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> “Failure to observe the expected effects of prednisone therapy should bring to mind the fact that a very rare patient may lack the hepatic enzyme system that converts prednisone to prednisolone, its active metabolite; the keto group at position 11 must be converted to a hydroxyl group before any glucocorticoid activity is exhibited. Accelerated catabolism of the active metabolite may also result in clinical effects below those expected.”1Might there be patients with inflammatory disorders who do not respond clinically as expected to prednisone but respond to prednisolone? Clinical medicine was transformed when corticosteroids were synthesized and made available for clinical use in the 1950s2,3; this is considered one of the landmarks in medicine3. [It seems appropriate that this work led to the awarding of the Nobel Prize to Philip S. Hench, MD, (the only rheumatologist to receive a Nobel Prize) and collaborators.] While we now know that corticosteroids are effective for certain patients with inflammatory diseases, there is no incontrovertible evidence to support uniform consensus for the selection of preparation, dosage, and duration for patients with differing conditions4–7. Use of corticosteroids remains more art than science. Indeed, some of us learned and taught that there were some patients with inflammatory conditions who responded poorly to prednisone but did well on methylprednisolone. This was articulated by John Decker, MD, a distinguished and authoritative rheumatologist, director of the US National Institute of Arthritis and Metabolic Diseases, National Institutes of Health, and President of the American Rheumatology Association [now American College of Rheumatology (ACR)].Unresponsiveness to prednisone is poorly studied, poorly documented in the literature, largely limited to experience and anecdote, and perhaps not widely known nor accepted, particularly among younger … Address correspondence to Dr. Panush; E-mail: rspanush{at}sbhcs.com

Are There Patients with Inflammatory Disease Who Do Not Respond to Prednisone?