Sick Day Rules The Sick Day rules are a set of guidelines to help keep you safe and reduce the chances of an adrenal crisis when you are feeling off-colour, injured or ill. As everyone's medication needs are different, they are guidance rather than concrete rules. Always listen to your body. Minor ailments can have a potentially serious effect on anyone with a steroid-dependent adrenal condition. This can either be due to your normal dose of steroids not being enough whilst you are unwell, or due to the symptoms of your illness interfering with how you absorb your steroid medication. Even when you feel unwell with what might be considered a minor ailment in someone with fully functioning adrenal glands, you must spot any early symptoms and adjust your steroid replacement medication. Common triggers of Adrenal Crisis If you are not able to absorb your usual hydrocortisone medication, and are not able to meet any increased demands for cortisol, as a result of being under the weather, you are at risk of adrenal crisis. An adrenal crisis is serious, uncomfortable and can be life-threatening. It is worth noting that Bereavement and stress (emotional or psychological stress) are also noted as triggers. Follow Sick Day Rules if you have; The Sick Day Rules are to always be used in the situations mentioned below, but may be needed in other scenarios too, if you feel you are heading into an adrenal crisis, irrespective of the cause. Sick Day Rules: recommended dose in a 24-hour period Start by immediately taking extra medication. Updose for 48 hours. If you are feeling better, go back to your usual dose. • If you don’t feel better after 48 hours, continue to updose and speak to your GP or your endocrine nurse / doctor for more advice. • If you are prescribed antibiotics, continue to updose until you finish the course or feel completely back to normal. Everyone is different and you need to listen to your body. Your endocrine nurse / doctor can give you advice on how to taper your increased dose down safely. Tapering To keep you stable, it’s important that you gradually taper any increased dose down to your usual dose, in line with feeling better, so don't suddenly reduce to your normal dose in one go. Do I change my fludrocortisone dose? Fludrocortisone is only taken by those with Addison's disease (primary adrenal insufficiency). If your 'upped' daily dose is now 50mg or more, and continues to be at this high level for over 7 days, it is recommended to stop your fludrocortisone dose. It is not needed if you are on very high levels of hydrocortisone. Discuss with your GP or endocrinologist if you should stop your fludrocortisone to reduce the risk of developing low blood potassium levels with an extended period on higher hydrocortisone. If you do temporarily stop it whilst you are on your upped daily dose of hydrocortisone, you can start it again once you taper back down. Learn more about fludrocortisone. What do I do if...? My temperature is high If your temperature is over 39 degrees, take 20mg of hydrocortisone every 6 hours (or 5mg of prednisolone every 6 hours) and seek immediate medical advice. A high temperature like this indicates a severe infection or the start of an adrenal crisis. Take paracetamol Increase your fluids I can't keep my meds down If you vomit and bring up your medication within 30 minutes of taking it, take a double dose again immediately. If bring up the second dose, inject yourself with 100mg of hydrocortisone and seek medical advice immediately. If you carry on vomiting, you will become dehydrated. You will need to go to hospital for a saline drip to prevent an adrenal crisis. Preparing for a hospital admission I have COVID-19 We have collated some general COVID-19 guidance on the management of Addison's medication and other information Article Video What else can I do? Get some rest Stay hydrated by drinking regularly (water is best). You can use the colour of your urine as an indicator of whether you need to drink more. If it is a dark yellow then you need to drink more fluids. Check you have enough steroid medication for your increased dose. Request a repeat prescription if you are unsure. You should always have three months reserve supply of your essential steroid medication. Download or print our Managing your Addison's and adrenal insufficiency leaflet for more information for yourself and those who support you when unwell. Webinar on Sick Day Rules Reinforce the rules by watching our Sick Day Rules webinar on YouTube, courtesy of our collaboration with Endocrine Nurse Aldons Chua and the Pituitary Foundation on Addison's Disease Day 2025. Sick Day Rules Webinar Antibiotics As mentioned above, the Sick Day Rules suggest updosing if you are on a course of antibiotics. We have often had queries asking about whether this is needed because of the illness you have which means you need antibiotics, or if it is the antibiotics themselves that interfere with how your replacement glucocorticoid works. We asked our Clinical Advisory panel for more information and were given the clarification below: 1. The most serious one to get right is if you have TB and need to take rifampicin (often a 6-month course), then you will need to increase your hydrocortisone in line with Sick Day Rules for the full 6 months as the antibiotic accelerates the degradation of hydrocortisone. 