Drug Name

Prednisone (Prednisone)

Generic Name

Prednisone (PRED-nih-sone)

Manufacturer / Distributor

ROXANE Laboratories, Inc.

Dosage Form

Tablets

Route Of Administration

ORAL

Imprint Code

54;760

Size

9mm

Alternatives

Asthma
Medrol (Methylprednisolone), Aristocort (Triamcinolone), Solu-Medrol, Depo-Medrol, Sterapred
Anti-inflammatory (Steroids)
Decadron (Dexamethasone), Medrol (Methylprednisolone), Solu-Medrol
Nephrotic Syndrome
Aristocort (Triamcinolone), Cytoxan (Cyclophosphamide), Sterapred, Cortisone, Prednisolone
Immunosuppression
Medrol (Methylprednisolone), Solu-Medrol, Depo-Medrol, Sterapred

Drug Uses

Prednisone is in a class of drugs called steroids. Prednisone reduces swelling and decreases the body's ability to fight infections.
Prednisone is used to treat many different conditions. It is used to treat endocrine (hormonal) disorders when the body does not produce enough of its own steroids. It is also used to treat many disorders such as arthritis, lupus, severe psoriasis, severe asthma, ulcerative colitis, and Crohn's disease.
Prednisone may also be used for purposes other than those listed in this medication guide.

Drug class

Corticosteroids (kor-ti-koe-STER-oyds) (cortisone-like medicines) are used to provide relief for inflamed areas of the body. They lessen swelling, redness, itching, and allergic reactions. They are often used as part of the treatment for a number of different diseases, such as severe allergies or skin problems, asthma, or arthritis. Corticosteroids may also be used for other conditions as determined by your doctor.
Your body naturally produces certain cortisone-like hormones that are necessary to maintain good health. If your body does not produce enough, your doctor may have prescribed this medicine to help make up the difference.
Corticosteroids are very strong medicines. In addition to their helpful effects in treating your medical problem, they have side effects that can be very serious. If your adrenal glands are not producing enough cortisone-like hormones, taking this medicine is not likely to cause problems unless you take too much of it. If you are taking this medicine to treat another medical problem, be sure that you discuss the risks and benefits of this medicine with your doctor.

Contains

Prednisone . . . . 20 or 40 mg
Inactive Ingredients: lactose anhydrous, magnesium stearate, starch (corn).

Chemical formula

Prednisone is a glucocorticoid. Glucocorticoids are adrenocortical steroids, both naturally occurring and synthetic, which are readily absorbed from the gastrointestinal tract. The molecular formula for Prednisone is C21H26O5. Chemically, it is 17,21-dihydroxypregna-1,4-diene-3,11,20-trione and has the following structural formula:



Prednisone is a white to practically white, odorless, crystalline powder and has a molecular weight of 358.44. It melts at about 230?C with some decomposition. Prednisone is very slightly soluble in water; slightly soluble in alcohol, chloroform, dioxane, and methanol. Each tablet, for oral administration, contains 1, 2.5, 5, 10, 20, or 50 mg of Prednisone. Prednisone Oral Solution contains 5 mg Prednisone per 5 mL, and Prednisone Intensol contains 5 mg Prednisone per mL.

Mechanism of Action

Prednisone is an oral, synthetic (man-made) corticosteroid used for suppressing the immune system and inflammation. It has effects similar to other corticosteroids such as triamcinolone (Kenacort), methylprednisolone (Medrol), prednisolone (Prelone) and dexamethasone (Decadron). These synthetic corticosteroids mimic the action of cortisol (hydrocortisone), the naturally-occurring corticosteroid produced in the body by the adrenal glands. Corticosteroids have many effects on the body, but they most often are used for their potent anti-inflammatory effects, particularly in those conditions in which the immune system plays an important role. Such conditions include arthritis, colitis, asthma, bronchitis, certain skin rashes, and allergic or inflammatory conditions of the nose and eyes. Prednisone is inactive in the body and, in order to be effective, first must be converted to prednisolone by enzymes in the liver. Therefore, prednisone may not work as effectively in people with liver disease whose ability to convert prednisone to prednisolone is impaired.

