What is the likelihood of getting type 2 diabetes on 10mg Prednisolone?

Bones, joints and muscles
1

Hi everyone. I was diagnosed with PMR in May and am a very atypical suffer. I am male, 59 years old and think I’ve had mild PMR symptoms for about 10 years until a huge flare up in March. I have managed to reduce my dose down to 10mg from 20mg leaving slight aches and pains and weak muscles.

I am concerned about side effects. My two questions are the following. How likely is it to get type 2 diabetes on my 10mg dose. I have tried to cut my sugar intake down to a minimum, this has been hard as I was a chocoholic and still like an occasional beer.

Also 2 weeks ago I had to stop taking Alendronic acid tablets because of eye redness and pain – will my dose of Pred still leach the old calcium from my bones and if so at what rate? I take Adcal tablets to create new calcium. My doctor says because of my age and gender I will be fine without the Alendronic acid, but I can’t find anything online to confirm this.

I am still quite fit, walk a lot and work part time in a fairly physical job. I ignore the PMR symptoms and consider myself very lucky compared to the suffering I read about on this forum.

All the best to you all.

2

Hi, and welcome!

Remember on this forum you will tend to come across the worst case scenarios and people in very early stages - it usually gets loads better as you go on! Now you are at 10mg I would suggest you stay there for some months: the Bristol group keep their patients at 10mg for a year. It reduces the rate of flares from 3 in 5 to 1 in 5.

Ask your doctor to send you for a dexascan for certainty - that will give you a baseline bone density reading. After I had been on pred for well over 3 years, much of that time at  over 10mg, probably about half at 15mg, my dexascan was essentially unchanged - the readings couldn't be compared as they were on different machines but both would have been accepted as nothing for real concern. I have only ever taken calcium and vit D supplements, no AA (disgusting stuff IMHO unless you need it, should never be used prophylactically). And I am a woman of a certain age who would be at risk according to usual creeds. If you were to develop osteoporosis there are other substances - they just aren't used prophylactically as the manufacturers of Fosomax (the original AA) managed to market it. Your GP isn't quite right about "age and gender" - they have always thought that but osteoporosis is beginning to be found in larger numbers of men, not sure why. Only 40% of patients on pred develop pred-related osteoporosis - and that is mostly at higher doses. 10mg is borderline moderate/low. It is now realised that there is some effect of even low doses of pred on bone density - but you may be one of the 60%, like me, and that is why a dexascan takes the guess-work out of the equation.

Type diabetes: also much over rated really at the doses we take for PMR unless you are otherwise at risk: overweight, inactive, eating a poor diet with too many processed carbs. However, reducing your processed carbs will help with that and also help avoid the weight gain that so often happens with pred. It doesn't HAVE to happen and it is possible to even LOSE weight while on pred. It just requires discipline and portion control. Keep the stuff that comes in a package for the birds and eat as low a carb diet as you can cope with comfortably and you stand a good chance of avoiding both (pre)diabetes and weight gain. Restricting salt is also important - possibly more difficult but it only takes a couple of months to re-educate your taste buds to a low salt diet and then you will find many foods in pubs and restaurants too salty by half!

The real criminals in weight gain are soft drinks (whether with sugar or sweetner surprisingly), manufactured baked goods of all sorts (the high fructose syrup that is used instead of sugar to make then tasty and have a long sell-by date leads to insulin resistance) and snacks. Ban them and use salad veggies for snacking, keep fruit (especially bananas) in moderation (except berries apparently) and reduce your portions of pasta, rice and potatoes to 50g instead of the usually quoted 100g. Veggies that grow above ground are best (restrict potatoes, sweet potatoes and other root veg). Use high quality chocolate - 75% cocoa solids - and just eat 1 square and then the occasional chocolate treat and beer will do little harm. Doing this I have lost 15kg whilst still on pred, most of it the mid-riff stuff that was pred-induced. And I didn't give up my wine ;-)

All the best

Eileen

3

Very useful info Eileen.  I have one of those Magic Bullets & I throw in blueberries, a banana, cheeries, peaches, yougurt, milk & blend.  Easy way to get lots of fruit in your diet.

