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Weaning from corticosteroids

Because they suppress the innate immune response and do significant long-term damage, all corticosteroids and hormonal steroids are contraindicated and must be discontinued before beginning the Marshall Protocol (MP). As damaging as they are, the abrupt discontinuation of corticosteroids can cause serious harm. MP patients currently taking corticosteroids should consult with their physicians to slowly wean off the drugs. The successful completion of this process can take months and sometimes a year or more. Members of the MP study site are advised not to begin steroid withdrawal without first discontinuing antibiotics and consulting with our support community.

Substances requiring weaning

Steroids are given by injection, inhaler, topically, nasally and via eye drops. Some can be obtained without a prescription. Of these, it is most important to wean and to wean carefully oral medications such as Prednisone.

DHEA, hormonal steroids and pregnenolone can be weaned much faster than Prednisone or cortisol. Most MP patients should be able to wean in a few weeks. A suggested schedule for weaning (as symptoms allow) is outlined below.

Steps for weaning oral corticosteroids

The following are general step-by-step suggestions on how to safely wean from high doses of corticosteroids, especially Prednisone. As always, MP patients should consult with their physicians to tailor these steps toward their individual circumstances. Please note that dividing a tablet may be necessary.

  1. 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. Occasionally, following these measures causes symptoms to increase to intolerable.
  2. Begin taking Benicar at the recommended dose: 40mg every 6-8 hours. Benicar can greatly relieve withdrawal symptoms and help ensure weaning success. It is recommended that Benicar 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. On the other hand, sometimes the immune system begins killing bacteria with the Benicar blockade in place. The resulting symptoms may make the weaning process even more difficult. If this is the case, the addition of low-dose high-frequency minocycline may be considered to act as an anti-inflammatory agent.
  3. Discontinue antibiotics. Taking antibiotics without Benicar while weaning may cause immune system reactions that result in intolerable or even dangerous symptoms. MP patients who are already taking minocycline or any other antibiotic must discontinue it at least four days (10 days for Zithromax) before starting Benicar.
  4. Divide each daily dose into a morning and an afternoon portion. Most patients taking Prednisone are told to take the entire day's dose in the morning. But the half-life of Prednisone in the bloodstream is only about four 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. (For instructions, see Dividing medications.)
  5. If the daily dose exceeds 20mg (and symptoms allow), reduce it by half every two weeks until the daily dose is 20mg. At 20mg per day, the adrenal cortex must begin to produce its own cortisol again, and the weaning process needs to progress more slowly 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 request temporary help with medications for pain, sleep, anxiety, etc. from your physician.
  6. Begin reducing the afternoon dose while maintaining the morning dose at the same level. Request a variety of tablet sizes to facilitate the fractional-dosing weaning process. When the daily Prednisone dose is below 5mg per day, 1mg tablets should be used in order to be more accurate with the dosages.
  7. When taking 10mg in the morning and 10mg in the afternoon, begin to decrease the afternoon dose by 2.5mg. Every seven days or more, decrease the afternoon dose by another 2.5mg.
  8. When the afternoon dose is zero, divide the 10mg morning dose in half again. Take 5mg in the morning and 5mg in the afternoon.
  9. Continue decreasing the afternoon dose by 2.5mg every seven or more days until the afternoon dose is again reduced to zero.
  10. Upon reaching 5mg per day, proceed more slowly. At this point, the adrenal glands need to be producing natural cortisol, as the Prednisone is no longer providing enough corticosteroid to keep the body functioning properly.
  11. At 5mg per day, it is usually advisable to reduce by only ½ mg at a time. Remain at each new dose level for periods of not less than one week and up to a month if symptoms dictate.
  12. Take 2.5mg in the morning and 2.5mg in the afternoon. Decrease the afternoon dose by ½ mg. every one to four weeks, depending on symptoms.
  13. When the afternoon dose is again reduced to zero, split the morning dose in half again and continue decreasing the afternoon dose by ½ mg as symptoms allow. Repeat the process until the dose is reduced to zero.
  14. Wait several months before contemplating the addition of minocycline. It would be very difficult to tolerate steroid withdrawal symptoms and symptoms of immunopathology at the same time.

The last few weeks on a corticosteroid are often the most difficult, and Th1 inflammatory symptoms, including pain, can continue to exacerbate for a few weeks after the last dose. Your physician may want to check adrenal function to verify that the body is, once again, producing enough cortisol.

Support while weaning is available

MP patients weaning from corticosteroids are expected to post their progress frequently in the Member Progress Forums where they can ask questions and get help with any problems that may come up. Members of the support community with experience weaning can often provide suggestions from their own experiences that will help make the weaning process more comfortable.

Side effects of weaning

Withdrawal from corticosteroids usually causes an exacerbation of existing and sometimes new disease symptoms such as pain, insomnia, breathing difficulties, fatigue and anxiety.

If prednisone is decreased too quickly below 15mg per day, the adrenal glands may not begin producing their own hormones again fast enough to meet the body's needs, and symptoms of adrenal insufficiency can result. This may be especially true of patients who have taken Prednisone for a very long time. A blood test can indicate whether or not the 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 Th1 inflammatory symptoms. Patients who have these symptoms and are concerned that they might be due to adrenal insufficiency can ask their physicians to test their adrenal function. In an emergency, the physician can also stimulate the adrenal glands with an ACTH injection, if necessary.

Withdrawal symptoms may persist after weaning

Some patients who have weaned from Prednisone report that they continue to experience the side effects of corticosteroid therapy, such as anxiety, depression and irritability for weeks or months following treatment. For this reason, adequate time to adjust is needed before starting minocycline, and the minocyline dose should be ramped slowly.

Weaning from short courses of corticosteroids

The current thinking among some physicians is that a short course of high-dose corticosteroids does not require weaning, but more than one of the MP health professionals has learned that even a single week of Prednisone requires careful weaning.

After watching her come down from 60mg of Prednisone for only five days, I will never do that to a patient again, no matter what the conventional wisdom is.

madwolf, MarshallProtocol.com

Managing withdrawal symptoms

For those who want to reduce the severity of withdrawal from steroids, there are a few options:

  1. Decrease rate of weaning.
  2. Take Benicar more frequently.
  3. Take low-dose, high-frequency minocycline.

Patient experiences

I started weaning from Prednisone at 5mg on September 27, 2005. It has taken me almost six months to get down to 0.5mg. 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 anti-inflammatory 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 [level] longer, but when I felt better I would just drop the dosage. 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 minocycline to help with symptom relief. The minocycline provides anti-inflammatory protection also.

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 minocycline, along with the other safeguards in place (NoIRs, sun/light avoidance, vitamin D avoidance, K2 cream).

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 minocycline 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, MarshallProtocol.com

Notes and comments

Adrenal crisis and severe acute adrenocortical insufficiency are often elusive diagnoses that may result in severe morbidity and mortality when undiagnosed or ineffectively treated.
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Every emergency physician should be familiar with adrenocortical insufficiency, which is a potentially life-threatening entity. The initial diagnosis and decision to treat are presumptive and are based on history, physical examination, and, occasionally, laboratory findings. Delay in treatment while attempting to confirm this diagnosis can result in poor patient outcomes.

Adrenal Insufficiency and Adrenal Crisis

References

Last modified: 01.25.2014
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