How Taken

Take prednisone exactly as directed by your doctor. Do not take more or less than is prescribed for you. If you do not understand these instructions, ask your pharmacist, nurse, or doctor to explain them to you.
Take each dose with a full glass of water.
Take prednisone with food or milk to lessen stomach upset.
Measure the liquid with the dropper provided or with a special dose-measuring spoon or cup. Ask your pharmacist for a dose-measuring spoon or cup if you do not have one.
If you are taking one dose daily, take that dose before 9 a.m. if possible, to follow the body's natural cycle. If you take more than one dose daily, space the doses evenly throughout the day as directed by your doctor. .
Do not stop taking prednisone suddenly if you have been taking it for a few weeks. You may need a gradual reduction in dosage before you stop taking this medication.
Carry some type of medical identification that will let others know you are taking prednisone in the case of an emergency.

Dosage and Administration

Dosage of Prednisone should be individualized according to the severity of the disease and the response of the patient. For infants and children, the recommended dosage should be governed by the same considerations rather than strict adherence to the ratio indicated by age or body weight.
Hormone therapy is an adjunct to, and not a replacement for, conventional therapy.
Dosage should be decreased or discontinued gradually when the drug has been administered for more than a few days.
The severity, prognosis, expected duration of the disease, and the reaction of the patient to medication are primary factors in determining dosage.
If a period of spontaneous remission occurs in a chronic condition, treatment should be discontinued.
Blood pressure, body weight, routine laboratory studies, including two-hour postprandial blood glucose and serum potassium, and a chest X-ray should be obtained at regular intervals during prolonged therapy. Upper GI X-rays are desirable in patients with known or suspected peptic ulcer disease.
The initial dosage of Prednisone may vary from 5 mg to 60 mg per day depending on the specific disease entity being treated. In situations of less severity lower doses will generally suffice, while in selected patients higher initial doses may be required. The initial dosage should be maintained or adjusted until a satisfactory response is noted. If after a reasonable period of time there is a lack of satisfactory clinical response, Prednisone should be discontinued and the patient transferred to other appropriate therapy.
IT SHOULD BE EMPHASIZED THAT DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE UNDER TREATMENT AND THE RESPONSE OF THE PATIENT.
After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small increments at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached. It should be kept in mind that constant monitoring is needed in regard to drug dosage. Included in the situations which may make dosage adjustments necessary are changes in clinical status secondary to remissions or exacerbations in the disease process, the patient's individual drug responsiveness, and the effect of patient exposure to stressful situations not directly related to the disease entity under treatment; in this latter situation, it may be necessary to increase the dosage of Prednisone for a period of time consistent with the patient's condition. If after long-term therapy the drug is to be stopped, it recommended that it be withdrawn gradually rather than abruptly.

Missed Dose

If you take one dose daily, take the missed dose as soon as you remember. However, if you don't remember until the next day, skip the dose you missed and take only your regular daily dose.
If you take more than one dose daily, you can either take the missed dose as soon as you remember, or you can take two doses at the next dose time.
If you take one dose every other day, take the missed dose as soon as you remember, then go back to your regular every-other-day schedule.

Overdose

Seek emergency medical attention if you think you have used too much of this medicine. Contact 1-800-222-1222 (the American Association of Poison Control Centers), your local poison control center ( http://www.aapcc.org/findyour.htm ), or emergency room immediately.

A single large dose of this medication is unlikely to cause symptoms or death. An overdose is more likely to be caused by a chronic overdose--large doses taken over a period of time.
Symptoms of an overdose include:

• obesity (especially around the stomach);
• a round face;
• increased hair growth (especially around the face);
• acne;
• bruising;
• increased blood pressure;
• swollen hands,
• feet, or ankles (fluid retention);
• and sore or weak muscles.

Storage

Store Prednisone at room temperature between 59 and 86 degrees F (15 and 30 degrees C).
Store away from heat, moisture, and light. Do not store in the bathroom.
Keep Prednisone out of the reach of children and away from pets.

What is the most important information I should know about Prednisone (Prednisone)?

