This handout is for pheochromocytoma / paraganglioma crisis (catecholamine-driven episodic htn crisis). Your care team identified this based on: episodic htn crisis + headache + diaphoresis + palpitations + pallor (lenders lancet 2005 pmid 16125595).
Other reasons your team may use this plan: adrenal incidentaloma on ct/mri + htn — biochemical screen for pheo (endocrine society 2014 pmid 24893135); plasma free metanephrines or 24h urine fractionated metanephrines >4× upper limit — strong pheo suggestion (lenders jama 2002 pmid 12087161); men2a/2b, vhl, nf1, sdhx mutation — surveillance htn crisis (endocrine society 2014).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| phentolamine | 5 mg IV bolus q5-15 min titrate (max 15 mg single dose) | IV | PRN bolus or 0.5-1 mg/min infusion | Endocrine Society 2014 PMID 24893135; Pacak NEJM 2007 PMID 17463337 — pure alpha-blocker fastest reversal of catecholamine HTN; rapid onset (1-2 min) + short half-life (~20 min) |
| phenoxybenzamine | 10 mg PO BID, increase by 10-20 mg q2-3 d to BP normal + orthostasis + nasal stuffiness, typical max 80-100 mg/d | PO | BID | Pacak NEJM 2007 PMID 17463337 — preop alpha-blockade × 7-14 d; titrate to nasal stuffiness (alpha-1 blockade marker), supine BP normal, mild orthostasis acceptable |
| doxazosin | 2 mg PO daily, titrate to 16 mg max | PO | daily | Endocrine Society 2014 — selective alpha-1 alternative to phenoxybenzamine; less reflex tachy; less postop hypotension; slightly less complete blockade |
| nicardipine | 5 mg/h IV titrate by 2.5 mg/h q5-15 min, max 15 mg/h | IV | continuous | ACC/AHA 2025 — predictable titration; combine with phentolamine; CCB acceptable in pheo (no unopposed-alpha concern) |
| nitroprusside | 0.25-3 mcg/kg/min IV titrate | IV | continuous | Acceptable in pheo crisis (no unopposed-alpha concern); short half-life allows tight control; AVOID >24-48h or eGFR <30 (cyanide risk) |
| metoprolol | ONLY after ≥24-48 h alpha-blockade established; 25 mg PO BID titrate | PO | BID | Endocrine Society 2014 — β-blocker ONLY after alpha-blockade established; never alone; for HR control + arrhythmia prophylaxis preop |
| propranolol | ONLY after ≥24-48 h alpha-blockade; 10 mg PO TID titrate | PO | TID | Historical preferred BB in pheo (after alpha) per Bravo NEJM 1979 PMID 481031; never alone |
| AVOID β-blocker monotherapy | AVOID | N/A | N/A | Endocrine Society 2014 PMID 24893135 — β-blocker without alpha-blockade causes UNOPPOSED ALPHA vasoconstriction → SEVERE paradoxical HTN crisis; absolute contraindication |
| AVOID dopamine, glucagon, metoclopramide, opioids | AVOID | N/A | N/A | These agents trigger catecholamine release from pheo → can precipitate crisis (Endocrine Society 2014 PMID 24893135) |
| IV fluids — high-salt diet preop + crystalloid intraop | Liberal NaCl PO + IV NS 1-2 L preop | PO + IV | continuous | Pacak NEJM 2007 PMID 17463337 — chronic catecholamine venoconstriction = volume-depleted; preop volume expansion prevents postop hypotension after tumor removal |
Plan: Pheochromocytoma crisis — alpha-blockade FIRST (NEVER β-blocker monotherapy); volume repletion despite HTN; preop alpha-blockade 7-14 d before surgical resection
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Postop catecholamine + metanephrine repeat at 4-6 wk to confirm biochemical cure; lifelong annual surveillance metanephrines (10-15% recurrence/metastasis rate); genetic counseling + family screening if SDHx or syndromic; annual BP + glucose + cardiac assessment if catecholamine cardiomyopathy
Guideline: Endocrine Society 2014 Pheochromocytoma & Paraganglioma CPG (Lenders JCEM 2014 PMID 24893135) + Lenders NEJM 2014 review (PMID 25006718) + 2025 ACC/AHA HTN (Whelton)