Steroid Sick-Day Rules

Steroid sick-day rules explain how patients at risk of adrenal insufficiency should adjust glucocorticoid treatment during acute illness, injury or a medical procedure.

During physical stress, a healthy adrenal gland increases cortisol secretion. A patient with adrenal insufficiency—or suppression of the hypothalamic–pituitary–adrenal axis from prolonged corticosteroid treatment—may be unable to mount this response. Without additional glucocorticoid cover, severe illness may precipitate an adrenal crisis.

🧬 Why Are Additional Steroids Needed?

Cortisol supports vascular tone, blood pressure, glucose availability and the physiological response to infection or injury. Exogenous corticosteroids suppress hypothalamic corticotropin-releasing hormone and pituitary ACTH secretion. Prolonged treatment may therefore cause adrenal cortical atrophy and an inadequate endogenous cortisol response when the patient becomes unwell.

👥 Who Is At Risk?

• Primary adrenal insufficiency, including Addison’s disease
• Secondary adrenal insufficiency caused by pituitary disease
• Adrenal insufficiency following pituitary or adrenal surgery
• Patients taking long-term systemic corticosteroids
• Patients who have recently stopped prolonged corticosteroid treatment

Adults taking approximately prednisolone 5 mg or more daily for four weeks or longer, or an equivalent glucocorticoid dose, may have clinically important adrenal suppression. The precise risk depends on dose, duration, timing, individual susceptibility and recent steroid exposure.

🤧 Minor Illness

No additional steroid is usually required for a trivial illness without systemic upset, such as:

• A mild cold without fever
• Minor headache
• Small superficial injury
• Brief emotional stress

The patient should continue their normal prescribed dose and monitor their symptoms.

🌡️ Significant Intercurrent Illness

Sick-day dosing is generally required for an illness causing physiological stress, including:

• Fever
• Influenza or significant viral illness
• Infection requiring antibiotics
• Marked systemic symptoms or bed rest
• Significant injury
• Minor surgery or an invasive procedure

💊 Patients Taking Steroids as Hormone Replacement

Patients taking physiological replacement doses should usually double their normal oral glucocorticoid dose, ensuring a minimum total daily dose equivalent to approximately hydrocortisone 30–40 mg.

• Hydrocortisone: increase the total dose to at least 30–40 mg daily, divided across the day.
• Prednisolone replacement: commonly increase to approximately 5 mg twice daily or follow the patient’s individual endocrine plan.

The increased dose is continued while the patient is systemically unwell—usually for 48 hours or until recovery—then the usual replacement dose can generally be resumed without tapering. Local endocrine plans may differ and should take precedence.

📈 Patients Taking Long-Term Prednisolone for Inflammatory Disease

The correct adjustment depends on the patient’s existing dose:

• Usual prednisolone dose below 10 mg daily: increase to a total of approximately 10 mg daily during significant illness.
• Usual dose of 10 mg daily or more: this generally already provides ordinary oral stress cover, so an automatic increase may not be required.
• High-dose treatment such as prednisolone 25 mg daily: do not routinely double it to 50 mg solely because the patient is mildly unwell.

Further increases may still be needed if required to treat the underlying inflammatory illness—for example, a severe asthma exacerbation—but that is treatment of the disease, not routine adrenal sick-day replacement. UK guidance therefore advises considering both the existing steroid dose and the clinical reason for which it is prescribed.

🤮 Vomiting or Diarrhoea

If the patient vomits once shortly after taking their steroid:

• Take an additional oral dose once vomiting has settled.
• For example, take an additional prednisolone 5 mg or hydrocortisone 20 mg, according to the individual emergency plan.

If vomiting recurs, tablets cannot be retained, or there is severe diarrhoea, oral absorption cannot be relied upon. The patient should:

• 💉 Receive hydrocortisone 100 mg intramuscularly or intravenously immediately
• 🚑 Seek urgent emergency medical assessment
• 🪪 Show their NHS Steroid Emergency Card

Repeated vomiting in a steroid-dependent patient should be treated as an impending adrenal crisis rather than managed by repeatedly attempting oral doses.

🚨 Suspected Adrenal Crisis

Clinical features may include:

• Severe weakness or collapse
• Hypotension, dizziness or syncope
• Vomiting, diarrhoea or abdominal pain
• Confusion, drowsiness or reduced consciousness
• Fever or severe systemic illness
• Hypoglycaemia
• Hyponatraemia and, particularly in primary adrenal failure, hyperkalaemia

Do not delay treatment while awaiting biochemical confirmation.

