A 38-year-old man presents with episodic severe hypertension, diaphoresis, and palpitations. 24-hour urinary metanephrines are markedly elevated. CT abdomen reveals a 4.2 cm left adrenal mass. Before adrenalectomy, the sequence of pre-operative pharmacological preparation should be:

• A Beta-blockade first, then alpha-blockade to prevent hypertensive crisis
• B Alpha-blockade first, then beta-blockade if tachycardia persists ✓
• C Calcium channel blocker alone is sufficient
• D Alpha and beta-blockade started simultaneously on day 1

Explanation

Alpha-blockade (phenoxybenzamine or doxazosin) must be established first for at least 10–14 days before adding a beta-blocker. If beta-blockers are given first in a patient with excess catecholamines, unopposed alpha-adrenergic stimulation precipitates a hypertensive crisis. Beta-blockers are then added only to control reflex tachycardia that follows adequate alpha-blockade. Calcium channel blockers alone are insufficient for complete peri-operative blood pressure control in phaeochromocytoma.

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

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