6. Stress Dosing and Sick Day Management
People living with adrenal insufficiency need to take extra hydrocortisone in addition to their daily doses when they are sick, injured and before any kind of surgery. This is called stress dosing or sick day dosing.
6. 1. Guidelines for stress and sick day dosing
Healthy adrenal glands are able to quickly release cortisol into the blood stream to help the body cope with occurring stress situations. People living with adrenal insufficiency require additional cortisol in times of emotional, medical or surgical stress, with doses proportionate to severity of the stress event.
Table: Stress dosing guidelines. Download one-page overview sheet here.
Source: Data shown were adapted/compiled from free access publications from the US, UK/Europe and Australia.
Keep your stress dosing guidelines handy and review them regularly
A recent study showed that more than half of the people living with adrenal insufficiency who were previously educated on the topic of stress dosing were not able to adjust the dose of hydrocortisone in hypothetical situations of physical and mental stress. The authors gave the following reasons: unaware of the seriousness of the described condition, ineffective coping strategies, the lack of experience with self-management skills and misconceptions. The same study identified repetition of education, the use of guidelines, learning from experience and optimising social support as important to Improve those results.
6. 2. Surgery and Special Diagnostic Procedures (planned and emergency)
People living with adrenal insufficiency should always inform their doctor, dentist or any specialist of their condition before undergoing procedures. This includes invasive diagnostic tests such as a colonoscopy or barium enema, dental treatment or minor outpatient surgery.
If general anaesthesia is required, stress dosing is needed before surgery begins. Usually IV injections of hydrocortisone and saline are given which may begin on the evening before the procedure (requiring an overnight stay at hospital) and continue until the patient is fully awake after surgery and able to take medication by mouth.
Ensure your surgical team is aware of your need for extra cortisol/medication and that they have checked the surgical guidelines for stress dosing.
Table: Medication requirements for surgical procedures. Download one-page overview sheet here.
Source: Woodcock T et al. Guidelines for the management of glucocorticoids during the peri‐operative period for patients with adrenal insufficiency Anaesthesia 2020, 75, 654–663
6. 3. Pregnancy
Women with primary adrenal insufficiency who become pregnant are treated with standard replacement therapy but require special monitoring. If nausea and vomiting in early pregnancy interfere with oral medication, injections of hydrocortisone may be necessary. At the onset of labour and if undergoing a caesarean section, the hydrocortisone dose has to be increased, see table above.
Ensure your doctor and medical team is aware of your need for extra cortisol/medication and that they have checked the surgical guidelines for stress dosing, see table above.
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Anatomy/Physiology | Types of Adrenal Insufficiency | Symptoms | Testing/Diagnosis | Treatment | Stress dosing/Sick day Management | Adrenal Crisis | Quality of Life and Risks | Other Conditions and Drugs | Long-term Management | Suggested Reading | Literature/References
Author: Gisela Spallek, MD PhD
Edited by Maria Stewart, Director of AIC and deputy editor Des Rolph, Associate Director of AIC