Educate Patients on Increasing Glucocorticoid Dosage During Intercurrent Illness, Fever, and Stress
STEP 1 — Gather Information
Collect the patient’s current daily glucocorticoid dose and regimen, recent illness history, ability to tolerate oral medications, presence of an up-to-date steroid emergency card and injection kit, vital signs (temperature, blood pressure), symptoms (fatigue, nausea, vomiting, abdominal pain), and recent stressors (infection, surgery, trauma, procedures). Assess the need for stress‑dosing education.
STEP 2 — Rule In / Rule Out
Confirm the patient has diagnosed primary adrenal insufficiency (PAI) and is not currently in adrenal crisis. If PAI is confirmed and the patient is stable, proceed to classification; if PAI is not confirmed or the patient is in acute crisis, rule out routine stress‑dosing education and initiate emergency adrenal‑crisis management.
STEP 3 — Classify or Stratify
Classify the illness/stress severity: fever ≥38°C but <39°C → double the usual oral glucocorticoid dose; fever ≥39°C → triple the dose; inability to tolerate oral meds due to vomiting, trauma, or fasting for a procedure → administer IM hydrocortisone 100 mg (adults) or weight‑based dose (children) and consider continuous infusion; minor‑moderate stress (e.g., dental work) → double dose; major stress (surgery, delivery, intensive care) → 100 mg IV bolus followed by continuous infusion of 200 mg hydrocortisone/24 h. Provide the specific dosing plan.
STEP 4 — Decide
Give the patient written sick‑day rules, ensure a steroid emergency card and hydrocortisone injection kit are prescribed and up‑to‑date, teach parenteral self‑administration, advise to seek medical care after any emergency injection, and schedule follow‑up reinforcement of education at each visit.
Clinical Guardrails / Mimics / Pitfalls
Do not delay glucocorticoid administration in suspected adrenal crisis; do not rely on oral dosing if the patient is vomiting or unable to tolerate pills; do not forget to renew the steroid card and injection kit supplies; avoid using dexamethasone for stress dosing because it lacks mineralocorticoid activity; do not omit fludrocortisone adjustment when hypertension develops; stress dosing is not a substitute for emergency medical evaluation.
Concrete Clinical Example
A 45‑year‑old woman on hydrocortisone 20 mg morning, 10 mg early afternoon, 5 mg evening develops fever 39.2 °C and sore throat. She doubles her total daily dose to 70 mg (40 mg morning, 20 mg early afternoon, 10 mg evening) and increases electrolyte‑containing fluids; after 48 hours she returns to her baseline dose.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, https://doi.org/10.1210/jc.2015-1710