Patients like prednisone for PMR. It works rapidly and that is what patients know and care about the most. There are also people who think doctors are idiots for not treating PMR correctly because they don't prescribe enough prednisone.

It is a tough decision for doctors to make. They don't enjoy their patients being in pain. However, they are reluctant to prescribe liberal doses of prednisone on a long term basis because they are fearful of the long term side effects.

I don't know the answer to this dilemma. Until something else works medically as well as prednisone, that is what we are stuck with.

I had a love/hate relationship with prednisone. I knew Prednisone wasn't good for me but I didn't think there were any alternatives to prednisone. I'm just happy my rhematologist was willing to try something that wasn't prednisone. The other part was my willingness to try the alternative.

Have you seen the cartoon about the running faucet with the sink overflowing?? The doctors are mopping up the mess without turning off the faucet. The carton wasn't about chronic inflammation but it seems pertinent to PMR.
https://www.facebook.com/watch/?v=3392414987722454
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https://www.liminstitute.org/publications/blog-post-title-two-3gz9m

The body does not produce more cortisol to shut down what the body (wrongly) perceives is an attack on itself which prompts a very strong immune response. The body doesn't know it's made an immune reaction mistake and is attacking healthy cells. So we need to add a drug to control the inflammation and pain caused by the attack. That's my understanding.

So, what can anyone, including docs, do to adjust this cortisol level?
I think it requires testing and close monitoring and most docs don't want to deal with that today. They like pred because it's quick. I don't know how they handle the barrage of complaints about the side effects, which must drive them crazy, and surely they don't have the time to deal with all of them, but that's not my problem. They prob have stock answers at the ready.

At any rate, here's what I found as a first response to the question about how docs adjust cortisol levels:

"Doctors can treat high cortisol levels, also known as hypercortisolism, with medications that control cortisol production in the adrenal glands. These medications include:
Ketoconazole, Osilodrostat (Isturisa), Mitotane (Lysodren), Levoketoconazole (Recorlev), Metyrapone (Metopirone), and Mifepristone (Korlym, Mifeprex).

Medicines to control cortisol production at the adrenal gland include ketoconazole, osilodrostat (Isturisa), mitotane (Lysodren), levoketoconazole (Recorlev), and metyrapone (Metopirone). Mifepristone (Korlym, Mifeprex) is approved for people with Cushing syndrome who have type 2 diabetes or high blood sugar. Jun 7, 2023"

Things we can do to help lower cortisol:

"Here are some things you can do to adjust cortisol levels:
Exercise
Regular exercise can improve cortisol levels in the long term, but some studies suggest that the best intensity level is unclear. The Physical Activity Guidelines for Americans recommend 150 minutes of moderate-intensity exercise and two days of muscle-strengthening activities per week. It's also important to stay hydrated, especially during hot weather.

Stress management
Try relaxation techniques like deep breathing, meditation, or journaling. You can also try spending time with supportive people, taking time for yourself, or setting boundaries in your relationships.

Diet
Eat a balanced diet that includes 30 different types of plants per week, like live yogurt, kimchi, kombucha, kefir, and sauerkraut. Avoid foods that increase cortisol, like caffeine, alcohol, saturated fats, and simple sugars.

Supplements
If recommended by a doctor, supplements like magnesium, vitamin B12, folic acid, and vitamin C can help regulate cortisol levels. "

Getting enough sleep and being out in nature were also suggested.

Best to all.