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Meg Mangin R.N.
Research Team (on leave)
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Posted: Sat Jul 5th, 2008 21:35 |
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Weaning From Steroid Medications
Some people with inflammatory diseases who want to try the Marshall Protocol (MP) are taking cortisosteroids[1] or hormonal steroids. Th1 inflammation is caused by intracellular bacteria and all steroids are contraindicated in the presence of bacterial infections and on the Marshall Protocol.
This document discusses weaning from oral steroid use. Steroids are also given by injection, inhaler, topically, nasally and via eye drops. Some can be obtained without a prescription. The use of all these products is contraindicated because they are absorbed systemically and will, to some degree, inhibit the immune system. They can also cause adverse side effects.
All oral, topical, nasal, inhaled and injected steroids must be discontinued before starting the minocycline.
Symptom palliation
Withdrawal from steriods usually causes an exacerbation of disease symptoms and often symptoms unique to steroid use. As well as your scripts for Benicar (and minocycline to have on hand) please consult with your doctor to obtain palliative medication for relief of symptoms such as pain, anxiety, and insomnia.
Occasionally steroid eye drops must be used to ameliorate dangerous inflammation. Talk to your doctor about weaning these steroid product/s as soon as the acute inflammation is under control.
Corticosteroids
Corticosteroids are a family of drugs that include synthetic drugs such as prednisone and cortisol (hydrocortisone) an adrenal hormone which is found naturally in the body. Though synthetic and natural corticosteroids are both potent anti-inflammatory compounds, the synthetics exert a stronger effect.
Corticosteroids- Rx & OTC [1]
Prednisone
Prednisolone
Beclomethasone
Beclomethasone (Beconase)
Betamethasone
Cortef/cortisol
Cortisone
Deflazacort
Dexamethasone
Dexamethasone (Decadron)
DHEA
Fluticazone (Flonase)
Fludrocortisone (Florinef)
Hydrocortisone (Cortef)
Methylprednisolone
Triamcinolone
Prednisone
Prednisone ruthlessly suppresses the immune system. It stops the body from fighting the pleomorphic, intracellular bacteria that trigger Th1 inflammatory diseases and, consequently, reduces the inflammation the body produces during that fight. This results in a temporary reduction in inflammatory symptoms such as joint/muscle pain, skin lesions, fatigue and shortness of breath. Chest Xrays often clear (temporarily) and the ACE level always falls (temporarily).
Meanwhile, the bacteria continue to multiply in the tissues without any hindrance because prednisone has shut down the body's ability to fight them. If prednisone is discontinued, relapse will occur, with previous inflammatory symptoms returning, often worse than before.[2]
Prednisone mimics the function of the natural hormones produced by the adrenal glands. When prednisone is taken for long periods of time, the production of natural adrenal hormones decreases because of the prednisone's effect on the pituitary, the master gland that controls the adrenals. This typically happens when the dose is higher than 5-7mg per day and used for periods longer than one month.
Stopping long-term, high-dose prednisone suddenly or weaning too quickly is dangerous.
Weaning from prednisone causes the return of the Th1 inflammatory symptoms that it was suppressing.[3] These withdrawal symptoms are usually not dangerous but they can be very uncomfortable, making it extremely difficult for some people to complete the weaning process. After you have weaned and proceed on the MP, keep in mind that prednisone's effect on the immune system may linger for months and could, therefore, continue to inhibit the immune system for some time.
Cortisol
Cortisol (Cortef) has an equivalency to prednisone of approximately 1:2. In other words, 5 to 10mg of Cortef is equivalent to 2.5 to 20mg of Prednisone.
DHEA
Taking DHEA supplements directly affects the operation of the Nuclear Receptors, and will delay or prevent recovery from Th1 disease. DHEA is a steroid, with actions very similar to corticosteroids, like prednisone. Although it is palliative, and reduces symptoms, it does that at the cost of slowing recovery and increasing the risk of complications from steroid use. You will need to wean off DHEA. After establishing the Benicar blockade, reduce the dose incrementally as slow as necessary to keep symptoms tolerable.
