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Meg Mangin R.N.
Research Team
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Posted: Fri Jan 21st, 2005 01:33 |
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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 5-7 days, 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 5-7 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 07Last edited on Mon Mar 10th, 2008 15:45 by Meg Mangin R.N.
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Meg Mangin R.N.
Research Team
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Posted: Sun Nov 20th, 2005 01:48 |
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Adrenal function tests
(filelink)
Taking corticosteroids (usually prednisone) can cause the adrenal glands to stop producing cortisol. Weaning from the long-term use of prednisone can cause temporary, secondary hypoadrenia (low production of cortisol by the adrenal glands).
Hypoadrenia symptoms include fatigue, joint pain, muscle aches, depression, impaired cognitive functioning, and digestive problems. The symptoms may go away after a few weeks or a few months. Full recovery can take up to one year after cessation of prednisone administration.
To determine how the adrenal glands are recovering from long-term prednisone use after weaning, your doctor may perform some tests.
Cortisol
The cortisol level measures the amount of cortisol being produced by the adrenal glands. Cortisol blood tests may be drawn at about 8 am, when cortisol should be at its peak, and again at about 4 pm, when the level should have dropped. Sometimes a resting sample will be obtained late in the evening to look at cortisol when it should be at its lowest concentration in the blood (about midnight). Obtaining more than one sample allows the doctor to evaluate the daily pattern of cortisol secretion (the diurnal variation).
Another cortisol test called the ACTH (Cortrosyn) stimulation test may be done. The am cortisol level is drawn, for a baseline, then a hormone is injected that challenges the adrenals. After a certain amount of time, either 30mins, 45mins, and/or 1-2 hrs later, more blood is drawn. This second test is compared to the baseline, and if the adrenals are working properly, the cortisol level should approximately double. The baseline cortisol is also taken into account.
ACTH
ACTH (adrenocorticotropic hormone) produced by the pituitary, stimulates the adrenal cortex to produce cortisol. It is a messenger -- it tells the adrenal cortex to produce cortisol. If there is insufficient ACTH then cortisol production is not stimulated.
Secondary adrenal insufficiency is due to a decrease in the production of ACTH and one cause is the use of corticosteroid therapy such as prednisone, especially if steroids are abruptly halted or weaned too rapidly. It can take several weeks or months for normal ACTH production to resume. With secondary adrenal insufficiency, aldosterone production by the adrenal cortex is usually not affected.
The level of ACTH may be tested if an abnormal cortisol level is detected and it may provide the clinician with information on how well the adrenals are being signalled to perform. As plasma cortisol levels increase, ACTH secretion is suppressed. As cortisol levels decrease, ACTH increases.
It isn't unusual for persons who have weaned from long-term prednisone use to have slightly lower than lab range levels of cortisol for some time as the adrenals slowly recover. This does not usually present a problem and the symptoms of adrenal insufficiency will slowly resolve.
........................
Dr. Marshall has said:
"The metabolite which is affected by the Th1 inflamation is actually ACTH, and (if necessary) you might be better to supplement that than the Cortisone itself. ACTH stimulates the release of Cortisol, of course, and ACTH is suppressed when paracrine 1,25-D is high (from the inflammation in your glands)."
Related info:
Adrenal Insufficiency and Adrenal Crisis
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Meg Mangin R.N.
Research Team
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Posted: Sat Feb 4th, 2006 15:04 |
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Adrenal insufficiency and Th1 inflammation
Question:
I've noticed that more than a few MPers have adrenal insufficiency (Addison's disease) and have been taking hydrocortisone (cortef). In your paper you write "Ripple-down effects of VDR activation include changes not only to the androgens and thyroid hormones, but also to ACTH, Insulin Receptors, P450C1, and many other biologically important metabolites". Since ACTH stimulates the adrenals to make cortisol, do you think that elevated 1,25D levels could be a cause of adrenal insufficiency? And could a Benicar blockade alleviate this condition?
Answer:
First let me emphasize that you are talking about adrenal sufficiency due to the disease, insufficiency which was in place long before the patient started the MP.
