Conflict with Rheumatologist over taking Prednisone for PMR in AM/PM

Cortisol is the lifeblood of your system. Your body needs it to survive. Therefore when taking steroids you replace your natural cortisol with prednisone produced. Thats why you taper when reducing the prednisone. Your body has a natural way of producing cortisol. It revolves around your sleep schedule. It also has many other triggers like stress throughout the day. I am guessing, but your Rhumy is worried about how you are providing your body its cortisol. It would be an unnatural production all at night. Prednisone has a half life of about 4 hrs and full life of about 12hrs. So it doesnt stay long . Here is a clip from an internet search.
"Your sleep-wake cycle follows a circadian rhythm. Every 24 hours, roughly synchronized with nighttime and daytime, your body enters a period of sleep followed by a waking period. The production of cortisol in your body follows a similar circadian rhythm. Cortisol production drops to its lowest point around midnight"

I take most of the dose in the morning and a smaller part of it, 2mg, early evening which definitely helps reduce morning aches. I'd previously thought that the morning dose was to more closely mimic the body's natural cortisol production throughout the day. Plenty of websites had said so, and the rationale for morning dosing was to reduce the chances of our adrenal glands not kicking back into production as we reduce and finish prednisone.

Now I'm confused. The image attached is natural cortisone production, with the peak being around 5am to 9am with a quick decline in level for the rest of the day. We do the opposite with a morning dose, taking the big prednisone dose as natural cortisol would be dropping fast. So you raise a good question. This is one of those times I wish we had doctor experienced with prednisone to answer our questions.

Hi @brian1950, you might also be interested in this related discussion:
- Timing of taking prednisone: https://connect.mayoclinic.org/discussion/timing-of-taking-prednisone/

It sounds like taking prednisone in the evening works well for you. I would want to understand better why they are making the recommendation and the goal of treatment and would ask questions like:
If taking it in the evening is working for me, what is the advantage of splitting the dose?
What is the goal of treatment?
Is there a risk associated with taking the full dose in the evening only?
In your experience and opinion, what is the advantage of taking it in the morning?

Brian, did you ask your rheumatologist whey they recommend taking in the morning or splitting the dose between the morning and evening?

The only advantage of taking the entire dose in the morning is supposedly the risk of developing adrenal insufficiency is less. Cortisol release from the adrenal glands follows a circadian rhythm with cortisol levels starting to decrease when we are getting ready for bed and increasing prior to waking up. Prednisone taken in the evening interferes with this sleep/wake cycle so it makes it hard for some people to fall asleep.

The artificial cortisol from Prednisone replaces the cortisol from the adrenal glands. Taking Prednisone in the early morning mimics the circadian rhythm of cortisol release more closely. I woke up in pain at 3 a.m. so that was when I took Prednisone. Prednisone doesn't stay in the system for a full 24 hours so the inflammation reducing effects were wearing off at about 3 a.m.

When I took my entire dose in the morning at 8 a. m. the early morning pain also disrupted my sleep/wake cycle. With a split dose, most of my Prednisone dose was at 8 a.m. while the rest in the evening allowed me to sleep the entire night without pain. I took 2/3 of the dose in the morning and 1/3 of the dose in the evening.

This link explains the sleep/wake cycle of cortisol release and how cortisol levels affect sleep.
https://sleepdoctor.com/how-sleep-works/cortisol/
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When I wasn't having pain in the middle of the night, I switched to taking my entire dose at 8 a.m. in the morning:

See the link below.
#6. Morning dosages are usually best for prednisone
If you take prednisone daily, for a long period, it can cause adrenal gland suppression. This is when your body stops producing cortisol by itself.

If you are on daily prednisone, experts recommend taking the dose in the morning, to reduce this risk. Taking prednisone too late in the evening can cause sleeplessness and insomnia, too. Make sure you also take your dose of prednisone with food, and just FYI, grapefruit juice has no effect on prednisone.

Prednisone has long-lasting effects and is usually prescribed once daily. Occasionally, people on higher dosages are instructed to take it twice a day for short periods before dropping it down to just a single dose.
https://www.drugs.com/medical-answers/prednisone-12-things-you-3573757/b
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By the way ... I don't think the early more pain had anything to do with a "new batch of inflammatory substances being released and they needed to be mopped up with Prednisone."

The inflammation is chronic so it is there all the time. Either cortisol or Prednisone is needed to regulate inflammation levels. If we decide to take Prednisone then the body turns off the production of cortisol. The cortisol suppressing effects caused by Prednisone makes it difficult to taper off Prednisone.

I take about half my daily dose at evening meal.

I started splitting my dose AM & PM after I read about someone else doing it, because I was waking up with pain and stiffness if i took the whole dose in the AM. Probably do what works best for you.

"Taking Prednisone in the early morning mimics the circadian rhythm of cortisol release more closely."
That's what some doctors say. Others recommend delayed release prednisone tablets to be taken at night that take effect before we wake to do away with morning waking pain. (Delayed release are not available in Australia). Split doses are recommended by other doctors to control morning pain, usually with the recommendation that no more than 1/3 of the daily dose should be taken at night.

One reason for not dosing at night, or for keeping the evening split dose fairly small, is that it can upset sleep in some people. That doesn't seem to be the case for @brian1950 and others of us who take a split dose.

Although it's repeated often and I used to repeat what you're saying too, the graphs of actual natural cortisol production say otherwise. Natural cortisol drops fast after we wake up.

I guess you could read from the chart that it tails off fast but it still says between 6a - 9am is the highest all day. Yes it tails off but I dont read the chart contradicting anything that was said. Its highest in the morning and tails off to nothing but midnight. I did read somewhere, to lazy to go look, that people that work night shift or up during the evening manage to manipulate their circadian rhythm. It definitely was not me. I worked third shift for about a year. About died from no sleep. I think Brian1950 original question was why the Rhumy pushback. I think this is a good explanation but only his DR knows. I say whatever works best. Maybe Brian1950 sleeps all day. I take about an hour nap.

Those nice smooth curves don't show what actually happens to cortisol levels. When the "average levels" are graphed, the graph doesn't represent what actually happens. My understanding is cortisol levels fluctuate throughout the day depending on what happens during the day.

The whole point being --- a daily dose of Prednisone is never going to duplicate what the HPA axis does and how cortisol levels are regulated by the body. Prednisone only puts a wrench into the entire mechanism.

Figure #1 in the following link illustrates the problem with averages.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475279/
"The peaks of cortisol at noon and around 18:00 represent meal-induced cortisol stimulation."
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Everyone will have a different curve because we are all individuals.

No two days are the same so the curve on one day won't be the same on another day.

My endocrinologist says checking single cortisol levels doesn't show the bigger picture. This is one reason why adrenal insufficiency is so difficult to diagnose and treat.

And that raises other questions.
1. If the natural cortisol level is highest early in the morning and cortisol is supposed to help with PMR pain, why is that the time that PMR pain is often worst?
2. Why are we told the best time is morning dosing when that extends the peak cortisol level well beyond the natural mid morning reduction? Does extending the peak cortisol time more effectively control inflammation, or...?
3. Since everyone's cortisol fluctuations are different, why do some doctors continue to push the one-size-fits-all regimen of one dose in the morning only, especially when altering that regimen would result in less pain and inflammation for some people?

I'm not expecting you to answer the questions, just posing them.