A 30-year-old woman presents with episodic hypertension, diaphoresis, headache and palpitations. 24-hour urine metanephrines are markedly elevated. CT abdomen reveals a 4 cm adrenal mass. Which pharmacological preparation is MANDATORY before surgical resection?
- A Alpha-blocker (phenoxybenzamine) for 10–14 days followed by beta-blocker if tachycardia persists ✓
- B Beta-blocker monotherapy starting at least 7 days preoperatively
- C Calcium channel blocker amlodipine monotherapy for 2 weeks
- D Metyrapone to suppress catecholamine synthesis 48 hours before surgery
Correct answer: A. Alpha-blocker (phenoxybenzamine) for 10–14 days followed by beta-blocker if tachycardia persists
Explanation
Alpha-blockade must be established first to prevent hypertensive crisis from unopposed alpha stimulation; phenoxybenzamine (irreversible, non-selective) is the classic agent given for 10–14 days. Beta-blockade is added only after adequate alpha-blockade to control reflex tachycardia — giving beta-blockers first would allow unopposed alpha vasoconstriction and precipitate a hypertensive crisis. Metyrapone blocks cortisol synthesis and is used in Cushing's, not phaeochromocytoma.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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