A 45-year-old woman presents with episodic severe headache, palpitations, diaphoresis, and hypertension (BP 220/130 mmHg). 24-hour urine metanephrines are 8× the upper limit of normal. Imaging reveals a 4 cm right adrenal mass. What is the correct sequence of management before surgical resection?

• A Start beta-blocker first, then alpha-blocker to avoid reflex tachycardia
• B Start calcium channel blocker alone without alpha or beta blockers
• C Proceed directly to surgery without preoperative medical preparation
• D Start alpha-blocker first, then add beta-blocker after adequate alpha blockade ✓

Explanation

For pheochromocytoma, the cardinal rule is alpha blockade FIRST (phenoxybenzamine for 7–14 days is the gold standard, or selective alpha-1 blockers like doxazosin) followed by beta blockade only after adequate alpha blockade is established. Starting beta-blockers first can cause unopposed alpha-adrenergic stimulation leading to hypertensive crisis due to absent beta-2 vasodilation. Adequate alpha blockade also requires high-salt diet and fluid loading to correct the contracted plasma volume before surgery.

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

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Written and medically reviewed by the StethoPrep medical team.