You should not use this medication if you are allergic to prednisone, or if you have a fungal infection anywhere in your body.
Before taking prednisone, tell your doctor about all of your medical conditions, and about all other medicines you are using. There are many other diseases that can be affected by steroid use, and many other medicines that can interact with steroids.
Your steroid medication needs may change if you have any unusual stress such as a serious illness, fever or infection, or if you have surgery or a medical emergency. Tell your doctor about any such situation that affects you during treatment.
Steroid medication can weaken your immune system, making it easier for you to get an infection or worsening an infection you already have or have recently had. Tell your doctor about any illness or infection you have had within the past several weeks.
Avoid being near people who are sick or have infections. Call your doctor for preventive treatment if you are exposed to chicken pox or measles. These conditions can be serious or even fatal in people who are using steroid medication.
Do not receive a "live" vaccine while you are taking prednisone. Vaccines may not work as well while you are taking a steroid.
Do not stop using prednisone suddenly, or you could have unpleasant withdrawal symptoms. Talk to your doctor about how to avoid withdrawal symptoms when stopping the medication. Carry an ID card or wear a medical alert bracelet stating that you are taking a steroid, in case of emergency.

What should I discuss with my doctor before taking Prednisone (Prednisone)?

You should not use this medication if you are allergic to prednisone, or if you have a fungal infection anywhere in your body.
Steroid medication can weaken your immune system, making it easier for you to get an infection. Steroids can also worsen an infection you already have, or reactivate an infection you recently had. Before taking this medication, tell your doctor about any illness or infection you have had within the past several weeks.
Other medical conditions you should tell your doctor about before taking prednisone include:

• liver disease (such as cirrhosis);
• kidney disease;
• a thyroid disorder;
• diabetes;
• a history of malaria;
• tuberculosis;
• osteoporosis;
• a muscle disorder such as myasthenia gravis;
• glaucoma or cataracts;
• herpes infection of the eyes;
• stomach ulcers, ulcerative colitis, or diverticulitis;
• depression or mental illness;
• congestive heart failure; or
• high blood pressure

If you have any of these conditions, you may need a dose adjustment or special tests to safely take prednisone.

FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Prednisone can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.
Steroids can affect growth in children. Talk with your doctor if you think your child is not growing at a normal rate while using this medication.

Absorption

Rapid, almost complete.

Distribution

Crosses placenta.

Metabolism

Mainly hepatic, also renal and in the tissue. Prednisone is inactive and rapidly metabolized to active prednisolone.

Excretion

Renal. Plasma t 1/2 is 3.4 to 3.8 h.

Peak

1 to 2 h..

Duration

1.25 to 1.5 days.

Clinical Pharmacology

Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. Their synthetic analogs, such as Prednisone, are primarily used for their potent anti-inflammatory effects in disorders of many organ systems.
Glucocorticoids, such as Prednisone, cause profound and varied metabolic effects. In addition, they modify the body's immune responses to diverse stimuli.

Possible side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Call your doctor at once if you have any of these serious side effects:

• problems with your vision;
• swelling, rapid weight gain, feeling short of breath;
• severe depression, unusual thoughts or behavior, seizure (convulsions);
• bloody or tarry stools, coughing up blood;
• pancreatitis (severe pain in your upper stomach spreading to your back, nausea and vomiting, fast heart rate);
• low potassium (confusion, uneven heart rate, extreme thirst, increased urination, leg discomfort, muscle weakness or limp feeling); or
• dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).

Less serious side effects may include:

• sleep problems (insomnia), mood changes;
• acne, dry skin, thinning skin, bruising or discoloration;
• slow wound healing;
• increased sweating;
• headache, dizziness, spinning sensation;
• nausea, stomach pain, bloating; or
changes in the shape or location of body fat (especially in your arms, legs, face, neck, breasts, and waist).

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.

What other drugs will affect Prednisone (Prednisone)?

