Health Advice

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 when you are unwell your adrenals 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.

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.

Extremely unwell: Take an extra 20mg of Prednisolone OR 50mg of Hydrocortisone and seek medical advice.

SICK DAY RULES: Pregnancy, Surgery and Dental procedures.

Pregnancy – carry on normal doses unless advised by your HCP. 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 Hydrocortisone before major dental work anaesthesia – discuss 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 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:
1) 100 mg of Hydrocortisone by IV or IM 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 Adjustment