Dr. Boers is careful to counsel his patients regarding possible side effects from taking glucocorticoids. For example, he advises them to resist the feelings of abnormal hunger, which may accompany the first few weeks of therapy, and to eat normal amounts to avoid weight gain. Before an injection of the drugs, he warns them about the effects of restlessness and a boost of energy. “If you explain things, people are very accepting,” he says.
Timing Is All
Dr. Cutolo has conducted many studies on the use of nighttime-release prednisone to combat the morning stiffness that is characteristic in RA, and which is a consequence of the circadian night reactivation of the immune/inflammatory process. If given in lower dosages, especially with attention to the body’s circadian cycles, says Dr. Cutolo, glucocorticoids function as hormone replacement for adrenal insufficiency. “You don’t expect any damage because you give the right dosage at the right time; it’s like giving insulin in diabetes,” he says.
The theory behind this approach is that the clinical efficacy of late-night (as opposed to upon-awakening) prednisone should prevent patients’ symptoms of morning stiffness. In fact, as already seen in such physiological conditions as polymyalgia rheumatica, the gradual rise of cortisol in the very early morning hours downregulates ongoing immune reactivity. The stiffness and resulting functional disability that RA patients experience upon awakening is consistent, he says, with the reduced physiological adrenal cortisol production during the night in realized chronic inflammatory conditions, which becomes insufficient to inhibit the ongoing immune/inflammatory reaction.