Congenital Adrenal Hyperplasia (CAH) and Illness: Stress Dosing When You’re Sick
Health ConditionsHormones & Metabolic Disorders

Congenital Adrenal Hyperplasia (CAH) and Illness: Stress Dosing When You’re Sick

Congenital Adrenal Hyperplasia (CAH) and Illness: Stress Dosing When You’re Sick
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Updated on March 10, 2026
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If you or your child uses steroids to manage congenital adrenal hyperplasia (CAH), you might need to be comfortable increasing the dosage during times of illness or extreme stress.

Stress dosing involves temporarily increasing the dose of your steroid medication when your body needs more cortisol, such as during illness, after an injury or surgery, or during periods of intense mental stress.

 “Stress dosing compensates for the missing cortisol and prevents life-threatening complications such as adrenal crisis,” says Victoria Finn, MD, a board-certified endocrinologist with the Medical Offices of Manhattan in New York City.

This article reviews the most common recommendations for stress dosing, but it is essential to develop an individualized plan with your medical team to avoid overdosing or underdosing.

When to Stress Dose

Illness is the most common reason that people need to stress dose.

When you’re stress dosing, make sure you drink plenty of fluids to avoid dehydration, and give your body ample time to rest.

 Additionally, be on the lookout for any new or worsening symptoms that warrant medical attention, such as dizziness, extreme fatigue, or low blood pressure, says Raul Herrera Pena, a physician and surgeon and an assistant professor of diabetes, endocrinology, and metabolism at the University of Minnesota Medical School in Minneapolis.

Fever

Fevers generally warrant doubling or tripling your typical glucocorticoid dose.

 How much extra you need depends on your temperature, says Dr. Herrera.
  • For fevers above 100.5 degrees F, double your dose for the entire day. For instance, if you normally take 20 milligrams (mg) of hydrocortisone daily (15 mg in the morning and 5 mg in the afternoon), take 40 mg daily (30 mg in the morning and 10 mg in the afternoon).
  • For fevers above 102 degrees F, triple your dose for the entire day. If you normally take 20 mg of hydrocortisone daily (15 mg in the morning and 5 mg in the afternoon), take 60 mg daily (either 45 mg in the morning and 15 mg in the afternoon, or 20 mg every 8 hours).

Vomiting

Triple your glucocorticoid dose in the event of vomiting, since vomiting makes it harder for your body to absorb your medication.

Pay attention to the time at which you take your dose. If you vomit within 30 minutes of dosing, the medication probably wasn’t absorbed. In that case, take another triple dose. If you vomit again, take injectable hydrocortisone immediately (which you should have on hand with assistance from your physician) and go to the emergency room or call 911.

Diarrhea

Triple your glucocorticoid dose in the event of diarrhea, since diarrhea can also make it harder for your body to absorb your medication. Try to sip fluids, preferably something with electrolytes, to stay hydrated, too.

What About Mild Cold Symptoms?

You generally don’t need to stress dose if your symptoms are limited to a runny nose, dry cough, or mild sore throat. But if you have questions or feel unsure about the best course of action, it’s always worth a call to your healthcare provider.

When to Use Injectable Hydrocortisone

You may need to use injectable steroids if you’re unable to keep down your oral medication, such as with repeated vomiting, or if you have signs of acute adrenal crisis, a life-threatening emergency in which the body doesn’t have enough cortisol.

 Signs can include severe weakness, confusion, dehydration, low blood pressure, loss of consciousness, or severe back, abdominal, or leg pain, says Herrera.
In these instances, take your injectable steroid immediately, then go to the emergency room or call 911. Without prompt treatment, acute adrenal crisis can send a person into shock.

Recovery: How Long to Stress Dose

You’re ready to stop stress dosing when you no longer feel sick and are able to go back to your usual activities, says Herrera.

If you only stress dosed for a few days, it’s fine to return to your regular dose immediately. But if you stress dosed for a longer period of time, you should taper your dose gradually to avoid possible withdrawal symptoms, such as fatigue and muscle pain, says Dr. Finn. Your doctor can recommend a safe tapering schedule for you based on the specifics of your stress dosing situation.

