Updated: 22/04/2020

COVID-19 Specific Sick Day Rules Guidance:
Healthcare professionals managing a patient with COVID-19 and Adrenal Insufficiency - please view the  latest guidance from the Society of Endocrinology.
If you have Addison's or Adrenal Insufficiency - watch our latest video on management of Addison's medication when you have COVID-19 from Professor Simon Pearce.  A transcript of this video is available via the above link. You should also read the ADSHG's general COVID-19 guidance.

What are the Sick Day rules? 

The Sick Day Rules are a set of rules you should follow if you become poorly to help prevent you experiencing an adrenal crisis. People with adrenal insufficiency are particularly vulnerable to adrenal crisis being triggered by seemingly "minor" ailments, including vomiting, diarrhoea, colds & flu. It's important to recognise the early symptoms of a bug or cold and adjust your steroid replacement medication accordingly.

These are the common triggers or causes of adrenal crisis :

adrenal crisis triggers

On days where you are feeling off-colour, injured or ill, follow these rules to keep safe and minimise the chances of an adrenal crisis.

Please note: During illness please keep taking your tablets. Our medics have confirmed that rumours and reports of our doses making people with Addison's Disease immuno-suppressed have been vastly over-exaggerated. 

Flu jab: Everyone with a steroid-dependent adrenal condition is eligible for and should get their free NHS flu jab to reduce their risk of getting the flu. This is because for people with Addison’s and adrenal insufficiency, catching flu can have serious consequences as it can cause an adrenal crisis. Getting the flu jab is the best way to protect yourself against the flu and reduce your risk of needing to go into hospital. Find out more by reading our flu jab blog post. You'll not usually need to take hydrocortisone to cover a flu jab.

If you are feeling unwell or have an accident

You should double your daily hydrocortisone or prednisolone dose if:

  • You get an infection with a temperature of 38.0 degrees Celsius or higher
  • You get a bad cold, ‘flu, diarrhoea or other infection that makes you feel poorly or weak
  • You break a bone or suffer from any similar significant injury

Minimum doses

For hydrocortisone users:

  • If you take less than 20mg of hydrocortisone in total as your regular daily dose, go up to 40mg daily as a minimum hydrocortisone dose during stress and illness.
  • Patients who usually take Plenadren should switch to the regular, immediate release hydrocortisone preparation and take 20 mg orally every 6 hours

Sick Day Rules Dosing when Unwell - Diagram of Timings

For prednisolone users:

  • If you take less than 5mg of prednisolone in total as your regular daily dose, go up to 10mg daily as a minimum prednisolone dose during stress and illness.

ADSHG Sick Day Dosing when Very Unwell DIagram of timings


  • Keep your dose of steroids doubled for 2 days and then go back to your usual dose, provided that you now feel better.
  • If you don’t feel better after 48hrs, keep your steroid dose doubled and seek advice from your GP or your endocrine nurse or doctor.
  • If you are prescribed antibiotics for an infection, double your hydrocortisone dose until you finish the course, or feel completely back to normal.

Get rest and keep hydrated

Rest, drink regularly and monitor how concentrated (dark) urine looks as a guide to how much fluid you should be drinking.

Becoming more ill with a temperature of 40 degrees

If you get a severe infection with a temperature above 40.0 degrees Celsius, then you need to take 3 times your normal hydrocortisone dose and seek advice from your doctor immediately. This could be the start of an adrenal crisis. For COVID-19, 1000mg paracetamol should be taken every 6 hours for fever (adjust appropriately for infants and children).

If you are hospitalised with COVID-19, you may be given high doses of hydrocortisone or dexamethasone. Read more about high dose steroids for COVID-19 treatment.

Note: If you up your dose higher than 50mg of Hydrocortisone due to illness, you don't need to take your Fludrocortisone at this time. This is because Hydrocortisone has some mineralcorticoid effect. Be sure to start it again once you taper back down.


If you vomit back your medication within 30 minutes of taking it, take a double dose again immediately. If you vomit this second dose back, then inject yourself with 100mg of hydrocortisone and seek medical advice immediately

Click here to view all our emergency injection videos on our YouTube channel.

If you carry on vomiting, you will become dehydrated and this will develop into an adrenal crisis unless you go to hospital for a saline drip. See our advice on preparing for hospital admission to ensure you have everything ready should you need to go there.

It is important to taper down your steroid doses after increasing them during illness

Gradual tapering of stress dose hydrocortisone down to your usual hydrocortisone dose after increasing it for illness is essential to keep stable. Avoid suddenly reducing back to normal. Discuss how to taper down with your Endocrinologist. Read more about tapering from high dose steroids given to you for COVID-19 treatment.