A 28-year-old man presents with headache, diaphoresis, and hypertension (200/120 mmHg). Plasma metanephrine is markedly elevated. Pre-operatively, adequate alpha-blockade is established with phenoxybenzamine. The next essential step before surgery is:
- A Add a beta-blocker AFTER adequate alpha-blockade ✓
- B Add a beta-blocker FIRST before alpha-blockade
- C Proceed directly to adrenalectomy without beta-blockade
- D Use labetalol alone as combined alpha-beta blockade
Correct answer: A. Add a beta-blocker AFTER adequate alpha-blockade
Explanation
In pheochromocytoma management, beta-blockade must never be initiated before alpha-blockade because blocking beta-2 vasodilation while leaving alpha-vasoconstriction unopposed can precipitate a hypertensive crisis. Once adequate alpha-blockade (phenoxybenzamine or selective alpha-1 blockers) is established over 10–14 days, a beta-blocker is added to control tachycardia and arrhythmias. Labetalol is not recommended as monotherapy due to its stronger beta than alpha activity.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.