What is the sick‑day rule for patients on chronic glucocorticoid therapy?

Sick Day Rules for Patients on Chronic Glucocorticoid Therapy

Patients on chronic glucocorticoid therapy must double their regular steroid dose during any febrile illness, vomiting, diarrhea, or significant physiological stress to prevent life-threatening adrenal crisis. 1, 2

Core Sick Day Rule: When to Double the Dose

Double your usual glucocorticoid dose immediately when you experience:

• Any fever (regardless of cause) 1
• Vomiting or diarrhea 2
• Significant infection (respiratory, urinary, skin, etc.) 1, 2
• Major physiological stress (trauma, severe illness) 1
• Inability to keep oral medications down 1

The rationale is straightforward: during physiological stress, the body normally increases cortisol production 5-10 fold, but patients on chronic steroids have suppressed adrenal function and cannot mount this response. 3 Doubling the dose provides partial compensation for this deficit. 1

Emergency Injectable Hydrocortisone: When to Use It

Inject 100 mg hydrocortisone intramuscularly or intravenously in these situations:

• Persistent vomiting preventing oral medication absorption 1, 2
• Major stress or surgery 1
• Severe illness with inability to take oral steroids 1, 2
• Signs of adrenal crisis (severe weakness, confusion, orthostatic hypotension, nausea) 1, 2

Every patient on chronic glucocorticoids should have an emergency hydrocortisone self-administration kit at home, and at least one family member or companion must be trained to administer the injection. 1, 2 This is non-negotiable for patient safety.

Immediate Medical Attention Required

Seek emergency care immediately if you develop:

• Nausea or vomiting that prevents keeping down your doubled steroid dose 1
• Severe weakness or somnolence 1, 2
• Confusion or altered mental status 1, 2
• Orthostatic hypotension (dizziness when standing) 1, 2
• Persistent hypotension despite fluids 1

These symptoms may indicate impending or established adrenal crisis, which carries significant mortality risk if not treated promptly with intravenous hydrocortisone and fluid resuscitation. 3

Peri-operative and Procedural Stress Dosing

For any surgery or procedure under general anesthesia:

• Administer hydrocortisone 100 mg IV at induction 1, 4
• Continue 50-100 mg IV every 6-8 hours for the first 24-48 hours post-operatively 4
• Once stable and tolerating oral intake, switch to twice the pre-stress oral dose for 48 hours 4
• Taper supplemental steroids over 5-7 days back to baseline maintenance 4

Critical pitfall: Do not reduce or discontinue steroid supplementation if postoperative fever develops—fever may signal adrenal insufficiency rather than infection. 1, 4 Maintain or increase glucocorticoid coverage until the patient is clinically stable. 1, 4

Patient Education and Safety Tools

Every patient on chronic glucocorticoids must have:

• A steroid emergency card documenting their regimen, carried at all times 1
• Medical alert bracelet or necklace identifying steroid dependence 1
• Written sick day rules instructions 1
• Emergency hydrocortisone injection kit (100 mg) at home 1, 2
• At least one trained family member who can administer the emergency injection 1, 2

The harsh reality is that many patients are discharged after starting chronic steroids with little or no education about sick day rules, creating dangerous knowledge gaps. 1, 5 A 2022 survey found that only 5.9% of rheumatology patients on long-term glucocorticoids had been counseled on sick day rules, and only 3.9% carried emergency identification. 5 This represents a systems failure that clinicians must actively address.

Common Pitfalls to Avoid

Do not assume patients understand sick day rules simply because they have been on steroids for months or years. 1 Cognitive and physical skills may be compromised during acute illness, making it difficult for patients to implement these rules without prior education and practice. 1

Never withhold stress-dose hydrocortisone due to concerns about transient hyperglycemia, fluid retention, or infection risk. 1, 4 The short-term metabolic side effects are easily managed and far outweigh the mortality risk of untreated adrenal crisis. 1, 4

Do not use etomidate for anesthesia induction in patients on chronic steroids. 4 Etomidate suppresses cortisol synthesis via 11-β-hydroxylase inhibition and can precipitate adrenal crisis. 4

Avoid starting thyroid hormone, testosterone, or estrogen replacement before ensuring adequate corticosteroid replacement. 2 These hormones increase metabolic demand and can precipitate adrenal crisis in patients with inadequate glucocorticoid coverage. 2

Special Populations

Pregnancy and delivery:

• Administer hydrocortisone 100 mg IV at onset of active labor 1
• Follow with continuous infusion of 200 mg/24 hours or 50 mg IM every 6 hours 1
• Taper rapidly over 1-3 days to regular replacement dose after uncomplicated delivery 1

Pediatric patients:

• Administer hydrocortisone 2 mg/kg IV at induction for any surgery under general anesthesia 1
• Continue 2 mg/kg every 4 hours IV/IM following major surgery 1
• For minor procedures, double the normal oral dose postoperatively 1

Infection Risk and Precautions

Patients on ≥20 mg/day prednisone (or equivalent) for ≥2 weeks are considered immunosuppressed. 2 Infection risk increases significantly at doses >15 mg/day. 2 This creates a paradox: sick day rules require doubling the dose during infection, which theoretically increases immunosuppression, but the immediate mortality risk of adrenal crisis far exceeds the incremental infection risk from short-term dose escalation. 2, 3

Avoid all live vaccines while on supraphysiologic steroid doses. 2 Wait at least 3 days to 2 weeks after discontinuing steroids before administering live vaccines, depending on dose and duration. 2