in reply to PMRpro]

Sorry - please can I check what you said: "3mg is loads to replace the lack of cortisol and suppress adrenal function. " Did you mean that even on 3mg the adrenals might not be prompted to make their (my) own cortisol? I'm just DSNS tapering from 3.5mg to 3mg.

[HeronNS in reply to ImC_]

This is my take on the question: I've been on pred since 2015. Currently I'm tapering, I hope, to zero. The reason I'm going extremely slowly is because my body is used to my taking a low dose of pred and therefore not used to producing quite the normal amount. It has been observed on this forum fairly recently that sometimes we on very low doses are very fatigued in the morning without our little boost of pred, but perk up in the late afternoon - which is, not coincidentally, a time when the body produces another smaller surge of cortisol. So as I reduce now I take no pred until I reach the day I feel exhausted in the late morning and the next day I take .5 mg. What this is telling me is that although my body is obviously producing cortisol it needs time to relearn how much to produce in the normal early morning surge. My understanding is that it can take up to a year after stopping pred to get entirely back to normal. So the short answer is, adrenal production is suppressed to the amount that one is taking pred, but below around 7 or 8 it isn't completely suppressed as it is above that dosage. As tapering progresses one expects the adrenal glands to gradually pick up but they will only do that if we take a bit less pred than we need on an ongoing basis.

[PMRpro Ambassador in reply to ImC_]

Recent work by Imperial in London decided that 2mg is an adequate replacement amount. And anything above that can suppress production to some extent. It depends on the person - some people start to notice a difference even at 10mg and experience fatigue. Others simply sail down the doses and get off pred no bother at all. But there is no way of predicting which you are until you get there!

[HeronNS in reply to PMRpro]

Today I actually forgot my half mg and decided when I did remember to just let it be and see how I am tomorrow morning. I wasn't having any shaky moments, although quite busy.... However my neck is really bothering me so I hope that isn't a bad sign.🤞

[Grammy80]

I can only echo....slow~! I take Actemra each week (States), and last fall, I got down to l mg per day and felt well enough. I have GCA. Then...I had a perforated bowel..lots of antibiotic IVs and pills, and no meds to suppress my autoimmune disease for almost six weeks; then I was a mess and back to 60 mg per day. I'm sure I was more of a 'medicine-mess' than GCA but my doctor took no chances.

My reduction pace now is l mg per month and I am down to 4. I know if I stutter at all, my rheumy will tell me to slow it down....and I'm in no rush. At 83, I want to feel as good as I can and I'm just getting engaged in life again. My best💞

[Temoral in reply to Grammy80]

Exactly Grammy80! I have GCA too. I hope you continue to improve and enjoy life x

[Grammy80 in reply to Temoral]

....and the same to you! We will all make it...we each have a different pace but it seems 'slowly' gives us the best results. Whatever it takes. 💞

[Temoral in reply to Grammy80]

I have just read your biography on here. Quite a ride you've has....but you sound like a really sassy and strong gal. A real role model for us warriors. Positive thinking helps too! Thank you x

[Grammy80 in reply to Temoral]

I believe positive thinking is HUGE~! Now that I feel better, my energy goes into things I enjoy and if want to nap later, I do.💞

[KASHMIRI1]

Good morning I was told to take omeprazole 1 hour before food and pred with breakfast. Its worked fine for me for four years.

[Broseley in reply to KASHMIRI1]

My instructions are to take my omeprazole either just before or with food! I do this and have had no problems. I then take my pred after my post breakfast coffee.

[Temoral in reply to KASHMIRI1]

Thank you

[Seasidelass]

Hi, I was always told to take Pred on a full stomach to hopefully avoid stomach issues taken it straight after breakfast & never had any problems.

[Temoral in reply to Seasidelass]

Thank you

[Hidden]

Hello Temoral.

It is possible that you could have an absorption problem, but your problem is not likely to be caused by food. Let me say more.

Pharmacokinectic (the way a drug is absorbed) literature shows that the absorption characteristics of prednisolone is not affected by low volumes of food.

The literature also shows that there are very wide intersubject variations in the absorption of prednisolone. Even tenfold differences in the maximum prednisolone blood level have been recorded in intersubject studies.

If these intersubject variables apply to individual subjects, then these intrasubject pharmacokinetic variations will have a big impact on the pharmacodynamics (pharmacological effect) of prednisolone. This in turn will have a big impact on the efficacy of therapy.

Put another way, these data indicate that some people will be good absorbers of prednisolone and some people will not . Also, the percent absorbed in any particular person on different days may be different.

So, what can be done about this?

It is a fact that the weaning process works providing the dose drop and timing between dose drops is suitable for any particular person. It is also said that it is possible to recover from PMR naturally.

I conclude from these two points that the immune disorder gradually recovers naturally with time and that the dose of prednisolone required to control symptoms gets less with time.

So, if your symptoms are not being control on 3.5 mg, you need to increase your dose to the value that did, and then extend the time interval between dose reductions.

It is also possible that your symptoms may be caused, in part at least, by adrenal insufficiency. This is because the output of cortisol is not keeping up with the reduced dose of prednisolone. This problem also argues for an extension of your weaning time.

Bye the way, omeprazole is destroyed by stomach acid, and it is best to take your dose around 1 hour before your breakfast.

Also, for your information, prednisolone is a prostaglandin inhibitor, and it causes stomach upset by a systemic rather than a direct irritant action. Food therefore has little or no protective action against irritation.

Regards.