Second, yes, abnormalities of the adrenal cortex, as well as of the thyroid, are often due to Th1 disease, not just by circulating levels of 1,25-D (which are fairly low) but especially by local paracrine levels due to local inflammation of the organs concerned.
It is typical for both of these problems to ease as folks progress through the MP.
An endocrinologist might find the chart we prepared at http://autoimmunityresearch.org/hormones.pdf some help, and it cites two Pubmed papers as sources (at lower right of image).
..Trevor..
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Synacthen is a long-acting adrenal stimulant. More info is available here:
http://www.medsafe.govt.nz/Consumers/cmi/s/synacthen.htm
Note that it should not be used if there is "a mental illness with disturbances in thinking, feelings and behaviour"
Doctors may want to give Syncathen if cortisone production is low (which is common in Th1 patients). Modern medicine believes that the way to treat disease is to give a drug to try and "normalize" the body's function. Rather than trying to understand the way the body works, modern medicine has created a set of rules to diagnosis, and then a number of rules as how to treat each diagnosis.
We are slowly changing that paradigm, but, in the meantime, it has proven quite dangerous for folk whose immune system have been "switched on" again by the MP to encounter physicians who are trained only in the pragma of "normalize." This is an especial risk in a hospital environment, where 'normalize and discharge' is the pragma. It is just not possible to fight these Th1 diseases with drugs, one has to understand and work with the body's response, rather than against it.
..Trevor..
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Meg Mangin R.N.
Research Team
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Posted: Tue Feb 28th, 2006 02:34 |
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link
Suggestions to help dampen steroid withdrawal symptoms
Palliative meds
It's okay (and may be essential to successful) to take palliative medications during the weaning process. If you need specidic guidance, ask a moderator.
Increase Benicar
Sometimes, the Benicar blockade, even while still on steroids, enables the immune system to function effectively, adding immunopathology symptoms to withdrawl symptoms and symptoms of disease relapse. If these symptoms become intolerable, increasing Benicar may help. See When and why should I vary my Benicar schedule?
Low-dose, high-frequency minocycline
If that doesn't help, the addition of low-dose, high-frequent minocycline (more often than every other day) may help reduce the inflammatory symptoms. See Why and when do you recommend taking minocycline frequently?
Last edited on Thu Nov 15th, 2007 06:02 by Meg Mangin R.N.
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Meg Mangin R.N.
Research Team
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Posted: Tue Feb 28th, 2006 02:41 |
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link
Prednisone's effect on the immune system may affect your progress on the MP
If you have been taking steroids, the immunosuppressive effect may be felt for months after weaning. This can diminish the immune system reaction (immunopathology). Patience is the answer. We caution not to increase minocycline too fast in case the immune sytem becomes active suddenly.
The way to know when you are no longer immunosuppressed is by observing your immunopathology symptoms.
Short course of high dose prednisone
The current thinking among some doctors is that a short course of high dose prednisone does not require weaning. One of my elderly Home Care patients had high dose prednisone abruptly discontinued after one week with a disastrous rebound symptom effect.
Please check with your Doctor about a weaning schedule if your dose has been short-term. It could probably be relatively rapid but I would not recommend a sudden cessation of prednisone no matter how short the course of treatment. ~Meg Mangin R.N.
-After watching her come down from 60mg of prednisone for only 5 days, I will never do that to a patient, again, no matter what the conventional wisdom is. ~madwolf, P.A.
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Aussie Barb
Research Team
| Joined: | Thu Jul 22nd, 2004 |
| Location: | Australia |
| Posts: | 18768 |
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Posted: Sun Apr 30th, 2006 02:05 |
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link
Members' experiences
-It's good to see you're making progress. I know it's challenging for you right now, but you can make it, one step at a time. I started weaning from prednisone at 5 mg on 09/27/05. It has taken me almost six months to get down to 1/2 (.50) mg. I started out taking Benicar every six hours for two weeks prior to beginning the weaning process. Taking the Benicar will help your system build up the antiinflammatory blockade needed to compensate for the reduction of prednisone.
