Why adrenal insufficiency can happen in people with aspergillosis
Many people with aspergillosis, particularly those with asthma-related conditions such as allergic bronchopulmonary aspergillosis (ABPA) or more severe chronic lung disease, need treatment with steroid medicines at some point. These treatments — often essential to control inflammation, protect the lungs, and improve breathing — may include repeated or long-term courses of steroids such as prednisolone.
When steroid treatment is used over time, it can reduce the body’s own production of cortisol by the adrenal glands. In some people, the adrenal glands do not fully recover, leading to adrenal insufficiency. Cortisol is a vital hormone that helps the body manage energy, illness, infection, and physical stress. When it cannot be made reliably, hydrocortisone replacement is needed to keep the body safe and functioning.
In this situation, hydrocortisone is prescribed to replace the cortisol your body can no longer make, usually after prednisolone has been reduced or stopped, or when prednisolone is no longer needed to control lung inflammation but adrenal support is still required.
Adrenal insufficiency in people with aspergillosis is not a failure and not something you have caused. It is a recognised consequence of necessary treatment for a serious, long-term condition. With the right information, a personalised dosing plan, and medical support, adrenal insufficiency can be managed safely alongside aspergillosis.
A patient guide to everyday (basal) dosing, higher-dose needs, and short-term stress dosing
If you take hydrocortisone because you have adrenal insufficiency, understanding how your dose works — both day to day and during illness or stress — is essential for your safety and wellbeing.
This guide explains:
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What your basal (everyday) dose is for
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Why some people need higher basal doses
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When and how stress dosing is used — and why it is short term
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Why some doctors may hesitate — and how to work safely with them
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Where to find trusted patient and clinician resources
Very important first point ❗
Any changes to your hydrocortisone dose must be agreed in advance with a doctor or specialist nurse who knows your adrenal insufficiency.
This includes:
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Your usual daily dose
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Your stress-dosing (“sick day”) plan
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Emergency injection instructions
This guide does not replace medical advice.
It is designed to help you understand your treatment and communicate clearly with healthcare professionals.
1) Your basal (everyday) hydrocortisone dose
What the basal dose is for
Your basal dose is the hydrocortisone you take on an ordinary day, when you are not ill or under unusual stress. Its purpose is to:
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Replace the cortisol your body cannot make reliably
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Support normal daily function (energy, blood pressure, mood)
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Help your body feel stable and safe
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Reduce the risk of chronic under-replacement
It is replacement, not treatment for inflammation.
A key point many patients are not told
Being consistently under-replaced does not help adrenal recovery.
Ongoing symptoms such as:
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Constant exhaustion
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Dizziness or nausea on standing
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Brain fog or low mood
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Poor tolerance of everyday stress
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Frequent “crashes” or infections
can delay recovery, not speed it. Stability supports healing.
What doctors usually mean by a “physiological” dose
Most adults naturally produce the equivalent of about 15–25 mg of hydrocortisone per day.
Doctors aim for a dose in this range and adjust for:
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Body size
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Activity level
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Other medical conditions
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Individual response
This is replacement, not “high-dose steroids”.
How basal hydrocortisone is usually taken
To mimic the body’s natural rhythm, doses are often split:
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A larger dose in the morning
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Smaller doses later in the day
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Avoiding late evening doses where possible
This supports:
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Energy and blood pressure
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Sleep
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Mood and concentration
Signs your basal dose may be too low
Tell your doctor if you have persistent:
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Severe fatigue despite rest
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“Wired but empty” feeling
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Dizziness, nausea, or salt craving
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Poor concentration or memory
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Low mood or anxiety
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Frequent need for rescue or stress doses
These symptoms matter even if blood tests look reassuring.
Blood tests are only part of the picture
Cortisol and ACTH tests:
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Help with diagnosis
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Are less helpful for adjusting daily dose
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Do not always reflect how well you function
Doctors experienced with adrenal insufficiency rely heavily on how you feel and cope day to day.
The right balance
Rather than “as low as possible,” a safer aim is:
Low enough to avoid overtreatment, but high enough to live a stable, functional life.
Living in constant deficit is not success.
2) When a higher basal dose may be appropriate
Some people with adrenal insufficiency — particularly those with chronic illness — may genuinely need a higher basal hydrocortisone dose (for example 25–30 mg/day).
This does not automatically mean overtreatment.
Well-recognised examples include:
Chronic inflammatory lung disease (including ABPA)
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Ongoing airway inflammation and immune activation
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Recurrent infective or inflammatory flares
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The body may never be in a true “resting” state
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Standard doses may leave patients under-replaced
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A stable higher dose can reduce repeated stress dosing and improve daily function
Frequent infections or slow recovery
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Repeated illness or prolonged recovery
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Frequent “temporary” stress dosing just to cope with everyday life
Long-standing steroid-induced adrenal insufficiency
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Years of prednisolone or similar treatment
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Deep suppression of the adrenal system
Larger body size or higher metabolic demand
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Cortisol needs vary with body size and activity
Autonomic symptoms or low blood pressure
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Postural dizziness or faintness
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Often benefit from a higher morning dose
Clinical clue:
If someone repeatedly needs stress dosing just to manage ordinary days, their basal dose may be too low for their current physiology.
