What are the sick‑day rules for a patient with primary adrenal insufficiency (Addison’s disease)?

Sick Day Rules for Addison's Disease (Primary Adrenal Insufficiency)

During any illness with fever >38.5°C, vomiting, diarrhea, or significant infection, patients with Addison's disease must immediately triple their usual hydrocortisone dose and maintain their regular fludrocortisone dose unchanged. 1

Core Sick Day Principles

Glucocorticoid stress dosing:

• Triple the usual daily hydrocortisone dose during fever, vomiting, diarrhea, or any significant illness 1
• If the usual dose is 20 mg daily (e.g., 10+5+5 mg), increase to 60 mg daily (e.g., 20+20+20 mg) 2, 3
• Continue the increased dose until 24-48 hours after symptoms resolve, then return to maintenance dosing 3

Mineralocorticoid dosing:

• Continue the regular fludrocortisone dose without change during illness 1
• Only glucocorticoid dosing is increased during stress; fludrocortisone remains at baseline 1

Emergency Injectable Hydrocortisone Protocol

When to inject immediately:

• If vomiting prevents oral medication intake 1
• If unable to keep down oral hydrocortisone after two attempts 3
• If experiencing severe weakness, confusion, or signs of impending crisis 3

Injection protocol:

• Administer 100 mg hydrocortisone intramuscularly immediately 1, 4
• Seek emergency medical care without delay after injection 1
• Do not wait to see if symptoms improve before going to hospital 3

Specific Illness Scenarios

Fever:

• Any fever >38.5°C requires tripling the hydrocortisone dose 1
• Continue increased dosing until fever resolves and patient feels well for 24 hours 3

Gastrointestinal illness:

• Vomiting or diarrhea necessitates immediate dose tripling 1
• If unable to retain oral medication, give 100 mg IM hydrocortisone and proceed to emergency department 1, 3
• Intravenous hydrocortisone 100 mg every 6-8 hours will be required until oral intake resumes 3, 5

Minor infections (colds, minor injuries):

• Double the usual hydrocortisone dose for minor stress 3
• If symptoms worsen or fever develops, escalate to triple dosing 1

Critical Pitfalls to Avoid

Never delay increasing glucocorticoid dose "to see how things go":

• Inadequate or delayed dose increases are the most common cause of preventable adrenal crises 1
• Failure to increase dose during illness despite prior education markedly raises crisis risk 1

Never stop or reduce fludrocortisone during illness:

• Mineralocorticoid replacement continues unchanged; only glucocorticoid dosing increases 1
• Stopping fludrocortisone during stress predisposes to hypotension and crisis 2

Never assume you can "tough it out" without dose adjustment:

• The adrenal glands cannot respond to stress in Addison's disease 6
• Without exogenous glucocorticoid increase, life-threatening crisis will develop 3, 4

Patient Preparedness Requirements

Emergency supplies:

• Keep a 100 mg hydrocortisone intramuscular injection kit at home and when traveling 1, 3
• Ensure family members or caregivers are trained in IM injection technique 1
• Carry extra oral hydrocortisone tablets at all times 3

Medical identification:

• Wear a medical alert bracelet indicating adrenal insufficiency 1, 3
• Carry a steroid emergency card with clear dosing instructions 1

Education reinforcement:

• Review sick day rules at every clinic visit 3
• Inadequate patient education is a frequent contributor to recurrent crises 1

Surgical or Procedural Stress

Major surgery:

• Requires hydrocortisone 100 mg IV at induction, then 100 mg IV every 6-8 hours post-operatively 3
• Once oral intake resumes, restart at double maintenance dose, then taper to baseline over 48 hours 1

Minor procedures (dental work, endoscopy):

• Take double the usual morning hydrocortisone dose 1-2 hours before the procedure 3
• Resume normal dosing the following day if no complications 3