Low dose prednisone question

[Landerman]

I've been puzzling over this...

Why is it that us PMR people often get stuck on long term, low dose prednisone?

If the average natural cortisol level equals about an average of 8 mg. of prednisone (lets say), and if I take 4 mg. of preds, the adrenals would produce (if healthy) the other 4 mg. to bring cortisol levels to normal.

Similarly, if I take 2 mg. of preds, my adrenals would then kick in the additional 6 mg.

But in both cases, the anti-inflammatory effect necessary to control PMR wouldn't be any more than if I took 0 mg. preds, and my adrenals produced the whole, normal amount of 8 mg.

The only thing I can think of is that the adrenals are not capable of producing the full amount of cortisol for normal physiological function, so prednisone must be added - but there must be more to the story...

I think I may be missing something.

[DorsetLady PMRGCAuk volunteer]

Not quite as simple as adrenals kicking in to replace the level of Pred… this link explains why,.

healthunlocked.com/pmrgcauk...

Basically once you’ve been on Pred for a few weeks and above the physiological amount of cortisol normally released in body [around 8mg] the adrenals have nothing to do so go to sleep. When you get back down and below that level they need waking up again but it’s not like flicking on a light switch - they need gentle nudging - which can take a lot longer that many realise… and even up to 12 months after actually coming off Pred they may not be at 100% capacity..

Think you may also be confusing what the adrenals do and what the Pred does for your PMR…Hope the attached clarifies re adrenals, and maybe re-read the introductory/info link I attached in my reply to your first post.

[Landerman in reply to DorsetLady]

Thanks for your reply, and the articles. I think I do understand a bit now that prednisone and natural cortisol overlap and interact, but do not affect the body in exactly the same way. And, of course, that it can take a long time for "asleep" adrenals to wake up (or maybe never completely in some cases),

It makes me wonder about long-term, low-dose prednisone being often relatively benign on overall health. Could it be that since the adrenals produce less cortisol when on low-dose prednisone, that the overall steroids in the body remains about near normal levels, and thus, low risk?

[PMRpro Ambassador in reply to Landerman]

Depends on the dose of pred you are on - if the pred dose is under 5-7mg, then the body doesn't produce cortisol, or very little. As the pred dose falls, the cortisol should increase so the total corticosteroid amounts remains fairly constant. Of course, if the adrenals aren't starting to work but the pred dose continues to fall, the steroid level falls.

[PMRpro Ambassador]

Cortisol doesn't have anything like the same antiinflammatory effect as pred - it is two separate things that cause the problem at low doses, the PMR must be controlled, that is why you take pred. Pred is a corticosteroid and can do the same job in the body as the cortisol does but because it is a bit of a big bully, it swamps the cortisol production and the body stops producing cortisol so there isn't even more steroid around. When you get to about 5mg pred the balance has changed and you need a bit of cortisol to top up the pred dose to the total amount required on a daily basis. But as DL has said, it isn't a smooth and simple process. And you can't just replace the pred with an artificial version of cortisol, hydrocortisone, which would tend to encourage the process, because it is unlikely to keep the PMR inflammation under control. It is a balancing act with 2 uneven partners in both cases, pred and cortisol having their own little tussle and the two against PMR on the other side.

[Landerman in reply to PMRpro]

That prednisone and natural cortisol are unequal partners in PMR control is very helpful to understand. Could it be said that if half of one's steroid levels are prednisone and the other half natural cortisol from the adrenals, that the anti-inflammatory effect on PMR would be greater than all natural cortisol and no preds (even though the total amounts of steroids are the same)?

It is interesting, and complex. Thanks for your response and explanations!

[PMRpro Ambassador in reply to Landerman]

Simply put - yes.