Smallest amount of prednisone for adrenal glands to work again?

This is not something for amateurs to manage on the internet.

I don't know the answer. It is hard to find any research on this topic. My endocrinologist instructed me to stay on 3 mg for an "extended period of time" until my cortisol level improved. My instructions were not precise and I was given leeway with my dose. I was also instructed to resist the temptation to increase or decrease my dose unless it was absolutely necessary if I wanted my cortisol level to improve. My endocrinologist offered to help me determine if my dose needed to be adjusted. The 3 mg dose is sometimes called a "maintenance dose" of prednisone for people diagnosed with adrenal insufficiency.

The following is some pertinent research that I have found. One is from 1970 and the other is more recent.
https://pubmed.ncbi.nlm.nih.gov/4321238/
and
https://pmc.ncbi.nlm.nih.gov/articles/PMC10388668/).
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I don't think there is a solution to the problem with prednisone induced adrenal insufficiency. I think we just hope for the best as we try to taper off prednisone. However, a "slow taper" isn't always the best option because staying on a low "fixed dose" is sometimes necessary.

We also need to prevent flares of PMR at the same time. Both of the problems with adrenal insufficiency and flares tend to happen concurrently at low doses of prednisone.

Good luck ... Prednisone might be the first miracle for treating our conditions. Getting off Prednisone is the second miracle that needs to happen.

My story is similar to the questioner. I appreciate this answer. I am currently at 3mg again after going down to 1.5 a year ago and experiencing great fatigue a flare. I went back up to 5 mg and had a good 4 months at that dose. I am taking my time and taking smaller steps this time. My doctor will only order bloodwork every 2 months and she is pushing for a taper to 2mg after 4 weeks at 3. I want to go slower after my experience last year.

Are you seeing an endocrinologist? They are the ones to manage adrenal insufficiency. I just went to one even though I doubted that he could help since I can't get below around 5 mg prednisone without PMR pain plus lots of other symptoms. Both my rheumatologist and the endocrinologist said that nausea is a major symptom of adrenal insufficiency and I haven't had that at my lowest dose. The endocrinologist said he could help me if I got down to 4 mg of prednisone without PMR pain. He would put me on hydrocortisone which has a shorter half-life than prednisone and needs to be taken twice a day. If I understood him correctly, he would test my cortisol level and also have me try cutting back or eliminating one of the 2 daily hydrocortisone doses to attempt to stimulate the adrenal glands to produce cortisol. He told me that in my present condition, without any major side effects from prednisone, staying on 5 to 6 mg prednisone indefinitely is what I may need to do. I think you need professional advice tailored to your situation.

@linda7
"He told me that in my present condition, without any major side effects from prednisone, staying on 5 to 6 mg prednisone indefinitely is what I may need to do. I think you need professional advice tailored to your situation."
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I absolutely agree with needing professional advice when trying to discontinue prednisone after long term use.

However, in my way of thinking, needing to stay on 5 to 6 mg prednisone indefinitely for prednisone induced adrenal indefinitely is a major side effect of Prednisone.

Now it is being learned there is no safe low dose of prednisone. It hasn't been learned for PMR/GCA yet but for other autoimmune disorders like Sjögren’s and rheumatoid arthritis --- there wasn't a completely safe lower dose of Prednisone---maybe just less severe side effects on a low dose.
https://sjogrens.org/blog/2020/what-are-the-side-effects-of-low-dose-prednisone
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I was only able to discontinue Prednisone after 12 years of treating PMR when a biologic was tried. The biologic didn't suppress my adrenal function while it controlled PMR. It still took me nearly a year on low dose Prednisone for my cortisol level to improve. It took another year or two for my symptoms of adrenal insufficiency to improve. The overwhelming fatigue on low doses of Prednisone and after I discontinued prednisone was overwhelming indeed.

There wasn't that much my endocrinologist said she could do if I still needed more than 3 mg of Prednisone to control PMR. There wasn't that much she could do for adrenal insufficiency after I got down to 3 mg.