Immediate management includes:

• Hydrocortisone 100 mg IV or IM immediately
• Rapid IV 0.9% sodium chloride
• Assessment and treatment of hypoglycaemia
• Investigation and treatment of the precipitating illness
• Continued parenteral hydrocortisone, commonly 200 mg over 24 hours or 50 mg every six hours

Hydrocortisone is safe in this emergency; the danger lies in delaying treatment.

🏥 Surgery and Procedures

Patients with adrenal insufficiency or significant adrenal suppression must inform the surgical, anaesthetic and dental teams in advance. Major surgery, general anaesthesia, significant trauma and invasive procedures may require parenteral hydrocortisone rather than oral sick-day dosing.

Minor dental surgery under local anaesthetic may require an additional pre-procedure dose and temporary doubling afterwards, whereas major dental surgery or general anaesthesia may require hydrocortisone 100 mg IM or IV. The precise regimen should follow local perioperative guidance.

🪪 Steroid Emergency Card

Patients at risk should:

• Carry an NHS Steroid Emergency Card
• Wear medical-alert identification where appropriate
• Keep an adequate supply of steroid medication
• Have written individual sick-day instructions
• Know when and how to use an emergency hydrocortisone injection
• Tell healthcare professionals about their steroid dependence

The Steroid Emergency Card helps clinicians recognise patients who may require urgent glucocorticoid treatment during illness, surgery or emergency care.

🧑‍⚕️ Case Example 1: Physiological Replacement

A 46-year-old woman with Addison’s disease takes hydrocortisone 10 mg on waking, 5 mg at lunchtime and 5 mg in the late afternoon. She develops influenza with fever and myalgia but can eat, drink and retain tablets.

Management: She increases her total hydrocortisone dose according to her sick-day plan—usually doubling the dose or taking at least 30–40 mg daily in divided doses—maintains fluid intake and monitors her symptoms.

Reasoning: Her normal 20 mg dose is physiological replacement and does not provide the additional cortisol normally produced during significant illness.

🧑‍⚕️ Case Example 2: Low-Dose Prednisolone

A 72-year-old man has taken prednisolone 5 mg daily for polymyalgia rheumatica for eight months. He develops a febrile urinary tract infection requiring antibiotics.

Management: His total prednisolone dose is temporarily increased to approximately 10 mg daily while systemically unwell, according to local guidance, before returning to 5 mg once recovered.

Reasoning: His hypothalamic–pituitary–adrenal axis may be suppressed, and his normal 5 mg dose may not provide sufficient stress coverage.

🧑‍⚕️ Case Example 3: Already Taking High-Dose Prednisolone

A 58-year-old woman is taking prednisolone 25 mg daily for active vasculitis. She develops an uncomplicated urinary infection but remains haemodynamically stable and can take oral medication.

Management: She continues prednisolone 25 mg daily. It should not automatically be increased to 50 mg as routine adrenal sick-day cover.

Reasoning: Prednisolone 25 mg is already substantially above the usual physiological stress dose. A higher dose would only be indicated if required for her vasculitis or another specific clinical reason.

🧑‍⚕️ Case Example 4: Persistent Vomiting

A 64-year-old man with pituitary adrenal insufficiency takes prednisolone replacement. He develops gastroenteritis and repeatedly vomits his tablets. He becomes dizzy and hypotensive.

Management: Give hydrocortisone 100 mg IM immediately using the emergency kit, call emergency services and arrange urgent hospital assessment.

Reasoning: Oral dosing cannot be relied upon, and hypotension suggests evolving adrenal crisis.

⚠️ Clinical Pearls

• Do not stop long-term corticosteroids abruptly.
• “Double the dose” is principally a rule for low-dose replacement therapy.
• Consider the absolute steroid dose, not merely the multiplication factor.
• A patient taking prednisolone 25 mg is already receiving much more glucocorticoid than a normal physiological replacement dose.
• Vomiting, hypotension or inability to retain tablets requires parenteral hydrocortisone and urgent assessment.
• Treat suspected adrenal crisis immediately—do not wait for a cortisol result.

⭐ Key Point

Steroid sick-day rules aim to reproduce the increased cortisol secretion required during physiological stress. Patients taking low replacement doses usually need additional glucocorticoid, whereas those already taking prednisolone 10 mg or more daily may already have sufficient routine stress coverage. Severe illness, persistent vomiting, trauma or haemodynamic instability requires urgent parenteral hydrocortisone and assessment for adrenal crisis.