Because of different symptoms arising during the course of weaning, I found I had to stay at a certain milligram longer, but when I felt better I would just drop the dosage. Bro, this treatment will be at your comfort level. No one knows your body better than you.
At times I even had to increase the Benicar dosage because of sun exposure or eating something containing D. I've also started taking frequent Minocin to help with symptom relief. The Minocin provides antiinflammatory protection also.
Bro, in reading your threads or posts, I did not see where you were taking the Benicar or the Minocin. You know, I've been on prednisone since 1985, at different dosages, of course, but I was never able to wean off, no matter how hard I tried or how much I wanted to. The MP has allowed me to basically take control of my health and say no more to prednisone. But, I have only been able to do that with the assistance of Benicar and Minocin, along with the other safeguards in place (NoIRs, sun/light avoidance, vitamin D avoidance, K2 cream).
Bro, it's going to take time. You know, we didn't get sick overnight! Plus, I keep reading how these are such slow-growing bacteria. Get your Benicar and Minocin and follow the guideline for weaning. Print it off, if you can. It helps to be able to read it from time to time. Be patient. We don't have to rush in this race. We will all be winners. We are in control now. ~Toni D
See Toni D Weaning Testimony:
____________________
Barb: Dx Inflammatory Disease Endocrine Imbalance 2003| 24+ years not Dx| Cut D/exp July04| NoIR Aug04 Comm Beni|Q| Sept05 off Thyroxine| CLICK ABCofMP
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Aussie Barb
Research Team
| Joined: | Thu Jul 22nd, 2004 |
| Location: | Australia |
| Posts: | 18768 |
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Posted: Fri Aug 4th, 2006 19:50 |
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link
How to divide a 1mg Prednisone tablet
Buy a sharp pill cutter. It's a small rectangular box. It costs around $2 or $3. It's well worth it.
-Just cut on the score to divide in half and then
-take each half and wedge down to the V and lower the cutter and there you go! You'll have 4 pieces equalling .25 mg.
Just take your time and make sure you do it when your eyesight is not blurry. Your pieces will be more or less equal in size. Just like dividing the Minocin into the gel capsules. Can't do it when your eyesight is blurry or at the last minute when you need to be popping a pill.
Otherwise you can crush the pill, and divide on a mirror or clean surface and divide into 4 equal doses and place in fresh empty capsules..
Label clearly and store safely in airtight container. ~ToniD
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Barb: Dx Inflammatory Disease Endocrine Imbalance 2003| 24+ years not Dx| Cut D/exp July04| NoIR Aug04 Comm Beni|Q| Sept05 off Thyroxine| CLICK ABCofMP
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Meg Mangin R.N.
Research Team
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Posted: Sat Aug 26th, 2006 00:16 |
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Cortisol is not a supplement
(cortisolfilelink)
"In March I gave a Visiting professor presentation to the FDA Center for Drug Evaluation and Review:
Marshall TG: Molecular genomics offers new insight into the exact mechanism of action of common drugs - ARBs, Statins, and Corticosteroids. FDA CDER Visiting Professor presentation, FDA Biosciences Library, Accession QH447.M27 2006
Copy available from URL http://autoimmunityresearch.org/fda-visiting-professor-7mar06.ram
The problem with viewing Cortisol "supplement" as a "replacement" is that Cortisol is a steroid, not a supplement. The body exquisitely balances the endogenous production of its steroid hormones in a manner which cannot be mimicked with endogenous drugs.
During my FDA presentation I explained the action of Cortisol on the innate immune system, the sympathetic immune system, the progesterone system, and the thyroid metabolism, via the respective nuclear receptors.
You might look at helping the patient with some ACTH stimulation. Endogenous production of ACTH has to be restored after a long period of administration of exogenous steroid, and sometimes this can take 6-18 months to get back to natural levels.
Our "weaning from steroids" document explains how to use Olmesartan to balance the immunosuppressive effects of the steroid, and help people wean from steroid dependence."
..Trevor..
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