Hormonal steroids
All the steroid hormones (depending on dose) have the potential to interfere with Benicar’s control of Vitamin D Receptor and PPARgamma and it's enabling effect on the immune system. After establishing the Benicar blockade, reduce the dose incrementally as slow as necessary to keep symptoms tolerable.
Pregnenolone
Pregnenolone is a steroid hormone involved in the steroidogenesis of progesterone, mineralocorticoids, glucocorticoids, androgens, and estrogens. As such it is a prohormone and must be weaned.
Pace of weaning DHEA, pregnenolone or hormonal steroids
DHEA, hormonal steroids and pregnenolone can be weaned much faster than prednisone or cortisol. You should be able to wean in a few weeks. A suggested schedule (as symptoms allow) is to half the daily dose each week times two, then take the lowered dose every other day, then discontinue.
Weaning guideline
Weaning from steroids can be a difficult process and guidance is sometimes lacking. Based on the experience of many who have successfully weaned, we offer the following guideline. It is written with prednisone doses in mind but can be adapted for those of you who must wean from any other steroid/s.
As always, consult with your physician regarding specifics related to your situation and work closely with him/her to monitor your progress as you wean.
Benicar
The adrenal glands stop producing cortisol when someone takes a steroid like prednisone at high enough doses for a lengthy period. Reducing the steroid dose without counteracting the resulting rebound inflammation with a Benicar blockade could be dangerous and we do not recommend it.
Benicar[4], an angiotensin receptor blocker, can greatly relieve these symptoms and ensure weaning success. It is recommended that it be started a week or two before beginning to wean. This will make the process easier by allowing the body to adjust to the hormonal changes caused by Benicar before the body needs to step up production of its own cortisol.
The recommended dose of Benicar is 40mg every six to eight hours to provide this essential inflammatory blockade.
Continue the Benicar blockade for one-two weeks before beginning the weaning process to allow the symptoms caused by hormonal changes to subside. See I just started Benicar. Why do I feel worse? What should I do? and How long should I stay on Benicar? Why don't I feel better?
Discontine antibiotics
If you are already taking minocycline or any other antibiotic, you must stop taking it at least 4 days (10 days for Zithromax) before you start taking Benicar. Taking antibiotics may cause immune system reactions that result in intolerable or even dangerous symptoms.
Avoid Vitamin D
It is also recommended to avoid all forms of ingested Vitamin D (food and supplements) and sun/lights, including wearing NoIR sunglasses (indoors and outdoors). This will help prevent symptoms caused by dysregulated vitamin D metabolism, which could add to the discomfort. These measures should also be started at least a week before beginning to wean from prednisone.[5] Ocasionally, following these measures causes symptoms to increase to intolerable. Please see Should I avoid sun exposure and vitamin D while I'm waiting to start the MP?
Weaning details
Most people are told to take the entire day's dose of prednisone in the morning. But the half-life of prednisone in the bloodstream is only 4 hours. Dividing the daily dose in half and taking one-half in the morning and one-half in the late afternoon (not at bedtime to avoid disrupting sleep) may alleviate some withdrawal symptoms.
Weaning from a high dose of prednisone to a moderate dose can be accomplished fairly quickly and safely. If symptoms allow, it is suggested that every two weeks the total daily dose be reduced by half until 20mg per day is reached. At 20mg per day, the body (adrenal cortex) must begin to produce its own cortisol again and the weaning process needs to go slower to minimize withdrawal symptoms and to avoid dangerous repercussions related to a lack of natural cortisol.
If withdrawal symptoms are intolerable, go slower and/or ask your doctor for temporary help with medications for pain, sleep, anxiety, etc.
At this point, begin your reductions with the PM dose, keeping the morning dose the same. Ask your doctor for a variety of tablet sizes to facilitate the fractional-dosing weaning process. When you get below 5mg of prednisone per day, you will want to be using 1mg tablets in order to be more accurate with the dosages.
The following schedule should allow for the safe return of adrenal cortex functioning:
You are now taking 10mg in the morning and 10mg in the late afternoon.