There are many other medicines that can interact with steroids. Below is only a partial list of these medicines:

• aspirin (taken on a daily basis or at high doses);
• a diuretic (water pill);
• a blood thinner such as warfarin (Coumadin);
• cyclosporine (Gengraf, Neoral, Sandimmune);
• insulin or diabetes medications you take by mouth;
• antibiotics such as ketoconazole (Nizoral), rifampin (Rifadin, Rifater, Rifamate, Rimactane), or troleandomycin (Tao); or
• seizure medications such as phenytoin (Dilantin) or phenobarbital (Luminal, Solfoton).

This list is not complete and there may be other drugs that can interact with prednisone. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

What should I avoid while taking Prednisone (Prednisone)?

Avoid alcohol. Acting together, alcohol and prednisone can be damaging to the stomach.
Avoid sources of infection. Wash your hands frequently and keep them away from the mouth and eyes. Your immune system may be weakened while taking prednisone.
Do not receive any immunizations during treatment with prednisone without first talking to your doctor.

Contraindications

Prednisone tablets and oral solutions are contraindicated in systemic fungal infections and known hypersensitivity to components.

Warnings

Do not get a smallpox vaccination or any other immunization while you are taking prednisone. The vaccination might not "take," and could do harm to the nervous system.
Prednisone may reactivate a dormant case of tuberculosis. If you have inactive TB and must take prednisone for an extended time, you should be given anti-TB medication as well.
If you have an underactive thyroid gland or cirrhosis of the liver, your doctor will probably need to prescribe prednisone for you at a lower-than-average dosage.
If you have an eye infection caused by the herpes simplex virus, prednisone should be used with great caution; there is a potential danger that the cornea will become perforated.
A few people taking prednisone develop Kaposi's sarcoma, a form of cancer; it may disappear when the drug is stopped.
Prednisone should also be taken with caution if you have any of the following conditions:

• Diverticulitis or other disorder of the intestine
• High blood pressure
• Kidney disorder
• Myasthenia gravis (a muscle-weakness disorder)
• Osteoporosis (brittle bones)
• Peptic ulcer
• Ulcerative colitis (inflammation of the bowel)

Long-term treatment with prednisone may stunt growth. If Prednisone is given to a child, the youngster's growth should be monitored carefully.
Diseases such as chickenpox or measles can be very serious or even fatal in both children and adults who are taking Prednisone. Try to avoid exposure to these diseases.

Precautions

Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage. This type of relative insufficiency may persist for months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted. Since mineralocorticoid secretion may be impaired, salt and/or a mineralocorticoid should be administered concurrently.
There is an enhanced effect of corticosteroids in patients with hypothyroidism and in those with cirrhosis.
Corticosteroids should be used cautiously in patients with ocular herpes simplex because of possible corneal perforation.
The lowest possible dose of corticosteroid should be used to control the condition under treatment, and when reduction in dosage is possible, the reduction should be gradual.
Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations. Also, existing emotional instability or psychotic tendencies may be aggravated by corticosteroids.
Steroids should be used with caution in nonspecific ulcerative colitis, if there is a probability of impending perforation, abscess, or other pyogenic infection, diverticulitis, fresh intestinal anastomoses, active or latent peptic ulcer, renal insufficiency, hypertension, osteoporosis, and myasthenia gravis.
Growth and development of infants and children on prolonged corticosteroid therapy should be carefully observed.
Kaposi's sarcoma has been reported to occur in patients receiving corticosteroid therapy. Discontinuation of corticosteroids may result in clinical remission.
Although controlled clinical trials have shown corticosteroids to be effective in speeding the resolution of acute exacerbations of multiple sclerosis, they do not show that corticosteroids affect the ultimate outcome or natural history of the disease. The studies do show that relatively high doses of corticosteroids are necessary to demonstrate a significant effect.
Since complications of treatment with glucocorticoids are dependent on the size of the dose and the duration of treatment, a risk/benefit decision must be made in each individual case as to dose and duration of treatment and as to whether daily or intermittent therapy should be used.
Convulsions have been reported with concurrent use of methylprednisolone and cyclosporin. Since concurrent use of these agents results in a mutual inhibition of metabolism, it is possible that adverse events associated with the individual use of either drug may be more apt to occur.

Information For Patients

Persons who are on immunosuppressant doses of corticosteroids should be warned to avoid exposure to chickenpox or measles. Patients should also be advised that if they are exposed, medical advice should be sought without delay.

