Pheochromocytoma: The Daily PANCE Blueprint

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Pheochromocytoma: The Daily PANCE Blueprint

A 44-year-old woman reports months of sudden "spells" — pounding headaches, drenching sweats, and a racing, palpitating heart — that last about 15 minutes and then fade. Between spells she feels fine, but her blood pressure is now persistently high and hard to control on two agents. During an episode in your office her blood pressure spikes to 210/120. Plasma free metanephrines are markedly elevated, and abdominal CT shows a 4-cm right adrenal mass. As you prepare her for surgery, which of the following is the most appropriate first step in her medical management?

A. Start a beta-blocker (propranolol)
B. Start a thiazide diuretic
C. Start an alpha-blocker (phenoxybenzamine)
D. Start an ACE inhibitor
E. Proceed directly to surgery with no blockade

Answer and topic summary

The answer is C. Start an alpha-blocker (phenoxybenzamine).

Episodic headache, sweating, and palpitations with paroxysmal hypertension and elevated plasma free metanephrines is a catecholamine-secreting pheochromocytoma. The cardinal rule is alpha-blockade first (classically phenoxybenzamine) to control the vasoconstriction, followed only afterward by a beta-blocker to control reflex tachycardia. If you start a beta-blocker first, you block the vasodilating beta-2 receptors while leaving alpha-mediated vasoconstriction unopposed — this can trigger a dangerous hypertensive crisis. Diuretics and ACE inhibitors don’t address the catecholamine surge, and taking a pheochromocytoma to the operating room without adequate preoperative alpha-blockade risks a fatal intraoperative crisis.

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Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Adrenal Disorders ⇒ Pheochromocytoma

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