Tapering budesonide capsules

I am not a doctor. I am not a pharmacist. This is not medical advice.

We’ve learned a few things about tapering the Mylan 3 mg extended release budesonide capsules. These capsules are designed to deliver a steroid dose to the intestines. These are a generic of Entocort EC.

We don’t have experience with other brands, because we have stuck with one brand (Mylan). We have heard that different brands may tend to release the medication at different points in the intestines due to different coating formulations, so once we started on one brand, we stuck with that brand for consistency.

Some amount of the steroid has systemic effects, not just local effects. That can make it important to taper carefully.

After a number of failed attempts to taper the dose of 3x 3 mg capsules (9 mg total) by dropping to 2 capsules, by dropping to 2 capsules every other day, or even by dropping to 2 capsules every several days, the doctor suggested we might have to use a compounding pharmacy to taper in smaller increments.

It turns out that the capsules are easy to open, and each capsule typically contains 20-21 tiny pellets. The outer capsules dissolve quickly in the stomach, and the pellets are what actually have a coating to delay the release of the budesonide until further down in the digestive tract. That means that it is possible to open a capsule, remove any number of pellets, close it back up, and taper your budesonide dose in as little as 0.15 mg increments instead of 3.0 mg increments. That allows for a much slower and more gentle taper when that turned out to be necessary.

Empty gelatin capsules are available from Amazon if you want to put pellets into new capsules, rather than just discard the extra pellets.

The will of the people

I've long hoped for a second Brexit referendum to reverse the results of the first one. It seems clear that the British public knows now that the promises of the Leave campaign are not going to be realized, knows the actual terms worked out for leaving the EU with a deal, and knows more of the consequences of leaving the EU without a deal at all. The logical (to me) conclusion is that enough people would change their minds that a second Brexit referendum would result in a majority of the public voting to Remain rather than implement either of the alternatives.

But that's not a guaranteed result. And even if it were, supporting a democratic vote only because I like the expected result is using democracy as a fig leaf, not honoring democracy.

However, it is also not honoring democracy to insist that a referendum result in 2016 be treated as a valid guide to public sentiment in 2019, and to insist that a subsequent vote based on new information would be anti-democratic.

A fundamental problem is that what the Leave campaign wanted (exiting the EU with the UK having full autonomy over trade and regulations and movement of people, a better economic position than before, no internal borders, no hard border between Ireland and Northern Ireland, and no negative consequences) turns out to be unachievable. It does not appear to be for lack of trying.

The original Brexit referendum question itself did not delve into details. It was simply Leave the EU or Remain in the EU. The government worked to implement the decision as comprehensively as possible while achieving the best possible result for Britain. That was the point of the last two years of negotiations. It seems right for the government to have pursued that goal, but there has also been far too much pretending that the democratic will was to "Leave the EU on whatever terms Theresa May and the EU negotiate." That's not what the referendum said in plain language, it's not what every Leave voter wanted, and it's not the only outcome that would honor the results of the referendum. Many Leave voters wanted to stop the free flow of people, but not all. Many Leave voters wanted to regain regulatory autonomy for Britain, but not all. Many Leave voters wanted a better economic outcome for Britain, as did many Remain voters. Some Leave voters may have imagined a Norway-style Brexit, other Leave voters may have imagined a Swiss-style Brexit, many Leave voters may have imagined a Brexit resembling the Leave campaign's fantasies, and few probably imagined anything like the present prospects. A singular notion of the will of the voters is a mirage.

I like to imagine a statesman in Britain making the point that the will of the people has been respected through the efforts of the government over the past 2+ years. The nation cannot be held hostage by a blind insistence that the Leave campaign's promised outcome is on the table. The negotiations show that the result the Leave campaign sought is not achievable. The only options available are different than the result the Leave campaign sought, and Parliament therefore needs to decide on the best path forward among the available options.

There were, to be sure, some Leave campaigners who wanted the economic self-immolation of a hard Brexit. They still see a possible victory, and will happily shed crocodile tears about the will of the voters. But that is not what the Leave campaign promised and it is not what the Leave voters wanted. The notion that a hard Brexit reflects the will of the voters must be forcefully rejected, and presumably will be rejected by Parliament shortly.

Parliament is where the will of the people must be implemented, and sometimes where it must be thwarted. Perhaps the politics are such that a second Referendum will lessen the social unrest that will follow from the failure of the government to achieve the unachievable. I suspect that the better way forward is for the government to say "We tried our best. We are sorry." Saying that convincingly will require someone quite unlike May or Corbyn.