If you are in an emergency situation, you can view the Cortisol Sick Day Rules table (a quick reference guide to managing illness for those taking cortisol replacement) and the Adrenal Crisis Signs Table (a quick reference for signs of potential adrenal crisis). These tables may be helpful in identifying an adrenal crisis and in managing sick days dosing.
The information on these tables are also shown below in a mobile friendly format.
During normal health and life, when we become ill or suffer injuries our bodies produce increased levels of cortisol to help us survive those stresses.
If you are unable to produce your own cortisol, you need to be aware of when to provide an increased cortisol level using medication. This may happen during stressful times or ill health. The amount of increase needed, the way the cortisol is given, and the length of time the increase is needed will vary depending on the situation you are in.
During normal health and life, when we become ill or suffer injuries our bodies produce increased levels of cortisol to help us survive those stresses.
If you are unable to produce your own cortisol, you need to be aware of when to provide an increased cortisol level using medication.
The page below outlines
This may happen during stressful times or ill health. The amount of increase needed, the way the cortisol is given, and the length of time the increase is needed will vary depending on the situation you are in.
Cortisol Clock
The cortisol clock gives approximate times of need for emergency medical help and replacement.
Emergency cortisol replacement peak timings for clinical use
A = period of first feeling unwell (within, or up to, one hour)
B = period of increasing illness (failure to retain oral cortisol) (during 2nd hour)
C = DANGER ZONE – emergency cortisol injection needed and call 999 stating adrenal crisis(by the 3rd hour)
Below we outline the more common life events when an increase in cortisol cover would be needed and provides advice as to how long the increase should be for and in what form the cortisol should be given (tablets, injection to muscle or direct into vein).
Illness/situation
Give emergency injection if possible, and then dial 999 and state adrenal crisis.
This is urgent, and hospital admission is needed to stabilise.
Action to take: 2-3 times all normal doses of Hydrocortisone for duration of infection
Level of care needed: GP/Self care, if symptoms not resolved at 48 hours see GP may need antibiotic treatment
Action to take: Double all normal doses for duration of antibiotics (usually 3-7 days)
Action to take: Take extra dose immediately at onset of vomiting. Emergency 100mg injection if vomiting recurs within 30mins of taking extra dose .
Level of care needed: Urgent if unable to tolerate fluids and emergency injection used need admission to stabilise. GP if able to tolerate fluids and retain oral Hydrocortisone, check Sodium within range. May need anti-sickness treatment.
Action to take: If no vomiting double all doses of Hydrocortisone until diarrhoea settles. If signs of adrenal crisis follow advice for that.
Level of care needed: Self care/GP. Urgent if signs of adrenal crisis.
Action to take: If able double dose hydrocortisone as soon as incident happens. If significant injury eg broken bone, give emergency injection.
Level of care needed: Self care. Urgent if significant injury as need hydrocortisone cover and injury treated
Action to take: Take 20mg as tablets if able or double usual dose of prednisolone if able. May need to use emergency injection if shock is severe.
Level of care needed: See GP or hospital for further advice. Sudden and severe shock may be classed as emergency – seek medical attention if in doubt.
Action to take: Double usual dose on day of flight. One double dose should suffice.
Action to take: Not usually required. Ask GP if concerned
Extraction with anaesthetic
Action to take: 100mg intra muscular (via injection) just before extraction
Level of care: Double dose 24 hours then return to normal
Root canal – local anaesthetic
Action to take: Double dose 1 hr prior to surgery
Level of care: Double dose 24 hours then return to normal
Filling, dental hygiene
Action to take: Double dose 1 hr prior to procedure
Level of care: Double dose 24 hours then return to normal
Surgery with long recovery – e.g. heart, bowel
Action to take: 100mg IV with anaesthetic, then 100mg IV every 6hrs or 200mg continuous IV over 24hrs until able to eat/drink. Then double normal dose for 48hrs, then taper back to normal.
Level of care needed: Tell the anaesthetist and surgeon that you take hydrocortisone before the operation. Replacement at time of surgery and immediately post operatively should be managed by surgical teams.
Surgery with quick recovery – e.g. joint replacement
Action to take: 100mg IV with anaesthetic, then 100mg IV every 6hrs or 200mg continuous IV over 24hrs until able to eat/drink. Then double normal dose for 48hrs, then taper back to normal.
Level of care needed: Tell the anaesthetist and surgeon that you take hydrocortisone before the operation. Replacement at time of surgery and immediately post operatively should be managed by surgical teams.
Minor surgery- cataract, hernia
Action to take: 100mg intra muscular (via injection) pre anaesthetic, double normal dose for 24 hrs post surgery, then normal doses.
Level of care needed: Tell the anaesthetist and surgeon that you take hydrocortisone before the operation. Replacement at time of surgery and immediately post operatively should be managed by surgical teams.
