Steroid Safety & Adrenal Insufficiency
How steroids suppress your body’s own defence, why sick-day rules save lives, and when NOT to stop — NICE-aligned guide.
You will hand out prednisolone and hydrocortisone on nearly every ward. They are incredibly effective — and incredibly dangerous if misunderstood. The biggest myth? “Steroids are just anti-inflammatories — you can stop them whenever you feel better.” Wrong. After as little as 3 weeks of moderate-dose oral steroids, your adrenal glands can shut down production completely. Stop abruptly, and the body cannot respond to stress — infection, surgery, even a bad bout of flu can tip them into life-threatening adrenal crisis.
This guide explains exactly how suppression happens, which patients are at risk, what to do when they’re unwell — and how to taper safely. Fully aligned with NICE NG243 and BNF Chapter 6.3.2.
1. National Guidance
All content aligned with: NICE NG243 — Adrenal Insufficiency: Identification and Management (Aug 2024); BNF Chapter 6.3.2 — Glucocorticoids; MHRA Drug Safety Update — Corticosteroids: Adrenal Suppression & Withdrawal.
📎 Source: NICE NG243 — Adrenal Insufficiency Full Guideline
⚠️ Local protocols vary. Sick-day dosing, cover for surgery, and tapering schedules should always be checked against your trust’s steroid policy and current BNF.
2. How Suppression Actually Happens — The Feedback Loop
Your adrenal glands make cortisol — the body’s natural stress hormone. Production follows a chain: hypothalamus → pituitary → adrenals = HPA axis. When you take steroid tablets, the body detects high levels and sends a signal: “plenty already — stop making your own.” The adrenals shrink and go to sleep. When you stop tablets, there is nothing ready to take over — and it can take weeks to months for the axis to wake back up.
Who Is At Risk?
Suppression is NOT just for long-term users. Watch these thresholds:
| Regime | Risk Level | Action Required |
|---|---|---|
| Pred >20mg/day for >3 weeks | 🔴 High — definite suppression likely | Never stop abruptly. Carry steroid card. Sick-day rules apply. |
| Even low dose (<5mg) long-term | 🟡 Moderate — suppression can develop slowly | Taper gradually when stopping. Sick-day rules still apply during illness. |
| Repeated short courses / high-dose inhaled + oral bursts | 🟡 Cumulative risk — adds up | Check last steroid date on admission — suppression can persist up to 12 months post-stop. |
| Short course (<3 weeks, low–moderate dose) | 🟢 Minimal — HPA usually intact | Can stop abruptly in most cases. Confirm local guidance. |
| Alternate-day therapy | 🟢 Reduced but NOT zero | Less suppression but still monitor — don’t become complacent. |
Other Routes — Don’t Be Fooled
Oral isn’t the only way suppression happens — ask about these too:
- High-dose inhaled steroids: Fluticasone, budesonide — systemic absorption increases at higher doses. Review asthma regimes if patient feels persistently tired or unwell.
- IV / IM pulses: Methylprednisolone 1g IV for 3–5 days — suppression risk real despite short duration. Cover needed afterwards.
- Joint injections: Repeated injections over months = cumulative systemic effect. Document every dose.
- Topical potent steroids: Wide application + occlusive dressing = enough absorption to suppress in rare cases.
3. Recognising Adrenal Crisis — The Life-Threatening Emergency
Adrenal crisis happens when cortisol drops below what the body needs to maintain blood pressure and metabolism. It can look identical to septic shock — and is treated completely differently. Miss it, and mortality is high.
| Feature | What You’ll See | Why It Happens |
|---|---|---|
| Hypotension / Shock | Systolic <100, dizzy standing up, cold clammy peripheries, reduced urine output | Cortisol maintains vascular tone — without it, vessels relax and fluid leaks out → shock |
| Hyponatraemia + Hyperkalaemia | Na⁺ <135, K⁺ ↑ often >5.5 — check U&E immediately | Sodium loss + potassium retention — aldosterone also drops. Electrolyte disturbance is classic clue |
| Hypoglycaemia | Sweaty, confused, shaky — especially in children and fasted patients | Cortisol raises blood glucose — without it, liver can’t release stores. Check BM in every unwell steroid patient |
| GI Distress | Severe vomiting, abdominal pain, diarrhoea — can mimic acute abdomen | GI mucosa atrophies; gut motility changes. Vomiting worsens fluid loss → cycle of deterioration |
| Confusion / Drowsiness | New confusion, reduced GCS — often mislabelled “delirium” | Reduced cerebral perfusion + hypoglycaemia. Escalate urgently if steroid history present |
| Other Clues | Severe fatigue, weight loss, no fever (or low temperature), hyperpigmentation IF primary disease | Primary vs secondary — ACTH levels differ. Don’t wait for pigmentation to treat |
- Give hydrocortisone IMMEDIATELY — do NOT wait for tests. 100mg IV/IM stat. If IV access difficult, IM is acceptable and effective — do NOT delay
- IV fluids: 0.9% Sodium Chloride — 1 litre over first hour, then guided by observations. Avoid dextrose alone initially
- Check glucose: Give IV dextrose if <4mmol/L — maintain 6–10mmol/L
- Investigate trigger: Infection? Missed dose? Stopped suddenly? Surgery? Treat underlying cause
- Continue cover: 100mg hydrocortisone every 6 hours IV/IM until stable, then wean to oral maintenance + sick-day doses
📎 Source: NICE NG243 — Adrenal Crisis Emergency Care
4. Sick-Day Rules — What Every Patient Must Know
This is the single most important education you deliver. Patients die because they “didn’t want to bother the doctor” and just soldiered on through flu, gastroenteritis, or a chest infection. Explain these rules clearly — in writing, not just verbally.