Important reassurance
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Higher basal doses can be appropriate, temporary, or longer-term
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They do not automatically prevent recovery
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Ongoing inflammation and repeated physiological stress suppress recovery more than adequate replacement
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Doses should always be prescribed, documented, and reviewed
3) Stress dosing — when your body temporarily needs more
What stress dosing means
A healthy body automatically makes more cortisol during:
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Illness or infection
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Fever
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Vomiting or diarrhoea
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Injury or trauma
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Severe pain
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Surgery or medical procedures
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Major physical stress
If you have adrenal insufficiency:
➡️ your body cannot do this, so doctors prescribe stress dosing in advance as part of your safety plan.
Stress dosing is essential — but it is short term
Stress dosing is meant to last only as long as the stress lasts.
It covers a temporary increase in need, not your everyday requirements.
What “short term” usually means
Stress dosing may last:
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24–48 hours for minor illness or fever
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Several days for infections or recovery from injury
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During and immediately after surgery or procedures
Your doctor should advise:
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When to increase
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How much to increase
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When and how to return to your usual dose
Why stress dosing should not continue indefinitely
If higher doses are needed for longer, something usually needs review:
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Infection or inflammation has not settled
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The basal dose may be too low
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Another medical problem is present
If stress dosing is still needed after the original stress has passed, it’s time to talk to your doctor.
Stepping back down safely
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Doctors usually advise returning to baseline
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Sometimes a 1–2 day step-down is used
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You should not remain on stress doses “just in case”
Stress dosing does NOT:
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Stop adrenal recovery
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Mean you are “failing”
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Cause long-term harm when used correctly
Not stress dosing can:
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Make you seriously unwell
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Delay recovery
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Lead to adrenal crisis
4) Why some doctors seem hesitant
Doctors outside endocrinology (GPs, A&E, ward teams):
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Are trained to minimise steroid use
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Often think of steroids only as anti-inflammatory drugs
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May rarely manage adrenal insufficiency
What they may not realise immediately:
Your hydrocortisone is replacing a missing hormone — it is essential, not extra.
5) How to advocate safely (with medical backing)
It is appropriate to say:
“I have adrenal insufficiency. My doctor has advised stress dosing during illness to prevent adrenal crisis.”
If you have them, show:
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Your Steroid Emergency Card
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A written stress-dosing plan
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A clinic letter or summary
6) Trusted resources & further support (with links)
The following organisations provide reliable, clinician-endorsed information on adrenal insufficiency, hydrocortisone replacement, stress dosing, and emergency care.
They are widely recognised by NHS endocrinology teams and safe to share with patients, families, and healthcare professionals.
UK patient and professional resources
Addison’s Disease Self-Help Group (ADSHG)
Website: https://www.addisonsdisease.org.uk
What it offers:
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Clear explanations of basal vs stress dosing
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Patient-friendly sick-day rules
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Emergency hydrocortisone injection guidance
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Downloadable patient leaflets used in NHS clinics
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Webinars, helpline, and peer support
Why it’s useful:
ADSHG explicitly supports individualised dosing and crisis prevention.
Society for Endocrinology
Steroid Emergency Card & adrenal crisis guidance:
https://www.endocrinology.org/clinical-practice/steroid-emergency-card/
Why it’s useful:
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Highly trusted by doctors, A&E, and ward teams
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Clear professional wording that reassures non-specialists
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Supports rapid decision-making in emergencies
NHS (England)
Steroid Emergency Card information:
https://www.nhs.uk/conditions/steroid-emergency-card/
Why it’s useful:
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Official NHS backing
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Useful for legitimacy in emergency or inpatient settings
International patient resources (useful supplements)
Endocrine Society
Patient information on adrenal insufficiency:
https://www.endocrine.org/patient-engagement/endocrine-library/adrenal-insufficiency
Why it’s useful:
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Clear explanations of cortisol physiology
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Conservative, authoritative tone
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Helpful for patients seeking international consensus
National Adrenal Diseases Foundation (NADF)
Website: https://www.nadf.us
What it offers:
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Practical sick-day rules
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Emergency preparedness guidance
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Injection training resources
Particularly helpful for patients with long-standing adrenal insufficiency or frequent illness.
Resources especially relevant for ABPA & chronic lung disease
National Aspergillosis Centre
Website: https://mft.nhs.uk/wythenshawe/services/infectious-diseases/national-aspergillosis-centre/
Why it’s relevant:
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Specialist centre where ABPA and adrenal insufficiency often overlap
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Supports personalised care plans in complex disease
Aspergillosis Trust
Website: https://www.aspergillosistrust.org
Why it’s useful:
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Patient-focused education and advocacy
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Helps explain the chronic physiological stress of ABPA
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Supports conversations about higher basal hydrocortisone needs
Quick-access patient checklist (phone / wallet)
Patients are encouraged to keep:
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Steroid Emergency Card
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Sick-day rules (ADSHG)
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Personal stress-dosing plan (agreed with doctor)
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Clinic letter or summary
Many patients keep photos of these documents on their phone for emergencies.
Final reassurance
These resources support — not replace — medical advice.
They exist to help patients stay safe, informed, and confident when managing hydrocortisone and communicating with healthcare professionals.
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