For Healthcare Professionals: Suggested management and hydrocortisone stress dose cover in patients with adrenal insufficiency and suspected or confirmed COVID-19 infection.

Clinical Scenario	Suggested Management
At home
Onset of signs and symptoms suggestive of COVID-19 (fever >38°C (>100 F), a new or continuous dry cough, sore throat, loss of sense of smell or taste, aches and pains, fatigue)	 Adults and adolescents should take 20 mg hydrocortisone orally every 6 hours (in children, their usual daily dose should be trebled (i.e. 3fold increase) and administered in four equal doses every 6 hours)  Patients on modified release hydrocortisone should switch to immediate release hydrocortisone and take 20 mg orally every 6 hours  Patients on 5-15 mg prednisolone daily should take 10 mg prednisolone every 12 hours; patients on oral prednisolone >15 mg should continue their usual dose but take it split into two equal doses of at least 10 mg each.  If on fludrocortisone, continue at usual dose  Take paracetamol 1000 mg every 6 hours for fever (adjust dose appropriately for infants and children)  Rest, drink regularly and monitor how concentrated (dark) urine looks is to guide further fluid intake  Request medical advice on the suspected COVID-19 infection
Onset of signs and symptoms of clinical deterioration (dizziness; intense thirst; shaking uncontrollably; drowsiness, confusion, lethargy; vomiting; severe diarrhoea; increasing shortness of breath, respiratory rate >24/min , difficulty speaking	 Immediately inject (patient or carer) 100 mg hydrocortisone per intramuscular injection in adults and adolescents (25 mg in infants, 50 mg in school children)  Call for emergency medical attention for treatment and transfer to hospital, consider making their own way to hospital  If patients cannot be taken or kept in hospital, then they should take 50 mg hydrocortisone every 6 hours orally at home; if possible, they should receive i.v. hydrocortisone and an isotonic saline infusion in the admissions unit
At hospital
On regular ward or intensive care ward, irrespective of whether breathing unaided or supported by continuous positive airway pressure (CPAP) respiration or mechanically ventilated	 Hydrocortisone 100 mg per iv injection in adults and adolescents, followed by continuous iv infusion of 200 mg hydrocortisone/24h (alternatively 50 mg every 6 h per intravenous or intramuscular bolus injection)  Infants and children should receive an initial parenteral injection of 50 mg hydrocortisone/m2 (usually 25mg in infants and 50 mg in children) followed by 50 mg/24h in infants and 100 mg/24 h in children  Pause fludrocortisone in adults  Continuous intravenous fluid resuscitation with isotonic saline; regularly check urea & electrolytes
Recovery; improving respiratory function, reducing or normal temperature	 Gradual tapering of stress dose hydrocortisone down to double regular replacement dose at time of discharge (endocrinologist to advise)  Re-start usual fludrocortisone dose in adults when total daily hydrocortisone dose <50 mg

We are grateful to the authors of the below guidance for producing this guidance. The below link takes you to the source document for this guidance where extra detail is provided :

Endocrinology in the time of COVID-19: Management of adrenal insufficiency

Please also ensure Patient Advocacy is provided via the patient's own Endocrinology team and over the phone with their formal or informal carers.

To read our News article about the release of this guidance, please visit - "EJE Guidance: Managing Adrenal Insufficiency in the time of COVID-19"