Steroid Sick Day Rules
This leaflet is intended for patients on steroid treatment at risk of adrenal insufficiency /adrenal crisis. It explains more about the steroid sick day rules. If you have any further questions, please speak to the Health Care Professional (HCP) supervising your care.
Why are steroid sick day rules important?
Taking steroid medication, such as prednisolone tablets, steroid inhalers and steroid injections, can stop your adrenal glands from making the hormone cortisol. When this occurs, it is known as adrenal insufficiency.
Cortisol is essential for life and in those without adrenal insufficiency, when they are unwell, adrenal glands produce more cortisol. You have been given this information because your HCP thinks you could be at risk of becoming seriously unwell (known as an adrenal crisis) if you are unwell or have a procedure, such as surgery, without an appropriate increase in your steroid medication.
What is an adrenal crisis?
An adrenal crisis occurs when there is insufficient circulating cortisol in the body. This can be life-threatening if not treated.
What are the signs and symptoms of an adrenal crisis?
- Low blood pressure.
- Feeling dizzy or light-headed.
- Fever, shivering or feeling very cold.
- Nausea and /or vomiting.
- Feeling very weak.
- Extreme tiredness, drowsiness or confusion.
- Aching muscles and/or joints.
- Stomach ache.
- Severe diarrhoea.
How can I prevent an adrenal crisis?
- Ensure you follow the sick day rules described below and know what to do when unwell.
- Ensure you have a sufficient supply of the steroid medications to take when unwell.
- Never stop your steroid treatment abruptly or skip doses.
- Only reduce your steroid dose as advised by your HCP.
- If you start to feel unwell following a steroid dose reduction, contact your HCP for advice.
- If you are unwell, make sure that the person treating you knows you are at risk of adrenal crisis and show them your NHS Steroid Emergency Card.
Sick Day Rules: when do I need to take more steroids?
Mild illness without fever: no change in dose.
Illness with fever: If your temperature is raised, your steroid dose needs to be increased for the duration of the illness. However, if you are already on prednisolone 15mg or more there is no need to take additional steroid medication.
Extremely unwell: Take an extra 20mg of prednisoloneOR50mg of hydrocortisone and seek medical advice.
Vomiting or diarrhoea: If you vomit once, take an extra 5mg of prednisolone OR 20mg of hydrocortisone by mouth.
If vomiting persists after you have taken the extra steroid dose, you must seek urgent medical attention: go to the Emergency Department, or call an ambulance via 999. Take your NHS Steroid Emergency Card with you and ensure that the team looking after you know that you are on steroid medication and that you are at risk of adrenal crisis and may need a steroid injection.
Sick Day Rules: pregnancy, surgery and dental procedures
Pregnancy
Carry on normal doses unless advised by your health care professional. At the onset of labour or start of a caesarean section, to start a continuous IV infusion of 200 mg hydrocortisone over 24 hours (alternatively 50 mg of hydrocortisone IV or IM every 6 hours). Double usual oral dose for 48 hours after the baby is born.
Minor Dental Surgery
Take 5mg of prednisolone OR 20mg of hydrocortisone one hour prior to the procedure and take a double dose for 24 hours after the procedure, then return to your normal dose.
Major Dental Surgery
You may need 100mg of IM (intramuscular) hydrocortisone before major dental work anaesthesia – please discuss this in advance with your dentist. Take a double dose for 24 hours after any dental procedure, then return to your normal dose.
Surgery and invasive procedures
100 mg of hydrocortisone by IV or IM (intramuscular) injection at the start of surgery followed by a continuous IV infusion of 200 mg hydrocortisone over 24 hours, or 50 mg of hydrocortisone IV or IM every 6 hours. Double usual dose when eating and drinking and reduce to usual dose over the next 1-2 weeks as you recover.
Hospital Treatment
If you are admitted to hospital unwell, we recommend:
-
100 mg of hydrocortisone by IV or IM (intramuscular) injection, followed by a continuous IV infusion of 200 mg hydrocortisone over 24, or 50 mg of hydrocortisone IV or IM every 6 hours.
| Sick Day Rules | |||
| Steroid Medication | Normal dose | Unwell with fever | COVID - suspected or confirmed |
| Prednisolone | 3-10mg daily | 5mg twice daily | 10mg twice daily |
| Prednisolone | 10mg or more daily | Split daily dose to twice daily | Split daily dose to twice daily e.g. 20mg daily becomes 10mg twice daily |
| Hydrocortisone | >10mg daily | 20mg immediately then 10mg 6 hourly | 20mg every 6 hours |
| Other steroid preparation | NA | 20mg hydrocortisone immediately, then 10mg 6 hourly | Hydrocortisone 20mg every 6 hours |
If you are at risk of adrenal insufficiency due to long term and/or high dose steroid use:
- Carry a Steroid Emergency Card https://www.endocrinology.org/media/3873/steroid- card.pdf
- Ensure you have a supply of oral prednisolone or hydrocortisone. You will need to take this in addition to your normal steroid medication if you are unwell in accordance with sick day rules
- A one month reserve of steroid medication is recommended, for example Hydrocortisone 10mg tablets x 2 boxes of 28 tablets
Resources
Adrenal Insufficiency Leaflet:
https://www.endocrinology.org/clinical-practice/patient-information/
Adrenal Crisis Information:
https://www.endocrinology.org/clinical-practice/clinical-guidance/adrenal-crisis/