[PMRpro Ambassador in reply to Hidden]

There is some dispute about the mechanism of stomach upset with pred. High doses of pred do exert some effect via the PG mechanism but many patients find in real life that pred on an empty stomach is uncomfortable but taken with food, especially yoghurt, the discomfort goes.

Do you have any links for the intersubject variation in pred absorption? I have seen some in the past but cannot find them again. Pharmacists (of all people) and doctors dispute there is a difference in absorption of pred between patients.

[Hidden in reply to PMRpro]

Dear PMRpro,

Thank you for your helpful reply on my point about prednisolone stomach irritation. I agree that I was a bit black and white on the topic!

Regarding your request for information on the subject of prednisolone pharmacokinetics, I would be pleased to send you a document, (without checking, around eight pages long) which gives much information on this subject.

I wrote the paper around six months ago, and gave the article to my rheumatologist. He found the contents of the article to be most useful. If you would give me an email address I would be pleased to send you a copy.

Just to give you some background - I am a retired PhD pharmaceutical scientist who spent 40 years developing drugs into prescription medicines in the pharmaceutical industry. I retired as a member of the Board of Directors of a British Company and as the Chief

Scientific Officer of an American Corporation.

Regards

[PMRpro Ambassador in reply to Hidden]

Thank you - I will send a private message with my contact email.

[Lclmlbls in reply to PMRpro]

Does Taking with food apply EC pred or just the plain ones?

[PMRpro Ambassador in reply to Lclmlbls]

Just the plain ones really, Taking e/c with food delays their absorption as that slows gastric emptying.

[Bluey-1 in reply to PMRpro]

This is all very interesting. I had no idea I may absorb pred differently to others and have no idea how I would know. I take enteric coated pred and my other morning tablets (Edoxaban & Bisoprolal) with a spoonful of yogurt followed later by a cup of tea and small bowl of porridge with Linwoods milled flaxseeds, nuts and coQ10. So this pattern would delay pred’s absorption? I can’t see that I’ve had a problem with that but then I may not know. I suppose it all goes to show the complexity and individuality of our immune systems and reaction to medication.

[PMRpro Ambassador in reply to Bluey-1]

It doesn't really matter - you are titrating the dose with the tapering. E/C pred taking longer to get in means it is there for longer at the other end so that balances out too after a few weeks.

It only becomes an issue when a doctor who doesn't understand PMR and the concept of titration decides you need to come off pred ...

[Bluey-1 in reply to PMRpro]

Thanks for the explanation. All is going smoothly on the tapering front so far. The advice you and DL give to adjust activity (and avoid stress) as you taper is helpful. I think that is the key, especially as you get to lower levels and the adrenals need to kick in again.

[Lclmlbls in reply to PMRpro]

When I asked my GP about coated pred, she said not to worry as there are no efficacy or absorption issues. I am currently taking mostly EC but have to top up with 1mg (or 1/2mg) uncoated as I haven't been issued with 1mg EC.

[Temoral in reply to Hidden]

Thank you...very interesting and shows just how individual our reactions are.

[Sandmason in reply to Hidden]

"Put another way, these data indicate that some people will be good absorbers of prednisolone and some people will not . Also, the percent absorbed in any particular person on different days may be different."

One thing I noticed in my various DNA mutation reports, (I'm a forensic genetic genealogist) is that genetic glucocorticoid resistance is a real thing, though not uncommon. I have seven of them, on gene NR3C1, starting at rs1866388,. "Mutation associated with generalized corticosteroid resistance, high cortisol, CFS"

"Encourage Phosphatidylserine, possibly ketogenic diet." From NutraHacker.

[Hidden in reply to Sandmason]

Thank you Sandmason - a very interesting point, fundamentally contected to prednisolone variability.

[BOBROBERTS]

Hello, I am resident in France, Prednisone packets here are marked to be taken during your food ie breakfast. I take my Omeprazole the when I get up.

Regards - Bob

[AlamedaCounty]

I take pred after breakfast, usually while finishing drinking tea. I think drinking in between tablets helps.

[Markandevie]

Try having the pred with yoghurt. I have had no issues since using

[Temoral in reply to Markandevie]

Thank you...I will try this.

[Sandmason]

I just started making kefir and buttermilk, and the kefir seems to make many trips to the loo. No problems taking pred at 4am with a cup of coffee with milk, and I try to take the other half of it at 4pm, well before dinner, sometimes with a can of light beer. No stomach problems at all, except for the kefir. 72 yo female, 11 months into this, US, taking 9mg and 8.75 2 days a week. I'm allegic to ppis, never take anything for my stomach.

[HeronNS]

I'm sure you've heard my story before but putting it here for others reading the thread. I'm actually a poster child for slow taper. Am currently approaching zero, but for the second time. The first time, starting late 2019 and continuing for a year into 2020 I tapered from 2 to zero by taking three months for each half mg taper. Within six weeks of being on zero I was back on pred and a few months later had a major flare - not too low a dose, which had been okay at about 2-3 for a while after failed flirtation with zero, but definitely increase in PMR activity. That was early 2021 (may have started earlier but I was in a bit of denial). It is now three years later and this time I've been tapering from 2, not by a schedule but by how I feel, but never speeding up, since September 2022. Today (Jan 30, 2023) was sixth day since most recent .5 mg dose. I anticipate a couple more weeks with occasional .5 mg. Then we wait and see....

Solution to a recent Cryptoquote: "Rivers know this: 'There is no hurry. We shall get there someday.' " A.A. Milne