Pregnancy

Category C .

Nursing Mothers

Excreted in breast milk.

Pediatric Use

Observe growth and development of infants and children on prolonged therapy.

Geriatric Use

May require lower doses.

Hypersensitivity

May occur, including anaphylaxis.

Renal Function

Use with caution; monitor renal function.

Adrenal suppression

Prolonged therapy may lead to HPA suppression.

Cardiovascular effects

Use drug with great caution in patients who have suffered recent MI.

Hepatitis

Drug may be harmful in patients with chronic active hepatitis positive for hepatitis B surface antigen.

Immunosuppression

Do not administer live virus vaccines during treatment.

Infections

May mask signs of infection. May decrease host-defense mechanisms to prevent dissemination of infection.

Ocular effects

Use systemic drug cautiously in ocular herpes simplex because of possible corneal perforation.

Ophthalmic use

Prolonged use may result in glaucoma, cataracts, or other complications.

Peptic ulcer

May contribute to peptic ulceration, especially with large doses.

Stress

Increased dosage of rapidly acting corticosteroid may be needed before, during and after stressful situations.

Withdrawal

Abrupt discontinuation may result in adrenal insufficiency.

Adverse Reactions

Fluid and Electrolyte Disturbances:

• Sodium retention.
• Fluid retention.
• Congestive heart failure in susceptible patients.
• Potassium loss.
• Hypokalemic alkalosis.
• Hypertension.

Musculoskeletal:

• Muscle weakness.
• Steroid myopathy.
• Loss of muscle mass.
• Osteoporosis.
• Tendon rupture, particularly of the Achilles tendon.
• Vertebral compression fractures.
• Aseptic necrosis of femoral and humeral heads.
• Pathologic fracture of long bones.

Gastrointestinal:

• Peptic ulcer with possible perforation and hemorrhage.
• Pancreatitis.
• Abdominal distention.
• Ulcerative esophagitis.
• Increases in alanine transaminase (ALT, SGPT), aspartate transaminase (AST, SGOT) and alkaline phosphatase have been observed following corticosteroid treatment.
These changes are usually small, not associated with any clinical syndrome and are reversible upon discontinuation.

Dermatologic:

• Impaired wound healing.
• Thin fragile skin.
• Petechiae and ecchymoses.
• Facial erythema.
• Increased sweating.
• May suppress reactions to skin tests.

Neurological:

• Convulsions.
• Increased intracranial pressure with papilledema (pseudo-tumor cerebri) usually after treatment.
• Vertigo.
• Headache.

Endocrine:

• Menstrual irregularities.
• Development of Cushingoid state.
• Suppression of growth in children.
• Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery or illness.
• Decreased carbohydrate tolerance.
• Manifestations of latent diabetes mellitus.
• Increased requirements for insulin or oral hypoglycemic agents in diabetics.

Ophthalmic:

• Posterior subcapsular cataracts.
• Increased intraocular pressure.
• Glaucoma.
• Exophthalmos.

Metabolic:

• Negative nitrogen balance due to protein catabolism.

Additional Reactions:

• Urticaria and other allergic, anaphylactic or hypersensitivity reactions.

ADT (Alternate Day Therapy)