Dosing for Extreme Stress and Trauma

Other situations may warrant stress dosing as well, including:

  • Severe injuries or physical trauma including concussion, broken bone, tooth extraction, surgery, or seizure

  • Intense exercise, such as an all-day sports tournament or running a marathon
  • Severe emotional stress, such as the death of a loved one

The rules for these situations aren’t exactly one-size-fits-all, especially when it comes to exercise or mental stress.

“The dose depends on the degree [of stress] and how these types of stressors have affected a patient in the past,” says Herrera. Unusual fatigue, dizziness, and nausea are early signs that your body may need an extra dose of steroids, says Finn. If you have CAH, you should work with your medical team to anticipate stressful situations and prepare a stress dosing strategy based on what has worked for you in the past.

Signs of Acute Adrenal Crisis

Acute adrenal crisis is a life-threatening emergency that happens when your body doesn’t have enough cortisol, and it can occur if you haven’t increased your dosage enough to account for illness, injury, or stress. It is also more likely to occur when you aren’t able to take your steroid medication by mouth (like with frequent vomiting) or if you become dehydrated.

“Immediate medical care is crucial … due to the risk of significant hypotension and shock,” says Herrera.

Symptoms of acute adrenal crisis can include:

  • Back, limb, or abdominal pain
  • Confusion, drowsiness, or loss of consciousness
  • Dizziness or lightheadedness
  • Extreme weakness
  • Feeling very cold or shaking uncontrollably
  • Headache
  • Vomiting

Stress dosing isn’t enough during an adrenal crisis. After administering injectable hydrocortisone, seek emergency medical attention or call 911 immediately.

Time can’t be wasted in these situations, even in an emergency room waiting area. Medical care is required as soon as possible. Your doctor can give you a signed protocol letter explaining this urgent need to emergency care providers, so you or your child can get the lifesaving care you need.

 (The CARES Foundation offers a sample letter you and your doctor can use.)

The Takeaway

  • If you use steroids to manage your congenital adrenal hyperplasia (CAH), you may sometimes need to stress dose: temporarily increasing your dose of steroid medication during times of physical or emotional stress.
  • People with CAH may be instructed to double or triple their glucocorticoid dose for fevers, vomiting, or diarrhea, though mild cold symptoms like a runny nose generally don’t require a stress dose. Emergency injectable steroids may be needed with repeated vomiting or if you have signs of acute adrenal crisis.
  • Stress dosing may also be necessary for major physical trauma, surgery, or intense emotional stress.
  • Illness, trauma, and stress can spike the risk of adrenal crisis, which cannot be managed with stress dosing and instead requires immediate emergency care in a hospital setting.

Resources We Trust

EDITORIAL SOURCES
Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.
Resources
  1. Tschaidse L et al. Frequency of Stress Dosing and Adrenal Crisis in Paediatric and Adult Patients With Congenital Adrenal Hyperplasia: A Prospective Study. European Journal of Endocrinology. April 2024.
  2. Sick Day Rules. Addison’s Self Help Group. April 2025.
  3. Emergency Instructions: Treatment for Congenital Adrenal Hyperplasia in Times of Stress. CARES Foundation.
  4. Guidelines for Stress Dosing and Sick Day Management. Adrenal Insufficiency Coalition. February 24, 2020.
  5. Adrenal Insufficiency: Instructions for Stress Dosing. Children’s Hospital of Philadelphia.
  6. Acute Adrenal Crisis. MedlinePlus. April 24, 2025.
  7. Adrenal Insufficiency and Stress Dose Steroids. Children’s Hospital of Philadelphia. July 2025.
  8. Elshimy G et al. Adrenal Crisis. StatPearls. February 15, 2025.
  9. Adrenal Crisis - Emergency Help. Addison’s Self Help Group.
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Elise M. Brett, MD

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Elise M Brett, MD, is a board-certified adult endocrinologist. She received a bachelor's degree from the University of Michigan and her MD degree from the Icahn School of Medicine at Mount Sinai. She completed her residency training in internal medicine and fellowship in endocrinology and metabolism at The Mount Sinai Hospital. She has been in private practice in Manhattan since 1999.

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