 

" Bristol group keep their patients at 10mg for a year. It reduces the rate of flares from 3 in 5 to 1 in 5."

I am very curious about this.  Do you think it is a good idea to stay at 10 mg for a year?  Seems I am having issues trying to reduce to 9mg after 4 and a half months.  You know you are still going to be on pred for the long haul & what would be the difference in terms of pred effect on the body by 2 or 3 mg?  Just curious.

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I take it a magic bullet is a juicer? Easy to get fruit into the diet yes - but beware! That fruit is a lot better for you as the whole fruit. Once you split the cell membranes you lose the benefit of the soluble fibre and you also release the sugar in the fruit so it hits your body as a sugar rush. They also turn out to be calorie bombs that go down SOOOOOO easily and you just don't notice! Take that banana out - have a look at its calorie and carb count!

Right - to my other hobby horse:

I do think it is a good idea to stay at 10mg for at least 6 months. Using my reduction scheme you could theoretically reduce steadily from the start going down about 1mg/month in a very slow gentle downhill slope. It is the steps that trip people up. However - it is found that 10mg is a particular stumbling block, so is about 7 and again at 5. There are various theories why.

What is certain is that if the underlying autoimmune problem is still active you will not be able to reduce below a certain level however you try to do it. Everyone is different, everyone needs a different dose of pred for that - hence our recommendation of such a slow reduction, spreading a drop over weeks rather than overnight. Then you are less likely to miss the right dose, less likely to suffer steroid withdrawal pain.

It has always been suggested PMR burns out in a couple of years - maybe it does for some, but by no means for everybody. About a quarter of patients manage to get off pred in a year or so - but they are at a high risk of relapse, needing then to start from the beginning. Half take 2 to 6 years to get off pred, the rest need it for much longer. 

Kirwan and co worked out their reduction over a period of trial and error I imagine - I don't know, but I suspect their relapses happen below 10 and I suspect too that if they then used our reduction concept below 10 even that relatively low rate of relapse would fall further. 

But I am not surprised you are having difficulty reducing below 10mg after only 4 months. I also think that remaining at 10mg for a year would, in the long run be less damaging than trying to reduce further, allowing inflammation to develop again and ending up yoyoing the dose - which is known to lead to more difficulty reducing. That inflammation also damages the body - causing cardiovascular problems and even predisposing you to some cancers. It isn't a simple equation - pred bad, no pred good. Not treating PMR because of fear of pred just puts you at other risks as well as leaving you in a lot of pain and unable to enjoy life.

Does it matter if I increase the chances of something happening in 20 years time when I am 80 or so very slightly? If the alternative is pain and immobility where I will increase my chances of osteoporosis and falling because of it I don't think so. And chronic illness and unremitting pain are great friends of depression and loneliness. 

Obviously you want the lowest dose that controls the symptoms and not more - but it is pointless trying to push. The PMR will bite back.

5

Thanks Eileen...words of wisdom as always.  I can't tell you how disappointed I was to have that awful pain back yesterday.  15mg for two days now & feel "normal" again. Quality of life can not be understated.

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Thanks Eileen, very informative. I'll definitely ask my GP for a dexascan. You've also put my mind at ease somewhat on both the diabetes and osteoporosis.

Kind regards

Clive

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Eileen I have changed my pred (10mg) from a split dose to a single early morning dose - however I am now having pain during the night that is bad enough to prevent me from going back to sleep. I have only been doing this for 2 nights so far.  In your opinion is it a possibility that I should go back up a step in the pred or will the life of the dose be the same

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Were you managing better when you took it in split doses? Or were you having problems (sorry if you have told me before but I can't remember)? If you were having problems both ways it sounds as if you aren't on quite enough. The antiinflammatory effect of pred lasts from 12 to 36 hours depending on the person - you are obviously a 12 hour person! Although paracetamol doesn't appear to work on PMR alone, some people have found that taking a dose at bedtime often helps the sort of problem you are having - again it depends on the person, did nothing for me for PMR but did work when I was reducing the dose - which could be part of your problem at the moment.

