Split dose

[Inertia]

I first developed PMR in May 2018 and managed successfully to come off Pred in Dec 2020. All well for 2.5 years until a resurgence in symptoms in May 2023. Since then again I have successfully managed down to 4 mg but am finding early mornings difficult. And so I have split the dose to 3 mg in the morning and 1 mg around 10:00 pm. This seems to work well for me but I would be grateful for any observations or comments regarding potential issues or downsides to this strategy especially as I continue to reduce.

[PMRpro Ambassador]

The only real downside of taking the 1mg at 10pm is that steroid will still be present in the blood stream, albeit at a very low level, at round about midnight which is the witching hour to trigger production of cortisol by the adrenal glands the next morning.

You don't say where you are - could you add that to your profile and make sure it is visible for others. If you are in the UK your pred is probably prednisolone which is in your system in an hour and will be lower at midnight than if you are in the USA where your pred is probably prednisone and that takes longer so the level will be higher at midnight as less will have been degraded.

[Inertia in reply to PMRpro]

I’ve added location etc (UK) Thankyou. Apart from affecting sleep - which at this low dose it has little/no effect - I wondered what the science tell us about splitting doses in this way? Is it better to continue in this way or recognise this as a warning that I may be on too low a dose and need to go up a notch; or even +5 and reduce down to 5 (4+1) after a couple of weeks? Views gratefully received!

[PMRpro Ambassador in reply to Inertia]

If you are a person for whom the antiinflammatory effect of pred is at the shorter end of the scale (12-36 hours depending on the person) then splitting is probably the best approach to dosing at any stage. In the early stages at high doses many people manage on single daily dosing, but not all. How much delay you need for the rest of the dose depends - mostly the suggestion is 2/3 in the morning and the rest later enough to extend the effect to 24 hours. It may be you can get away with taking it at lunchtime - problem solved.

[agingfeminist in reply to PMRpro]

I am confused. If it is recommended to take pred at 2 a.m. because it anicipates the release of the interleukins at 4 a.,m. -the cause of the inflammaiton - then why do we need it to last 24 hours? Just wondering what is going on here...

[PMRpro Ambassador in reply to agingfeminist]

Because if the antiinflammatory effect of pred doesn't last until the next daily dose then you will start to get breakthrough pain and stiffness as it wears off. Same as with a headache or any other pain - the effect of the pain killer will wear off sooner or later. By no means everyone is able to go the full 24 hours to the next dose - there have been loads of posts about pain returning in the afternoon or evening whatever time you take the pred and the best way to split the dose.

[agingfeminist in reply to PMRpro]

this doesn't really answer my original question. This presupposes a different model for PMR. Perhaps one model doesn't fit all of us. But the recommendation of taking the 2 a.m. dose is based on the idea that the inflammation is caused by a flood of cytokines at 4a.m. You basically zap the inflammation as soon as it begins.

I am aware that some people can have problems later in the day. Does this mean that something else happens after the interleukin production at 4a.m?

[PMRpro Ambassador in reply to agingfeminist]

The ILs are present in the body all the time - but the pred is not, it is steadily excreted and at some point gets too low to control YOUR inflammation. Several reasons that may contribute to that are mentioned in this paper:

jacionline.org/article/0091...

The pred doesn't stop the action of the ILs, it reduces the inflammation caused but only as long as there is enough to keep it under control.

[agingfeminist in reply to PMRpro]

many thanks. I had a too simple model.

[PMRpro Ambassador in reply to agingfeminist]

And I didn't know how to explain it simply - I know what I mean ...

[taichikung in reply to Inertia]

I have been splitting doses for a while now with good results. I also take one paracetamol 500mg with steroids at breakfast when I start a new reduction. I find I only need that for a week or so. Good luck.

[cranberryt]

I have used this method several times over the years. It definitely helped me continue to taper. What I usually do is taper the next drop off the bedtime dose and see how that goes. Eventually I end up back at a morning only dose. But if that evening pain creeps back I split the dose and operate that way again. If splitting the dose doesn’t help then I assume my dose got too low and I go back up 1/2mg. I am at 1.5mg now all in the morning.

[sidra1968]

I have to split mine, it wears off quickly for me..seems to be working.