Every 7 days or more, decrease the PM dose by 2.5mg. When the PM dose is zero, divide the morning dose in half again (you will be taking 5mg in the morning and 5mg in the late afternoon) and continue decreasing the PM dose by 2.5mg every 7 or more days until you have reached 5mg per day.
When you have reached this milestone of 5mg per day, you must proceed more slowly. At this point you need your own adrenal glands to be producing natural cortisol, as the prednisone tablets no longer are providing enough corticosteroid to keep your body functioning properly.
At 5mg per day, it is usually advisable to reduce by only ½ mg at a time, remaining at each new dose level for periods of not less than one week and up to a month if symptoms dictate.
Take 2.5mg in the morning and 2.5mg in the PM. Decrease the PM dose by ½ mg. every one to four weeks, depending on symptoms. When the PM dose is zero, split the morning dose in half again and continue decreasing the PM dose by ½ mg. as symptoms allow. Repeat the process until you aren't taking any prednisone.
Adrenal insufficiency
If prednisone is decreased too quickly below 15mg per day, the adrenal glands may not begin making their own hormones again fast enough to meet the body's needs, and symptoms of adrenal insufficiency can result. This is especially true if you have taken prednisone for a very long time. Your doctor can measure the cortisol in your blood to make sure your own body has started to manufacture cortisol again.
The symptoms of adrenal insufficiency which can occur during this last phase of the weaning process (below 15mg) are nausea and vomiting, anorexia, extreme fatigue, muscle pain, lethargy, dizziness, shortness of breath, weakness, joint pain and positional hypotension (low blood pressure).
Some of these symptoms may be similar to your Th1 inflammatory symptoms. If you have these symptoms and are concerned that they might be due to adrenal insufficiency, you can ask your doctor to do tests of adrenal function. In an emergency, your doctor can also stimulate the adrenal glands with an ACTH injection, if necessary.
Nearing your goal
The last few weeks on prednisone are often the most difficult and Th1 inflammatory symptoms, including pain, can continue to exacerbate for a few weeks after the last dose. Your doctor may want to check adrenal function to verify that the body is, once again, producing enough cortisol. Please see Adrenal Function Tests
Withdrawal symptoms may persist after weaning
Some patients who have weaned from prednisone report that they continue to experience the side effects of steroid therapy, such as anxiety, depression and irritability for weeks or months following treatment so give yourself time to adjust before starting minocycline and keep this in mind as you ramp up the minocyline dose slowly.
Minocycline
It is essential that you complete the steroid weaning process and wait at least two weeks before you begin minocycline. It would be very difficult to tolerate steroid withdrawal symptoms and immunopathology symptoms at the same time.
Moderator assistance is available
You are expected to post a weekly progress report in the Weaning from Steroids forum where you can ask questions and get help with any problems that may occur. The moderators can provide many suggestions to make the weaning process more comfortable.
Immunopathology
Occasionally, the immune system begins functioning with the Benicar blockade in place and begins killing bacteria. These immunopathology symptoms may make the weaning process even more difficult. In that case, the addition of low-dose, frequent minocycline may be considered to act as an anti-inflammatory agent.
Steroid use on the MP
While on the MP, limited use of sniffed, inhaled or topical steroids is allowed for intolerable symptoms of nasal congestion, shortness of breath or itching if management of MP medications fails to dampen immunopathology symptoms. Steroid eye drops may be necessary. Please see EYE INFLAMMATION.
References:
1. Medications To Avoid While On the Marshall Protocol
2. Outcome in Sarcoidosis. The Relationship of Relapse to Corticosteroid Therapy.
3. An Approach to the Treatment of Pulmonary Sarcoidosis with Corticosteroids
4. Putative Antibacterial Mechanisms for Angiotensin II Receptor Blockers
5. Photosensitivity During Recovery from Th1 Inflammatory Disease
(C)Copyright 2004 SarcInfo.com All rights Reserved. Revisions: Jan 05 & Aug 07
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Nothing contained in this site is or should be considered, or used as a substitute for, medical advice, diagnosis or treatment by your physician.
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