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endo.pheochromocytoma.v1PRODUCTION
endo.pheochromocytoma.v1

Pheochromocytoma / paraganglioma

endocrinologychronicacutesubacuteadultpediatric
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm pheo / paraganglioma via fractionated metanephrines; rule out interfering drugs / mimics (ADA 2026)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Biochemical confirmation

Patient inputs (15)

Pediatric pheo more often hereditary (ADA 2026)

Crisis recognition + preop target (ADA 2026)

Crisis recognition (ADA 2026)

Tachycardia drives β-blocker timing (ADA 2026)

Diagnostic timing (ADA 2026)

TCAs, MAOIs, sympathomimetics, levodopa, labetalol affect metanephrines (ADA 2026)

Drug interferences + preop sequencing (ADA 2026)

Screening test; both forms acceptable (ADA 2026)

Baseline; pre-op (ADA 2026)

Hyperglycemia common (catecholamine effect) (ADA 2026)

Imaging contrast; drug dosing (ADA 2026)

Localisation (ADA 2026)

30–40% heritable; specific syndromes shape surveillance (ADA 2026)

Metastatic / extra-adrenal / multifocal (ADA 2026)

Catecholamine cardiomyopathy assessment (ADA 2026)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningpheo_hypertensive_crisis
    BP ≥180/120 with end-organ damage in patient with pheo (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbeta_before_alpha_misuse
    β-blocker started before adequate α-blockade in pheo (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpregnancy_with_pheo
    Pheo in pregnancy (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremetanephrines_3x_upper_limit
    Plasma free metanephrines ≥3× upper reference limit (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparaganglioma_extra_adrenal
    Extra-adrenal paraganglioma (head, neck, thorax, abdomen) (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremetastatic_pheo
    Metastatic pheochromocytoma (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecatecholamine_cardiomyopathy
    New LV dysfunction / Takotsubo / arrhythmia in pheo (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Preoperative α then β blockade (ADA 2026)
axis: pheo_preop_blockade
Selected axis "Preoperative α then β blockade (ADA 2026)" by default fallback (first axis)
  • phenoxybenzamine
    first line
    alpha_blocker_non_selective
    10 mg BID, titrate by 10–20 mg q2–3 d to BP <130/80 + mild postural • PO • BID for 10–14 d preop
    triggers: preop_pheo
    Endocrine Society 2014 — irreversible α-blockade preferred
    rxcui 8149
  • doxazosin
    second line
    alpha_1_blocker_selective
    1 mg → 8 mg • PO • daily, titrate
    triggers: phenoxybenzamine_unavailable, short_preop_window
    Selective α1 reversible — alternative; less reflex tachy (Endocrine Society 2014 pheo/PGL guideline)
    rxcui 49276
  • prazosin
    second line
    alpha_1_blocker_selective
    1 mg TID, titrate • PO • TID
    triggers: doxazosin_alternative
    Alternative selective α1 (ADA 2026)
    rxcui 8629
  • metoprolol_tartrate
    add on
    beta_blocker_cardioselective
    12.5–25 mg BID • PO • BID
    triggers: adequate_alpha_blockade_with_persistent_tachycardia
    β only after α; otherwise unopposed α → crisis (ADA 2026)
    rxcui 203191
  • propranolol
    add on
    beta_blocker_non_selective
    20 mg TID • PO • TID
    triggers: adequate_alpha, sympathetic_storm
    Alternative non-selective; only AFTER α (ADA 2026)
    rxcui 8787
  • amlodipine
    add on
    DHP_CCB
    5–10 mg • PO • daily
    triggers: adjuvant_BP_control
    Adjunct preop (ADA 2026)
    rxcui 17767

outpatient playbook — drug actions (3)