Minor surgery with local anaesthetic – mole removal
Action to take: Take extra dose 1 hour pre procedure, extra dose 1 hour post procedure, then normal doses.
Action to take: Double your usual dose as soon as the preparatory laxatives take effect and for duration
of the preparation.
For colonoscopy only: a 100mg injection 30 minutes before procedure to be given by doctor. Take usual dose on morning of procedure.
Some centres may want to admit you to hospital the night before to give the bowel prep and provide hydrocortisone cover.
Level of cover needed: Drink lots of water to prevent dehydration. Tell the doctor before procedure that you take hydrocortisone.
Action to take: 100mg intra muscular or intra venous at start of procedure.
Level of cover needed: Tell the doctor before procedure that you take hydrocortisone. Double dose for 24 hours.
Action to take: 100mg intra muscular immediately pre-procedure.
Level of cover needed: Double dose 24hr then resume as normal. Tell the doctor before procedure that you take hydrocortisone.
Adrenal Crisis
If you cannot absorb your tablets, or your usual replacement wasn’t sufficient for an acute shock or illness. This may happen gradually or perhaps quite quickly. You would feel weak, sickly and light headed. Below we outline the signs of adrenal crisis and the actions needed to take. If you find you have more than one of these symptoms at the same time, your Cortisol levels are likely to be dropping or too low. Equally, if you find symptoms start to accumulate, e.g. headache, followed by nausea, then feel shivery cold, with legs aches and fatigue, this may also indicate a likely reduction in cortisol levels. Taking extra Cortisol by mouth as instructed for Sick Day cover at this time can often prevent a full-blown adrenal crisis.
Our emergency information page gives more guidance on how to deliver an emergency hydrocortisone injection.
You should always seek medical advice if you have needed to use your emergency injection or if an increased dose of your tablets has not helped to resolve your symptoms.
Symptom
Action: If new symptom, ensure adequate fluids have been taken. Check signs of infection/illness/ sudden significant stress – if yes, increase Cortisol intake as per sick days
Urgency: Treat at home with increased cortisol replacement by mouth. Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E. Emergency injection and 999 if progressing toward adrenal crisis.
Action: If nausea alone, check if out of normal pattern for you, if yes follow cortisol sick day rules.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If new, check signs of infection/over active in recent days/sudden significant stress.
Increase Cortisol as per sick days.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If new, check signs of infection/over active in recent days/sudden significant stress.
Increase Cortisol as per sick days.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If new, and no obvious other cause:
Check signs of infection/illness/sudden undue significant stress.
Increase Cortisol intake as per sick days.
Urgent: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: Exclude activity as a cause.
Check for signs of infection- temperature above 37.5c
Any other symptoms for adrenal crisis
Hydrocortisone as per sick days
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If new and no obvious other cause – check signs of infection/illness/sudden undue significant stress.
Increase Cortisol intake as per sick days.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If new and no obvious other cause – check signs of infection/illness/sudden undue significant stress.
Increase Cortisol intake as per sick days.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If new and no obvious other cause – check signs of infection/illness/sudden undue significant stress.
Increase Cortisol intake as per sick days.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: Ensure enough fluids taken.
Check for signs of infection/illness.
Increase Cortisol as per sick day rules.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If new and no obvious other cause – check signs of infection/illness/sudden undue significant stress.
Increase Cortisol intake as per sick days.
Urgency: Treat at home with increased cortisol replacement by mouth.
Monitor symptoms if worsening or not resolving seek medical help via GP, or A&E.
Emergency injection and 999 if progressing toward adrenal crisis.
Action: If vomit once and can take cortisol by mouth treat at home with cortisol; increase as per sick days.
If repeated vomiting and unable to retain tablets taken by mouth, then give emergency injection and call 999.
Urgency: May be able to treat at home. If repeated vomiting and/or unable to retain Cortisol tablets then give emergency injection and call 999.
Give emergency injection and call 999, stating adrenal crisis.
Give emergency injection and call 999, stating adrenal crisis.
Signs of infection:
- Body temperature above 38c, skin hot to touch
- Shivery/feeling cold/chills
- Headache
- Muscle and joint pains
- Increased tiredness/fatigue
- Swollen lymph nodes- neck armpit and groin
- Nausea and possibly vomiting
- You may notice increased respiratory rate, increase in pulse rate
Symptoms should stabilise with the increase in oral cortisol replacement; if this does not happen then seek medical attention via NHS111/A&E. If symptoms stabilise but do not resolve within 48-72hrs then seek GP review, especially if signs of infection as further treatments may be needed. If in any doubt, an increase in oral cortisol replacement is likely to do little harm, not increasing may push you towards adrenal crisis. Seek medical advice if unsure about how to increase oral doses, or for how long to keep the increase in place.
