Download What Time to Take Prednisolone - PMR

What Time to Take Prednisolone, ESR & CPR Markers and Diagnosis.
There has been some considerable discussion on the ‘time’ to take your dose of Prednisolone.
We know there are different theories and that what works for one does not always work for another. But it is
worth knowing why we are advised to take it in the morning.
Recommended Time and Why.
The recommended time for taking steroids is normally as a single dose first thing in the morning as this is the
closest mimic of the body's normal production of cortisol.
By taking it like this there is the least suppression of the HPA axis which is the posh name for the
hypothalamus, pituitary and adrenal glands which produce a whole range of chemicals which together make
a lot of the rest of our body operate normally (thyroid etc).
It has been shown in studies that taking a dose of less than 15 mg* in the morning has no suppressive effect
whilst 5mg in the evening does suppress the early morning activation of the HPA axis. *Guidelines referred
to are British Society of Rheumatologists June 2009)
The anti-inflammatory effect of prednisolone lasts for between 12 and 36 hours and that is the underlying
idea of alternate day therapy (ADT) where you take double the dose one day and nothing the next.
If you are amongst the lucky people for whom the anti-inflammatory effect lasts longer you can change to
ADT with no problems on the second day and this allows your body to have a day without the suppressive
effect. On the other hand, if you start to get stiff and sore again after the 12 hours, you might feel that taking
an evening dose is helpful and this is often used for rheumatoid arthritis patients as steroids are sometimes
used together with other medications for them. Evening doses are generally to be discouraged for those with
PMR. Some people also find that they cannot sleep as well if they take the dose late in the day.
Whilst many people are terrified of taking steroids, in fact there are a lot of drugs out there for rheumatic
disease/arthritis with even worse potential side effects and which require far closer monitoring than steroids
do. But steroids have nasty side effects as well e.g. weight gain, fractures, diabetes, cataract, glaucoma,
hypertension and over–prescription and intake of steroids is not in anyone’s best interest.
Size in Relation to Dose.
Someone asked recently how the dose is decided, as we are all different sizes.
In fact, the relation is not to weight but to the area of your skin, which doesn't vary as much with weight as
you would think!
The dose you need is decided relatively empirically: it's the dose that gets rid of the symptoms! But pain in
an older person can also come from other sources such as wear and tear, which steroids relieve as well.
Basically, the lower the steroid dose the less likely you are to suffer the side-effects which is the reason for
wanting to get the dose down as low as possible as quickly as possible but is must also be as gradually as
possible.
So when you have found the dose that sorts the problem (maybe starting low and going up until you find the
right level), then you can work back down slowly until the symptoms start to re-appear and then, at this
point, go back to the dose at which you had no problems.
BSR guidelines for PMR suggest starting at 15mg. Occasionally this may need to go to 20mg, but no higher.
A need for a higher dose signals that the diagnosis of PMR may not have been correct in the first place. If
your Doctor thinks you might have GCA then the dose will be higher – they are not exactly the same disease,
just related.
In some cases a change of half a mg over 2 days is the difference between being near enough pain-free and
able to do a lot of things or being in constant pain and able to do almost nothing. After a stabilisation period it seems best to be several weeks - it's worth trying again to reduce. It seems to me that there is little point
reducing the dose for the sake of reducing it: if such a small difference in dose makes such a big difference in
physical status, stick with the dose that works for a bit longer.
Note: Medical people advise that below a dose of 5 mg they are less than enthusiastic of drastic reduction if
there is symptom recurrence.
Remember, going down 1mg from a dose of 10mg is a 10% reduction, going down 1mg from 5mg is a 20%
reduction – double the jump.
And yet again, let us emphasise that you must always bear in mind that steroids ARE NOT A CURE for
PMR, they make the symptoms manageable by reducing the amount of inflammation.
ESR and CRP Markers (Rates).
An interesting fact is that there is not necessarily a relationship between your symptoms improving and the
inflammatory markers changing (the ESR and CRP) so if you feel OK at a lower dose there is absolutely no
need to stay on a higher dose just because the ESR stays high. (In the UK, different hospitals use different
marker levels there does not seem to be a consensus).
Your ESR is only a very non-specific indication that there is something wrong - it may be high if you have a
cold - and may never have been increased in some patients. It is a guide, no more than that, and may be
misleading.
PMR should be suspected on the basis of the CLINICAL HISTORY and presence of at least 3 of a group of
about 8 or 9 certain quite specific symptoms (amongst them shoulder pain/stiffness, hip girdle pain/stiffness,
more than 1 hour early morning stiffness, stiffness after not moving for a short time, night sweats,
joint/tendon pain) and exclusion of other possible things such as hypothyroidism, rheumatoid arthritis and
other causes of inflammation, infection or nastier conditions sometimes such as cancer .
A rapid response of these symptoms to a moderate dose of steroids (not more than 20mg) is typical for PMR
and should be taken as fairly confirmatory of the diagnosis. They will help loads of other diseases but it is
the speed of response which so characteristic. The response in PMR is also complete (normal inflammation
as well) and sustained
Far too many of our problems in being diagnosed are due to a lack of clinical skills and too heavy
dependence on "the lab values". Most practices have only a few diagnosed cases on their books and the line
taken is "it's not typical". If this is not typical the GP should refer patients to a Rheumatologist.
My response to that is that some 50% of cases will fall outside the "average" and a total of 10% will fall into
the little black hole at each end of the normal distribution curve (that bell-shaped curve in statistics) which is
below the 95th percentile and considered as way out - so one in ten of us could be considered to not exist!! "
This article was written by a patient for patients. It has been checked to ensure that the medical
parts are correct at the time of writing. June 2010.
Website www.pmr-gca-northeast.org.uk
Email [email protected]