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I was managing a little better although I was still having bad days/better days. Oh to be a 30 hr plus person - I'm definitely a 12hr ( or less) person.  I'm going back to the Doc today and will see what she thinks. It could be just the change and maybe I'll tough it out for another couple of days to see what happens if it doesn't get better I'll ask Dr if I should go back up in dose for a while a bit.  I tried paracetamol last night - made me sleep a little better but like you it did nothing for the PMR.

10

Eileen, great info, as always. As you are the master-doser here, can you advise me, too?

My PMR symptoms disappeared about four months ago, in fact I was lucky and it only lasted about three months. But I have RA too, as well as a slew of other autommune diseases, and altho I'm fairly symptom free right now, I must still expect RA to flare again at any time for the rest of my life.

I was on 5mg prednisolone a day and my rheumy has just brought me down to 5mg alternate days, ie 2.5mg a day.

Keeping in mind your advice about super-slow reductions, I decided to alternate 5 with 2.5 instead.

But would that slow reduction plan of yours also apply to RA – do you know? – or even to a symptom free PMR (is there such a thing?)

Of course I would prefer to reduce the preds as much as possibe but don't want to risk another flare.

Could you give your opinion here?

As for Clive's diabetes concern...

This is the first I've heard of a correlation between preds and diabetes.

Judging from your answer to him, I'm assuming you are responding because of the weight-gain that often results from taking preds, and then linking that weight-gain to possibe diabetes... In other words, preds could lead to diabetes indirectly if he puts on a huge amount of weight.

But could I be wrong? Is there a more direct conection between preds and diabetes I've ever heard of before?

I hope you can help.

11

PMR eventually goes into remission on its own - but there are two sorts of remission: drug induced remission and remission because the underlying autoimmune cause has burnt itself out, the nearest to cure there is. When you start on the 15mg or whatever your doctor chooses as a starting dose the idea is to knock the inflammation on its head - the underllying problem is still there. Then you should reduce slowly to find the lowest dose that controls the symptoms.The smaller the steps you make during the reduction the better result you will get - you won't suffer so much from steroid withdrawal symptoms nor are you so likely to miss the right dose. You might be fine at 5mg but not at 2.5mg - but somewhere inbetween might the answer. Go 1/2mg at a time and you find 3mg is good, 2.5mg not - and it is far less than the 5mg daily dose so much better for you overall. 

RA isn't quite the same - although it too can go into remission for years. However, again reducing in tiny steps helps avoid the steroid withdrawal pain: some people are particularly sensitive to the pred being lowered and the symptoms are often the same as the illness for which you were given the pred in the first place. So in your case I would choose to reduce by the smallest steps I could and have a small rest at each new dose to make sure you have no return of any symptoms that have been controlled by the pred.

Pred alters the way our bodies metabolise simple carbohydrate - it isn't just the weight gain that puts us at risk of diabetes. It often just seems to make the fasting blood sugar level higher and it can remain stable at that with values after food being a bit high but then returning to near normal - but in someone who was already pre-diabetic it could be enough to actually tip them over the edge into diabetes proper and they find they have wildly fluctuating blood sugars. A good doctor will check fasting blood sugars regularly and also check the Hba1c value - this is an indictor of longer term blood sugar values. If you have a high blood sugar a lot of the time the amount of Hba1c in the blood rises compared to ordinary haemaglobin because of the effect of the sugar on it. If that gets above a certain level you have diabetes and will possibly need medication. Reducing carbs also reduces the amount of sugar in the blood: before insulin was discovered and manufactured it was the only way of controlling diabetes. 

Pred can also lead to increased cholesterol levels - but both high cholesterol and blood sugars should return to more normal levels as the pred dose falls. Some people never have problems with either. I've never had a dodgy blood sugar level but I don't actually eat much carb anyway. My cholesterol was high but since I changed to my current version of pred and altered my diet it has fallen and is now just slightly high but high because my HDL (the so-called "good" cholesterol) is very high.

So it isn't just indirect risk - there is a direct connection too. 

I hope this makes sense - I hate writing a long post when I can only see 8 lines of it!!!!! Bah to "new improved" ;-)

12

A little o/t, but what do you think of statin drugs?  Like yourself, my cholesterol is a little high (240), but my HDL is also high & although I have started statins (prevastatin) many times have difficulty sticking with them as they make me feel awful.  I know there are many theories about statins & some suggestions that way too many people are put on them as they have their own negatives.

