Medical management of pheochromocytoma

Patients with catecholamine-secreting pheochromocytomas and paragangliomas require medical treatment to control blood pressure and tachyarrhythmias and to prepare the patient for surgical tumor resection. The mainstay of medical treatment is α-adrenergic receptor blockade, and both nonselective and α₁-selective adrenergic receptor blockers can be used. Once blood pressure control is achieved, β-adrenergic receptor blockers can be added to control tachycardia and arrhythmias. When blood pressure cannot be achieved by α-blockade alone, calcium channel blockers and metyrosine can be added. Such treatment, along with fluid and salt replacement, should be carried out for 7–14 days prior to surgery to avoid postoperative hypotension. Uncommonly, patients may present with hypertensive emergencies and require ICU admission with intravenous α-adrenergic receptor blockade with phentolamine and other antihypertensive agents. Another uncommon presentation is acute heart failure which can rapidly progress to cardiogenic shock; such patients also require ICU admission and rapid institution of α- and then β-adrenergic receptor blockade. Patients with metastatic disease may require chronic adrenergic receptor blockade, and new chemotherapeutic agents have varying success. Overall, medical therapy with subsequent surgery of patients with pheochromocytomas is quite successful, and most patients do very well.