  1. 1. phenoxybenzamine 10 mg BID titrate
    10 → 60 mg/day • PO • BID
    trigger: Preop, 10–14 d (ADA 2026)
    Endocrine Society 2014
  2. 2. add metoprolol after α adequate
    12.5–25 mg BID • PO • BID
    trigger: Persistent tachycardia after α (ADA 2026)
    Only AFTER α (ADA 2026)
  3. 3. add amlodipine if BP not at target
    5–10 mg • PO • daily
    trigger: BP >130/80 on α (ADA 2026)
    Adjunct (ADA 2026)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Classic triad — paroxysmal headache + palpitations + diaphoresis (ADA 2026); Paroxysmal HTN or resistant HTN (ADA 2026); Adrenal incidentaloma >4 cm or imaging features (high HU, intense uptake) (ADA 2026).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pheochromocytoma / paraganglioma** (endo.pheochromocytoma.v1).
Phenotype framing: Pheo vs paraganglioma vs cocaine / TCA / MAOI / clonidine withdrawal vs panic vs hyperthyroid vs carcinoid (ADA 2026)
Scope: Confirm pheo / paraganglioma via fractionated metanephrines; rule out interfering drugs / mimics (ADA 2026)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Preoperative α then β blockade (ADA 2026)**.
1. phenoxybenzamine 10 mg BID, titrate by 10–20 mg q2–3 d to BP <130/80 + mild postural PO BID for 10–14 d preop (alpha_blocker_non_selective, first line) — Endocrine Society 2014 — irreversible α-blockade preferred
2. doxazosin 1 mg → 8 mg PO daily, titrate (alpha_1_blocker_selective, second line) — Selective α1 reversible — alternative; less reflex tachy (Endocrine Society 2014 pheo/PGL guideline)
3. prazosin 1 mg TID, titrate PO TID (alpha_1_blocker_selective, second line) — Alternative selective α1 (ADA 2026)
4. metoprolol_tartrate 12.5–25 mg BID PO BID (beta_blocker_cardioselective, add on) — β only after α; otherwise unopposed α → crisis (ADA 2026)
5. propranolol 20 mg TID PO TID (beta_blocker_non_selective, add on) — Alternative non-selective; only AFTER α (ADA 2026)
6. amlodipine 5–10 mg PO daily (DHP_CCB, add on) — Adjunct preop (ADA 2026)

Setting playbook (outpatient) — Confirm, localise, plan surgery, initiate α-blockade, genetic counselling (ADA 2026)
7. phenoxybenzamine 10 mg BID titrate 10 → 60 mg/day PO BID — Preop, 10–14 d (ADA 2026) (Endocrine Society 2014)
8. add metoprolol after α adequate 12.5–25 mg BID PO BID — Persistent tachycardia after α (ADA 2026) (Only AFTER α (ADA 2026))
9. add amlodipine if BP not at target 5–10 mg PO daily — BP >130/80 on α (ADA 2026) (Adjunct (ADA 2026))

Non-pharmacologic actions:
- High Na diet (5–6 g/day) preop (ADA 2026)
- IV NS preop bolus to expand volume (ADA 2026)
- Genetic testing + family screening (ADA 2026)
- Surgery referral (laparoscopic adrenalectomy) (ADA 2026)

AVOID / contraindication checks:
- Beta blocker NEVER before alpha in pheo (ADA 2026)
- Metyrosine only in specialised centres (ADA 2026)
- Phenoxybenzamine postural hypotension counsel (ADA 2026)

Monitoring

Regimen monitoring:
- BP home log with postural (ADA 2026)
- HR monitoring (ADA 2026)
- volume status daily

Setting (outpatient) monitoring:
- Home BP log (ADA 2026)
- Postural BP (ADA 2026)
- HR

Follow-up plan: Endo + surgery + genetics; lifelong annual surveillance (ADA 2026)
- Close-out criterion: Follow-up booked

Monitoring phase: BP home log, metanephrines post-op, recurrence surveillance, genetic counselling (ADA 2026)

Disposition

Current setting: outpatient — Confirm, localise, plan surgery, initiate α-blockade, genetic counselling (ADA 2026)

Disposition criteria:
- Discharge once preop optimisation complete (ADA 2026)

Escalation triggers (move to higher acuity):
- Crisis → ED (ADA 2026)
- Cardiomyopathy → cardiology (ADA 2026)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] BP ≥180/120 with end-organ damage in patient with pheo (ADA 2026)
- [LIFE_THREATENING] β-blocker started before adequate α-blockade in pheo (ADA 2026)
- [LIFE_THREATENING] Pheo in pregnancy (ADA 2026)

Citations

- Endocrine Society 2014 Pheo/Paraganglioma Guideline (Lenders); ENS@T-PHEO; NANETS 2021 [PMID:24893135](https://pubmed.ncbi.nlm.nih.gov/24893135/)
- Cited evidence (PMID 33939658) [PMID:33939658](https://pubmed.ncbi.nlm.nih.gov/33939658/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Endocrine Society 2014 Pheo/Paraganglioma Guideline (Lenders); ENS@T-PHEO; NANETS 2021 — PMID:24893135
  • Cited evidence (PMID 33939658) — PMID:33939658