@dadcue Two professionals do not think I have adrenal insufficiency judging by my symptoms when I taper very slowly as low as I can and stay there for 10 days. There is no way I can function below 5 mg prednisone. I have tried Methotrexate, Kevzara and Actemra. There could be something else going on but I have done research and don't have any ideas and neither do my doctors. Sometimes there is not an easy answer and you just have to do the best you can with your situation. You had good results with Actemra and lots of side effects with prednisone, which is very different from my case. I don't believe that everyone who can't get off prednisone has adrenal insufficiency. My father had GCA and PMR, was on prednisone at a low dose for 10-15 years, finally got off in his early 90's and lived another 10 years without any major health problems. I hesitate to comment on this site because you have such strong opinions about prednisone and adrenal insufficiency which I do not think apply to everyone. I may not comment any more.

I think I understand what you are saying. If I don't ... keep posting so I can understand better.

I actually thought I would be fine taking Prednisone for the rest of my life when Actemra was tried. I didn't think Actemra would work and I only tried it because I made a semi commitment to my rheumatologist before he sought the authorization to treat me with Actemra.

I went into Actemra thinking I would get the "inevitable flare" over and done so I could take more Prednisone again. I couldn't function on anything less than 7 mg and 10 mg was better. If you can manage on 5 mg ... that is better than I could do.

Now ... I'm just very grateful to be off Prednisone ... that's all. If Actemra didn't work for me, I would still be taking Prednisone. Actually ... Actemra doesn't work that well for all my autoimmune conditions.

When I was on Actemra and tapered off Prednisone the first time, I had a massive flare of panuveitis shortly after tapering off prednisone.
https://www.mayoclinic.org/diseases-conditions/uveitis/symptoms-causes/syc-20378734
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My ophthalmologist was rather adamant that I be on Humira instead of Actemra to prevent recurring flares of uveitis. I went from zero prednisone to 60 mg again in one fell swoop. Humira was started and Actemra was stopped. When I tried to taper off Prednisone again ... I only managed to get back to 15 mg. My flare of uveitis was controlled but PMR wasn't.

My rheumatologist acknowledged that it would be impossible to adequately treat all of my autoimmune conditions with a single biologic. I could only be on one biologic so I needed to choose between Actemra or Humira. My only other option was to stay on prednisone. It was solely my decision to go back on Actemra because I had too much pain on Humira and I couldn't taper off Prednisone again. I only chose Actemra with the understanding that I might need Prednisone again in the future.

@bluebird25
You could try the alternating taper….1 day 4, 2day 3, 3day 4, 4day 3 etc, for 1 week….you are actually at 3.5 dose this way. Give it a week, maybe more.
Thats another way to taper slow.

@tweetypie13

That is what I have done this time to get down from 5 to 3…..very gradual transitions alternating between 5 and 4.5, then hold, 4.5 and 4, then hold, 4 and 3.5, then hold, 3.5 and 3, then hold, and now 3 mg. It has taken time. I am nervous about dropping further but will probably continue these very gradual steps. Others on this site have suggested this kind of a schedule.

If you were sick and needed stress dose steroids in the hospital the typical treatment is hydrocortisone 100 mg 3 times a day. If you are well and needed regular adrenal replacement typically hydrocortisone 15-30 mg 2 or three times a day. Prednisone equivalent 2-5 mg per day. Ask your doc about dividing the dose into 2 or three times a day, for example maybe 1 mg three times per day for the first few days.

But definitely do what your doctor recommends, my thoughts are just hypothetical.

My understanding is that the critical point for waking up your adrenal glands is somewhere between 10 mg to 0mg. The NP that works with my Rheumy says they have some patient they cannot get below 2 or 3mg. I have not had that problem.
You need to realize that once you get to 10mg then a drop by 1mg represent 10% drop. The drop between 5mg and 4mg is a 20% drop in prednisone. The percentage drop can be what you are struggling with. I have been known to take the higher dose on day one, then the 1mg lower dose on day two, alternating like this until I'm comfortable going to the lower dose. Then I stay at the lower dose for about a month before trying to drop again. Talk with your doctor to see if they are comfortable with this approach.