I agree with you an edit button would really be nice.

13

Personally speaking: I won't touch statins with the proverbial sterilised barge pole! I was persuaded, much against my will, to take a statin just over 2 years ago when I had had back problems and then reacted to iv valium by developing atrial fibrillation. The medical consultants decided my cholesterol was "extremely high", it wasn't, I reserve that for cholesterol values in double figures, but it was raised. They promised to monitor me carefully (they didn't) and didn't give me simvastatin, they gave me atorvastatin (Lipitor). After my escapades in hospital I was walking fine albeit on crutches (an achilles problem), the back was not right but far better than it had been, and I went home. Within days I couldn't walk mosre than 50 yards on the flat, the slightest slope was the end and as for steps - I could forget them!

After a week I decided to stop taking the statin and told the pain clinic anaesthetist what I was doing - she felt it was fair enough in the short term, I could discuss it with the cardiologist. A few weeks later I told her - and she was fine about it. I offered to try another, she said I needn't. It took me a year to get back to where I had been pre-statin.

There is evidence to suggest that for all men and women who have already had a cardiovascular event (heart attack or stroke) taking a statin may protect them from having a second one. That is not the case for women who have not yet had a cardiac event. A/f doesn't count as a "cardiac event" so it doesn't apply so I am perfectly happy not to take them.

I don't mind too much the concept of them being used in an attempt to stop a second "event". I have absolutely no problem when they are used for patients with "familial hypercholesteraemia" - very high cholesterol, readings in double figures. But the idea of using them for otherwise healthy people is appaling! 

The problem is that when patients develop side effects that are bad enough to make a change or discontinuation necessary, it isn't reported using the yellow card system. Too many doctors say "it's a known side effect, no need to report it". That isn't true. The true rate of side effects only becomes known once drugs are out of clinical trials with limited numbers of people, many healthy, and approved and released for use in the general population - and thousands of patients with real illnesses. But to know that - any side effects must be reported.

The real rate of side effects with statins is far closer to the high rates that some doctors are claiming than the low rates the statin supporters re claiming. If you can take a statin without any problems and you are at a high risk of a heart attack, fair enough. But the rate of confusion and dementia in the elderly is increasing dramatically - how much is actually due to statins? That is one of the commonest side-effects in elderly frail patients. And if you have muscle problems already - why take a medication that is already suspected to possibly trigger such illnesses?

If a statin or any other drug makes you feel ill - a very realistic appraisal of the risk/benefit relationship should be undertaken. Since 200-239 is perceived as "borderline high" by the Mayo I really wouldn't class 240 as high (you can't measure it that accurately!) and if your HDL is high that makes your LDL only a bit into borderline. I wouldn't consider taking a statin in that situation. But that is me. We already take a load of medication - we don't need another unless essential. And the cholesterol is slightly high because we're older and on pred - don't panic yet is my mantra. 

14

Thank you, thank you, thank you.  Totally agree.  In the US now you have to question what you are prescribed as big pharma is influencing the whole medical profession as to what is & is not significant. Studies are often flawed & bend towards certain results.  Years ago read a book, "The Truth About Choslesterol" which offered some interesting info.  Lipitor is just the worst & I know many who are taking it have a lot of complictions & develop even worse problems, but it's a big money maker in the US.

15

They all are - and what disgusts me is that several people on the NICE expert panel who decide whether a drug/treatment should be approved for use in the NHS are associated with pharmaceutical companies - and are pushing this concept of medicalising healthy people. It was suggested at one time that the biggest money-saver for the cash-strapped NHS would be to stop statins for the people who don't really need them! 

My brother takes one - nothing would persuade me to take one again. 

 

16

If you can get The Great Cholesterol Con by Dr Kerrick from the library it is really enlightening and also he has written it in a very entertaining way so it is not heavy reading. I would not touch statins unless a very good reason were given, having seen what they did to my father. It tok two years for a new GP to agree to have a two week trial without them and he was a changed man!

17

Thank you Eileen. This is very helpful.

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That is the book I was talking about.  I had the wrong title.  You can get it on Amazon for about 10.00 dollars.  A good read.