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Q: Prednisone Pack & Risk/Benefit
Dear Dr. Phelps-
I am a 50 year old, highly athletic male, recently diagnosed with bipolar
disorder, ADHD, treated medically &therapeutically, currently on
Lamictal(25mg/day), Seroquel(25mg/night) & Ambien(5mg as needed.) I reviewed
your Q's regarding prednisone and have a follow-up. I also recently incured an
injury to my right knee, clearly diagnosed as bakers cyst. Two months of "RICE",
swimming, stretching, massage, acupuncture, and no running or cycling has not
improved the condition, and consequently, I have been in a prolonged depressive
episode, yet rising steadily. Exercise is very important and helpful to me, thus
another challenge being "benched."
My orthopedist wants to treat the knee with a 10-day prednisone pack, titrating
down from 60mg day-one to 5mg day-ten. Being prudent yet desirous to go forward,
I am holding off until I can clear it with my Psychiatrist, who unfortunately
is on vacation for a few weeks. I have not filled the script, and won't do so
until I see him; however, in the meantime I would value another (YOUR) opinion
of the relative risk here of a catastrophic effect. I am not suicidal, never
have been, and feel I can gut through the likely side effects for 10 days, if
need be. I welcome your thoughts, thank you.
Regards,
Dear Mr. J' -
Tricky. First, I've never seen good numbers on what percentage of patients with
bipolar disorder will have an exacerbation of their illness from predisone. I
have a rough figure from an oncologist that about 1 person in 100 has something
really obvious in terms of a bad mental health reaction, in people who do not
have obvious bipolar disorder. As you can see, we don't have the data we need
to give you a "how much risk of an adverse reaction am I taking?" answer.
Your willingness to gut through side effects for 10
days, if necessary, is understandable (spoken by a comparably aged similarly
athletically inclined male). Unfortunately there's a theoretical tilt you have
to take into account as well, at least at the "what are the most extreme
possible risks?" level: bipolar disorder in some folks seems to have the
capacity to worsen over time; in them, it often appears as though each episode
of mood symptoms makes subsequent episodes more likely and/or more severe. This
pattern may be somewhat more true in Bipolar I, and perhaps in women more than
men. But, you can see the implication: if the prednisone caused a significant
mood episode which somehow make subsequent episodes more likely or severe, then
there's a bigger price to pay, perhaps, than gutting out a period of side
effects.
You may have already known all this, and that's why you
wrote. Sorry to just go over the same territory, in that case. I can certainly
relate to the difficulty you're having. My strategy for bone/joint limitations
that are not healing as hoped has been to shift my emphasis to another sport
that doesn't exacerbate the problem, for a while, but unfortunately the result
is that I'm just enjoying new sports but not seeming to be able to go back to
the old ones! (lost sports include volleyball, basketball, singles tennis, bike
touring, etc; at this rate I'll be taking up sailplanes a lot sooner than
planned...) Good luck with your risk/benefit analysis.
Dr. Phelps
Published November, 2004
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