Rule 1 — Double (or Triple) the Dose When Unwell
- Fever / infection / bed rest: At least double usual dose — minimum prednisolone 10mg OD or hydrocortisone 40mg/day in divided doses
- Major illness / surgery / trauma: IV/IM cover needed — 100mg hydrocortisone + continuous infusion or 6-hourly bolus
- Minor illness (cold without fever): May not need increase — but if unsure, better to cover
Rule 2 — If Vomiting → Inject or Go to Hospital
- If vomits within 30 mins of dose → repeat once at double strength. Still vomiting → use emergency hydrocortisone injection and attend A&E
- Anyone at risk should carry a 100mg hydrocortisone emergency pack + written instructions
- Advise family/carers how to give IM — don’t leave patient alone when too unwell to self-administer
Rule 3 — Don’t Stop Until Fully Recovered — Then Taper
- Continue increased dose until well for 24–48 hours, then reduce gradually back to maintenance over several days
- Document the increase and planned reduction — handover clearly between shifts
- Recovery isn’t instant — fatigue can persist after fever settles
Surgery & Procedure Cover
Patients on long-term steroids need cover matched to surgical stress. Use this general framework — confirm local protocol:
| Surgery Level | Typical Cover | Notes |
|---|---|---|
| Minor (dental, skin) | Usual morning dose + hydrocortisone 25mg IV at induction | No extra needed post-op unless complications |
| Moderate (joint, abdominal) | Usual dose + hydrocortisone 50–100mg IV at induction → 50mg every 8hrs × 24–48hrs | Resume oral when eating — overlap doses |
| Major / emergency | 100mg hydrocortisone IV → 100mg every 6hrs or infusion × 48–72hrs | Taper over 2–3 days to maintenance. Monitor fluid balance — watch for fluid retention |
Key point: Patients who stopped steroids within the past 12 months may still have suppressed HPA axis — apply the same cover. Don’t assume “they stopped months ago” = safe.
5. Tapering — How to Stop Safely
The goal of tapering is to let the HPA axis wake up gradually while providing enough steroid to prevent symptoms. There is no single perfect schedule — individualise, but these principles apply:
General Taper Framework
- Above 7.5–10mg prednisolone daily: Reduce by 2.5–5mg every 1–2 weeks until down to 7.5–10mg
- Below 7.5–10mg: Slower now — reduce by 1–2.5mg every 2–4 weeks. Axis is waking but fragile
- Below 5mg: Even slower — 0.5–1mg every 4–8 weeks. Watch for return of original symptoms as you go
- Final step: Stop completely only when on physiological replacement dose (pred ~5–7.5mg = hydrocortisone 20–30mg)
Withdrawal Symptoms vs Relapse — The Confusing Part
As you reduce dose, patient may feel worse. Is it the original condition coming back — or withdrawal? They feel similar but respond differently:
| Feature | Withdrawal (too fast) | Relapse (condition returning) |
|---|---|---|
| Timing | Within days of dose cut; affects whole body | Weeks after; targets original affected area |
| Symptoms | General malaise, fatigue, low mood, joint aches, dizziness, low appetite — NO local inflammation | Specific inflammation returns — pain, swelling, redness, stiffness in known affected sites |
| Action | Slow taper — stay at current dose longer, then smaller cuts | May need temporary small increase, then try tapering again more slowly |
6. Long-Term Side Effects — Monitoring & Prevention
Steroids don’t just suppress adrenals — they affect nearly every system. Patients on >3 months need regular monitoring and protection:
- Bone health — osteoporosis: Rapid bone loss first 6–12 months. Offer calcium + vitamin D supplements routinely. Bisphosphonates if additional risk factors. See osteoporosis guide for dosing rules
- Diabetes / glucose intolerance: Steroids raise glucose — peak 4–8hrs post-dose. Check BM regularly; existing diabetes may need temporary insulin increase. Exam-relevant monitoring
- Infection risk — masked signs: Steroids suppress inflammation — fever and redness may be absent despite serious infection. Patient feels “just not right” — investigate thoroughly. Low threshold for sepsis screening
- GI risk — PPI co-prescription: Steroids irritate gastric mucosa — combine with NSAIDs = dangerous. Always co-prescribe PPI if both unavoidable
- Psychiatric effects: Mood swings, insomnia, anxiety, rare psychosis — most common high dose first 2 weeks. Give morning to reduce sleep disruption
- Fluid & weight: Sodium retention → oedema, hypertension. Low-salt diet helps. Monitor BP and weight
- Eye health: Cataracts and glaucoma with prolonged use — annual ophthalmology review
7. Your Admission & Discharge Checklist
Every patient on steroids — no exceptions — gets these questions on admission:
- What steroid? What dose? What time(s) of day?
- How long have you taken them?
- Have you missed any doses recently? Any vomiting?
- Do you have a steroid card? Emergency hydrocortisone pack?
- Any recent illness, surgery, or stress needing dose increase?
- Last date stopped if no longer taking — cover needed if within 12 months
On discharge — handover is your responsibility:
- Provide written sick-day rules — don’t rely on memory
- Ensure steroid card is issued and carried
- Prescribe emergency IM hydrocortisone 100mg if at risk of vomiting / unable to take oral
- Confirm GP knows — update records explicitly
- Explain: “Never stop suddenly — always taper. Tell every doctor, dentist, nurse you see that you take steroids”