Prednisone vs. Hydrocortisone for Adrenal Suppression: Pros, Cons, and Tips

One of the things that always puzzled me as I read through medical journals and textbooks was one would say to use Prednisone while another would say to use Hydrocortisone for adrenal suppression. These were always one-off sentences, almost throwaways and there was never any elaboration on the why of it. Nor a comparison/contrast of one steroid over the other.

I think I know the why part of it. Maybe.

It's a half life thing.

Prednisone sits and sits and sits in your system. If memory serves, the endo calculated a half life of slightly over 24 hours.

So if you take Prednisone every morning, there is never a time where you are without and this can work against HPA axis recovery.

Hydrocortisone, on the other hand, has a half life of 12ish hours. So you have at least half a day without any steroids in your system, time in which your brain is supposed to go 'oh sh*t, we need steroids STAT' and trigger natural steroid production. The 'oh sh*t' moments help the HPA axis recover functionality.

Now, when I was very first diagnosed as being suppressed, my am cortisol was 1.3 and Prednisone was used to treat it. I am torn on whether or not this was a good thing. At a level of 1, your body needs some help--a cortisol of 1 is not really compatible with life--and it's probably not a great idea to have a short half life steroid, at least not initially.

However, I don't think we needed to use Prednisone the entire year and I wonder how that prolonged the recovery. Also, I ended up with a pretty bad case of exogenous Cushings from the treatment, which tells me the docs weren't doing the greatest job of calculating my dose.

And this was with regular ACTH challenges. So they had data. I don't know what they were thinking. If I'm in the mood for masochism, I'll find some old pictures and show how bloated my moon face was back then. I even had a hump! I might have benefited from switching to Hydrocortisone during that episode.

Of course switching from Prednisone to Hydrocortisone this time was not easy either. It took me a very long time to adjust. So long the endo even said 'Wow, that's a long time' when I told him that I didn't adjust until February.

The pain. Oh God. The pain.

It was enough to make me fantasize about narcotics. Or drinking. Or narcotics and drinking together.

I don't drink.

I hate narcotics.

But I thought about them, very fondly, from December through February.

What I ended up doing was splitting the dose even though the endo told me not to. I came clean last week and told them I did it anyway in the hopes of helping other patients down the line. It made life livable and it did not impede recovery as far as I could tell. (And the endo doesn't seem to hate me for being such a rebel, I was clear the situation was intolerable without split dosing.)

Knowing that the goal was to be without steroids in my system as much as possible, I did the split doses all before noon. To be clear, I didn't change my total dose, just split it in two.

I took the first dose in the morning when I got up (usually between 7 and 9am) and then the second dose between 10 and 11am. This made it so that the excruciating muscle pain did not hit until after I had finished my evening job and put my toddler to bed.

At night, I used Tylenol pm or Advil pm or Benadryl to help me sleep through the pain.

Gradually, over time, I took the second dose earlier and earlier until it merged with my morning dose. That was the point where things seemed to improve. The pain faded. I began to exercise. Tapers started happening faster and faster.

Hydrocortisone has not caused severe Cushings like the Prednisone did, but we've also been working with much lower doses. My memory is a little foggy, but I seem to recall starting at 20mg of Prednisone last time and camping there for months, which is a lot.

Prednisone seems to be less painful, but also less effective than Hydrocortisone. Which is not ideal when you have the lazy stubborn azzhole HPA axis I do.