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.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Adrenal crisis or steroid-associated infection
Hypotension, collapse, vomiting, severe weakness, hypoglycaemia, hyponatraemia, fever or confusion in a steroid-exposed patient may represent adrenal crisis, severe infection or both; glucocorticoids can suppress typical inflammatory signs.
Action: Treat suspected adrenal crisis immediately with hydrocortisone 100 mg intravenously or intramuscularly, rapid isotonic saline and endocrine guidance, while obtaining cultures and treating sepsis without waiting for a cortisol result; never stop chronic glucocorticoid abruptly during acute illness.
Synopsis
Use systemic and local glucocorticoids only for a defined inflammatory indication, prescribe a time-limited regimen with an exit strategy, and prevent adrenal, infectious, metabolic, skeletal and psychiatric harm.
Glucocorticoids are a bridge or rescue treatment, not a substitute for diagnosis and disease-modifying therapy; record the indication, dose, duration, taper and review date at initiation.
In rheumatoid arthritis, NICE permits short-term glucocorticoid bridging when starting a new conventional DMARD and short-term treatment for flares; continuing longer requires discussion of long-term complications and alternatives.
Use the lowest effective dose for the shortest period. A disease-specific regimen takes precedence over an improvised standard dose, particularly in giant-cell arteritis, vasculitis and organ-threatening connective-tissue disease.
Key red flags
Collapse, hypotension, vomiting, abdominal pain, hyponatraemia or hypoglycaemia during illness or after steroid interruption requires immediate adrenal-crisis treatment.
Adrenal insufficiency
Fatigue, anorexia, nausea, abdominal pain, postural dizziness, hypotension, hyponatraemia or hypoglycaemia during taper or illness suggests inadequate endogenous cortisol.
Investigation priorities
01
First-line baseline risk inventoryFirst stepFirst line
Define infection, metabolic, skeletal, psychiatric, ocular and adrenal vulnerability before a planned systemic course.
Management branches
First prescribing stepDefine bridge, rescue and exit
Active inflammatory disease requires rapid control and glucocorticoid benefit is judged to outweigh immediate risk.
Name the diagnosis and target, exclude important infection, reconcile all steroid routes and document a baseline toxicity profile.
Select the disease-specific preparation, dose, route and duration, and start or optimise the steroid-sparing treatment that will maintain control.
Key medicines
PrednisoloneFor a selected inflammatory-arthritis bridge, a common specialist regimen is 5–10 mg orally once each morning for the shortest feasible period with an explicit taper; organ-threatening diseases use diagnosis-specific higher regimens and must not be inferred from this example.
Methylprednisolone intravenous pulseFor selected organ-threatening autoimmune disease, specialist protocols use 250–1000 mg intravenously once daily for one to three days, followed by a diagnosis-specific oral and steroid-sparing plan.
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.