WEANING AN AUTOIMMUNE PATIENT OFF OF PREDNISONE CONT

QUESTION: Granulomatosis Polyangitis: What is your experience with helping patients wean off of Prednisone when appropriate? I have a 43 yo Caucasian female diagnosed with granulomatosis polyangitis (aka Wegener’s Granulomatosis). Her main issues are related to her respiratory system. There is a scar tissue formation issue in her trachea and as more scar tissue forms, the more narrow her airway becomes. She has to go in for special surgical procedures to dilate and remove the scar tissue about every 4 months. She is on oxygen, Budesonide 0.25mg/2mL nebulizer solution daily, 9mg of Prednisone, Azathioprine 50mg tabs-2 tabs daily Acyclovir 400 mg tabs QD-TID prn for 5 days at a time, Rituxan 100mg infusions every 6 months, Lansoprazole 30mg prn when on high dose prednisone to prevent any reflux as it aggravates trachea, Plexus probiotics, and a multivitamin (unknown). Her goals are to get off prednisone and decrease her scar tissue growth. Whenever she has tried to get off Prednisone in the past, she cannot get below 7mg daily before her system gets overwhelmed and aggravated. She has a full health care team on board with a PCP, rheumatologist, pulmonologist, throat surgeon, and now me. I do not feel she is ready to start weaning off of the Prednisone yet, and I feel it is important to help modulate her immune system and decrease her inflammation, in an effort to decrease the continued scar tissue growth in her trachea. Once that is better managed I feel we can start to address decreasing the Prednisone. Any thoughts about how to help this patient achieve her goals?

ANSWER:Complicated cases like this often have this situation where they cannot ever totally drop the Prednisone.

That said, I have seen Wegners’ and like Dz get on very low steroid doses or even off of them (and need them for flares only).

The order in which I would do this is:

1. Over support the adrenals and HPA axis (generally 2-4X the ‘typical’ adrenal support need of supplements are required if they ever want to try to taper.

2. If thyroid is Rx’d make sure Ab’s and rT3 are not rising. Thyroid has to be maximally treated or they won;t handle a Pred taper either.

3. Treat the underlying (best you can – this is a tough disease) – but Diet and all the normal stuff are crucial. MSM can help some with the scarring so they can take MSM powder in juice 2-3 grams TID. Then I like combination Boswelya – Curcumin in these cases

4. Then I would come “in behind” the Pred with a lateral transfer of 9 mg Pred to a combo of 5 mg Pred + 20 mg Hydrocortisone. That is about the same steroid but the HC is easier for some to taper (but you arent replacing all the Pred at once so less shock).

5. After all this, and if all the basics, adrenal/HPA and Thyroid are good (and they are doing your other AI therapies) I wait 2-3 months then start a very slow corticoid taper. Basically first try 1 mg of Pred less every 1-2 months till she is just on HC. Then maybe taper that long term – but in any flare they’ll need to add HC or pred back in.

I also have some of the blog posts on HC dosing, and some webcalls past that are recorded and future coming on the topic.

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