Skip to textbook content
Doctor’s PassportTextbook
TopicsAll topics

Loading topic navigation…

Textbook navigation
TopicsAll topics

Loading topic navigation…
Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Glucocorticoid replacement and steroid sick-day rules

Endocrinology and metabolism · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
!
Escalate

A patient with adrenal insufficiency who cannot retain oral medication, becomes hypotensive, confused or severely weak, or has persistent vomiting or diarrhoea should use emergency hydrocortisone as trained and call 999 for hospital treatment. Oral sick-day dosing is not adequate when absorption is unreliable.

Synopsis

Deliver physiological glucocorticoid replacement, teach proportionate stress dosing and create reliable oral, injectable and peri-procedural safeguards that prevent crisis without chronic overexposure.

  • Physiological replacement aims to mimic the cortisol day: the largest hydrocortisone dose is generally taken on waking, with smaller later doses and avoidance of unnecessary late-evening exposure.
  • NICE adult replacement options include hydrocortisone 15 to 25 mg daily in divided doses or prednisolone 3 to 5 mg daily when appropriate; individual clinical response and specialist review govern selection.
  • For significant physiological stress, NICE advises at least 40 mg oral hydrocortisone daily in two to four divided doses or at least 10 mg prednisolone daily in one or two divided doses until the acute illness resolves.
  • A patient already taking prednisolone 10 mg or more daily may not need a higher total sick-day dose, but dose timing and the individual endocrine plan still matter.
  • If vomiting occurs within 30 minutes of an oral dose, NICE advises repeating after vomiting settles at double the original dose; further vomiting triggers intramuscular hydrocortisone and emergency attendance.
  • Fever, infection requiring antibiotics, significant trauma and invasive procedures need stress planning. Minor emotional stress or a brief uncomplicated cold does not justify indefinite supraphysiological dosing.
  • Every at-risk patient needs an NHS Steroid Emergency Card, extra oral tablets and training for a 100 mg IM emergency injection, with a carer trained where possible.
  • Never stop long-term glucocorticoid abruptly. Tapering is determined by the inflammatory indication first, then by hypothalamic-pituitary-adrenal recovery assessment once near physiological exposure.
  • Stress dosing can worsen glucose, fluid retention, blood pressure, infection and mental state, but these risks are managed with monitoring; they do not justify under-treating major physiological stress.
  • Peri-operative cover depends on procedure, anaesthesia, fasting and baseline steroid exposure. Use the current local anaesthetic-endocrine protocol and confirm who will prescribe, administer and step down each dose.

Key red flags

Injection threshold

Repeated vomiting, severe diarrhoea, inability to swallow, major trauma, collapse, confusion or shock makes oral absorption unsafe and requires emergency hydrocortisone plus urgent hospital assessment.

Procedure exposure

Fasting, bowel preparation, sedation, general or regional anaesthesia and tissue trauma change cortisol need. A missing peri-procedure plan is a safety defect even when the regular morning tablet was taken.

Investigation priorities

01
Structured dose and timing reviewFirst step

Determine actual daily glucocorticoid exposure and whether symptoms cluster around dose gaps.

Management branches

Daily replacementMinimise peaks and gaps

Stable primary, secondary or tertiary adrenal insufficiency outside acute physiological stress.

  1. Agree a total daily hydrocortisone or prednisolone regimen with endocrinology, giving the largest hydrocortisone component on waking and adapting clock time for shift workers.
  2. Review symptoms before and after doses, adherence, interacting medicines and metabolic/bone effects; change one variable at a time and document the maintenance schedule clearly.
  3. Ensure mineralocorticoid replacement is separately optimised in primary disease and that every routine prescription includes enough reserve for sick-day dosing.

Key medicines

Hydrocortisone maintenanceUsually 15 to 25 mg orally per day in two to four divided doses for adults under NICE guidance, tailored to the individual.Late doses can disturb sleep and chronic excess causes metabolic and bone harm. Do not reduce below a safe plan during illness and do not stop suddenly.
Hydrocortisone oral sick-day regimenAt least 40 mg orally daily in two to four divided doses during significant physiological stress, continued until the acute illness resolves.This is not sufficient with recurrent vomiting, severe diarrhoea, collapse or confusion. Monitor glucose and hydration, and seek clinical review when illness is prolonged or worsening.
Open full textbook →Answer 2 questions
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG243 adrenal insufficiency recommendationsCurrent maintenance, stress dosing, vomiting and emergency-kit recommendations.
  • BNF adrenal insufficiency treatment summaryUK replacement options and prescribing safeguards.
  • Society for Endocrinology adrenal crisis resourcesEmergency injection, patient education and crisis prevention framework.
  • JBDS inpatient guideline indexCurrent JBDS glucocorticoid-associated hyperglycaemia guidance and hospital pathways.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom