A 38-year-old woman presents with episodic headaches, diaphoresis, and palpitations. BP is 195/110 mmHg during the attack. Plasma metanephrines are elevated 4-fold. After confirming the diagnosis biochemically, the FIRST pharmacological step before proceeding to adrenalectomy is:

• A Begin propranolol immediately
• B Begin labetalol alone
• C Urgent adrenalectomy without pre-treatment
• D Begin phenoxybenzamine for at least 7–14 days ✓

Explanation

Alpha-blockade must precede beta-blockade in pheochromocytoma management to avoid unopposed alpha-adrenergic vasoconstriction. Phenoxybenzamine (irreversible non-selective alpha blocker) is administered for at least 1–2 weeks pre-operatively to control BP and allow volume expansion. Beta-blockers are added only after adequate alpha-blockade is established. Starting propranolol without prior alpha blockade can precipitate hypertensive crisis. Adrenalectomy without medical preparation carries prohibitive surgical mortality.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.