2. For other antibiotics, the logic is that if you are sick enough to need an antibiotic, then you are sick enough to need to increase your hydrocortisone to ’sick day rules’ levels. For a regular course of antibiotics, this is only 5 or 7 days. If you feel perfectly back to normal before the end of the 5 or 7-day course, then it is appropriate to taper your dose back down to normal, however, they suggested that up-dosing for 5 to 7 days doesn’t seem unreasonable for most infections. A suggested exception, where it is a case of a common-sense approach, may be something like a superficial skin infection where you feel fine throughout so do not feel it is necessary to updose. 3. There is a class of antibiotics known as macrolides, which includes clarithromycin and erythromycin. These inhibit the breakdown of hydrocortisone (ie the opposite of rifampicin in point 1,). As a result, taking increased doses of hydrocortisone for a long course of these antibiotics (eg 3 or 4 weeks) could, theoretically, lead to excess steroid side effects, although the consultant pointed out that he had not seen this in practice. For a standard course of these antibiotics (5-7 days) it is not a problem to follow Sick Day rules for the duration of the course. Should I get a flu jab? We strongly recommend anyone with a steroid-dependent adrenal condition get their free NHS flu jab to reduce their risk of getting the flu. This will help to reduce the risk of an adrenal crisis if you were to catch the flu. Find out more by reading our flu jab page. You shouldn’t need to take hydrocortisone to cover a flu jab. Should I change my medication dose for emotional stress? It is more difficult to define how emotional and psychological challenges affect the stress response and how to manage cortisol replacement, mostly because each challenge is unique, and individuals may respond in different ways. Whether to temporarily increase the dose of steroids in case of emotional and psychological stress should be considered on a case-by-case basis, and patients are best suited to do this. While it is not advisable to routinely take a stress dose of glucocorticoids for minor stressful life events, a top-up should be considered when coping with grief and loss, a job interview, or a final-year exam, for example. Find out more by reading our 'Coping with psychological stress' page. 3 months reserve supply of essential steroid medicine Due to the Sick Day Rules it is necessary to always have three months reserve supply of your essential steroid medicine. This is to ensure you have enough to keep you safe through an episode of illness which requires increased dosing, or to cover if there is a shortage of your medicine. If you need to discuss with your GP adjusting your repeat prescription length, follow the steps on our GP page. For more detailed information on 'normal day' cortisol replacement medication, including doses, times of day to take your medication, and which medication is right for you, visit our cortisol replacement page. Cortisol Replacement Medication Further information: Society for Endocrinology webpage: www.endocrinology.org/adrenal-crisis 'Living with Addison's Disease' book: www.addisonsdisease.org.uk/News/living-with-addisons-disease-book Watch Prof John Wass, Chair of the ADSHG Clinical Advisory Panel, discuss the symptoms of an adrenal crisis and when to give an emergency injection: https://youtu.be/oucbVQ0Whq8 Watch our video with CoMICS "What is Adrenal Crisis & How to Manage It?" https://youtu.be/v3BsSishg0g Guidance on the need for 3 months reserve supply of essential steroid medication This guidance has been prepared by the Addison’s Clinical Advisory Panel (ACAP) Professor Wiebke Arlt, University Hospital, Birmingham Professor Simon Pearce, Royal Victoria Infirmary, Newcastle Dr Helen Simpson, University College Hospital, London Professor John Wass, University of Oxford Updated: Apr 2025 Are you a member of our charity? 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