ADT is a corticosteroid dosing regimen in which twice the usual daily dose of corticoid is administered every other morning. The purpose of this mode of therapy is to provide the patient requiring long-term pharmacologic dose treatment with the beneficial effects of corticoids while minimizing certain undesirable effects, including pituitary-adrenal suppression, the Cushingoid state, corticoid withdrawal symptoms, and growth suppression in children.
The rationale for this treatment schedule is based on two major premises: (a) the anti-inflammatory or therapeutic effect of corticoids persists longer than their physical presence and metabolic effects and (b) administration of the corticosteroid every other morning allows for re-establishment of more nearly normal hypothalamic-pituitary-adrenal (HPA) activity on the off-steroid day.
A brief review of the HPA physiology may be helpful in understanding this rationale. Acting primarily through the hypothalamus a fall in free cortisol stimulates the pituitary gland to produce increasing amounts of corticotropin (ACTH) while a rise in free cortisol inhibits ACTH secretion. Normally the HPA system is characterized by diurnal (circadian) rhythm. Serum levels of ACTH rise from a low point about 10 pm to a peak level about 6 am. Increasing levels of ACTH stimulate adrenocortical activity resulting in a rise in plasma cortisol with maximal levels occurring between 2 am and 8 am. This rise in cortisol dampens ACTH production and in turn adrenocortical activity. There is a gradual fall in plasma corticoids during the day with lowest levels occurring about midnight.
The diurnal rhythm of the HPA axis is lost in Cushing's disease, a syndrome of adrenocortical hyperfunction characterized by obesity with centripetal fat distribution, thinning of the skin with easy bruisability, muscle wasting with weakness, hypertension, latent diabetes, osteoporosis, electrolyte imbalance, etc. The same clinical findings of hyperadrenocorticism may be noted during long-term pharmacologic dose corticoid therapy administered in conventional daily divided doses. It would appear, then, that a disturbance in the diurnal cycle with maintenance of elevated corticoid values during the night may play a significant role in the development of undesirable corticoid effects. Escape from these constantly elevated plasma levels for even short periods of time may be instrumental in protecting against undesirable pharmacologic effects.
During conventional pharmacologic dose corticosteroid therapy, ACTH production is inhibited with subsequent suppression of cortisol production by the adrenal cortex. Recovery time for normal HPA activity is variable depending upon the dose and duration of treatment. During this time the patient is vulnerable to any stressful situation. Although it has been shown that there is considerably less adrenal suppression following a single morning dose of prednisolone (10 mg) as opposed to a quarter of that dose administered every 6 hours, there is evidence that some suppressive effect on adrenal activity may be carried over into the following day when pharmacologic doses are used. Further, it has been shown that a single dose of certain corticosteroids will produce adrenocortical suppression for two or more days. Other corticoids, including methylprednisolone, hydrocortisone, Prednisone, and prednisolone, are considered to be short acting (producing adrenocortical suppression for 1 1/4 to 1 1/2 days following a single dose) and thus are recommended for alternate day therapy.
The following should be kept in mind when considering alternate day therapy:

• 1. Basic principles and indications for corticosteroid therapy should apply. The benefits of ADT should not encourage the indiscriminate use of steroids.
• 2. ADT is a therapeutic technique primarily designed for patients in whom long-term pharmacologic corticoid therapy is anticipated.
• 3. In less severe disease processes in which corticoid therapy is indicated, it may be possible to initiate treatment with ADT. More severe disease states usually will require daily divided high dose therapy for initial control of the disease process. The initial suppressive dose level should be continued until satisfactory clinical response is obtained, usually four to ten days in the case of many allergic and collagen diseases. It is important to keep the period of initial suppressive dose as brief as possible particularly when subsequent use of alternate day therapy is intended. Once control has been established, two courses are available: (a) change to ADT and then gradually reduce the amount of corticoid given every other day or (b) following control of the disease process reduce the daily dose of corticoid to the lowest effective level as rapidly as possible and then change over to an alternate day schedule. Theoretically, course (a) may be preferable.
• 4. Because of the advantages of ADT, it may be desirable to try patients on this form of therapy who have been on daily corticoids for long periods of time (eg, patients with rheumatoid arthritis). Since these patients may already have a sup-pressed HPA axis, establishing them on ADT may be difficult and not always successful. However, it is recommended that regular attempts be made to change them over. It may be helpful to triple or even quadruple the daily maintenance dose and administer this every other day rather than just doubling the daily dose if difficulty is encountered. Once the patient is again controlled, an attempt should be made to reduce this dose to a minimum.
• 5. As indicated above, certain corticosteroids, because of their prolonged suppressive effect on adrenal activity, are not recommended for alternate day therapy (eg, dexamethasone and betamethasone).
• 6. The maximal activity of the adrenal cortex is between 2 am and 8 am, and it is minimal between 4 pm and midnight. Exogenous corticosteroids suppress adrenocortical activity the least, when given at the time of maximal activ