Fellow multiple myeloma surivor, Nebraskan Jim Omel, is one of the smartest guys I know. A retired physician, Jim works tirelessly to help his fellow patients. Readers often ask me if it matters when they take their dexamethasone. Scheduled to start consolidation therapy this week, I’ve been wondering about it, too.
I emailed Jim earlier this week to see if he had an opinion. He was kind enough to write a detailed explanation, giving me the green light to share it with my readers:
Cortisol is an adrenocorticoid produced each day by the adrenal glands. It is essential to life, is a starting point for many organic compounds such as testosterone and estrogen and androstendione and many others. The body (pituitary) constantly monitors body hormone levels and, being the “master gland”, tells the other glands to work harder or slow down. For instance it produces TSH (thyroid stimulating hormone) to “whip” the thyroid to get to work when it senses there isn’t enough circulating thyroid hormone passing by. In a similar manner the pituitary monitors the adrenal glands (located above the kidneys). Cortisol serum levels are diurnal, meaning they naturally fluctuate by the time of the day. We always take two serum cortisol levels when checking adrenal gland function….one at 8:00 AM and one at 4:00 PM. The peak level is always there at 8 AM because that is the time the pituitary is telling the adrenal gland to get to work. The patient is getting up, starting his day, and needs the stimulus effect of cortisol. We expect a trough level at 4 PM. If there isn’t a significant difference between the 8 and 4 serum cortisol levels, doctors know there is a problem with either that patient’s adrenal or pituitary function! The body is really remarkable isn’t it?
Now let’s assume that the pituitary monitors your serum cortisol level tomorrow morning and finds that the level is quite high (as it would be if you took a whopping unphysiologic dose of 40 mg dexamethasone the night before). Dex and cortisol are not chemical equals, but physiologically they affect the pituitary and adrenal glands exactly the same way. Anyway, the pituitary will discover that there is PLENTY of steroid in your system and tells the adrenal gland to cool it…..do NOT produce any cortisol for our patient today. The adrenal glands say OK, does nothing, and produces no cortisol. That means there is no base corticosteroid for the liver or gonads to produce androstenedione, or testosterone, or estrogen. Those organs cannot turn Dex into those essential compounds. They require cortisol as a starting point, but the adrenal glands produce no cortisol on the morning following a Dex binge.
The bottom line therefore is that it is much more physiologic to take all corticosteroids (Dex, prednisone, prednisolone, Solu-Medrol, etc) in the morning when the body expects there to be an elevated steroid level. You will get much less adrenal gland suppression if you take steroids in the morning than if you take them at night, allowing them to still affect the adrenal gland the next morning.
To further help your understanding lets consider what happens when cortisone (dex) is taken four days in a row, the way it often used to be prescribed. Also consider what happens to the adrenal glands when a person suffering severe allergies is given 10 days of continuous cortisone by mouth. For ten mornings the adrenal glands are told by the pituitary to stand down….do nothing. Now let’s assume the allergy sufferer is better and he abruptly stops his daily cortisone. The pituitary tells the adrenal gland to get to work. The adrenal glands have become lazy, unresponsive, and does nothing. The pituitary begins SCREAMING by producing adrenal-stimulating hormones. The adrenal glands sort of say…yeah, whatever… In time the adrenal glands finally shake the dust off, and gets back to work producing daily cortisol, the way they are supposed to do every morning. In the meantime the patient has no whip, no stimulus to increase metabolic activity when the rest of the body is begging for help. A perfect example is surgery. Anesthesiologists always ask their patients if they have been taking any steroids. If they have, the doctor expects that there may be a blood pressure problem or wake-up problem because that patient’s adrenal glands have become quite lazy and unresponsive. The worst of these possibilities leads to “Adrenal Crisis” which can translate to a true medical emergency.
What I just described happens because of external forces……cortisone tablets given to the patient. The same thing can occur by disease too. It is called Addison’s Disease and is what happens when the adrenal glands do not work. JFK had Addison’s Disease and it nearly killed him on several occasions. He often required steroid injections before international summits, surgery, and even day to day activities needing systemic physiologic stimulation. I think I read that he actually started each day with cortisone injections, but I’m not positive about that.
Bottom line….it is physiologically much wiser to take all steroids in the morning hours, not at night. You will probably do just fine if you take them at night, but your pituitary and adrenal glands will work much more the way they are designed to work if you give that steroid bolus in the morning.
Isn’t that interesting? I expected a short, three or four line answer. I should have know that isn’t the way Dr. Omel is wired.
Knowing that I’ll also be taking pomalidomide, Jim added this in a follow up email last night:
Yes absolutely, dex should always be taken with breakfast. Steroids can do awful things to unprotected gastric epithelium, like erosive gastric ulcers. I’ve not taken Pom, but understand it should be taken on an empty stomach.
I had been taking dex right before bedtime, hoping to fall asleep before insomnia had a chance to kick in. Not anymore. I took my ten, little green tablets this morning with breakfast–and my pomalidomde capsule last night before bed on an empty stomach.
Thanks, Jim! I’m fortunate to have friends “in the know” like you. If only dealing with all the side effects was this easy!
Feel good and keep smiling! Pat