What is the recommended drug to manage hypertensive crisis in a patient with pheochromocytoma?

From the Guidelines

Phentolamine is the recommended drug to manage hypertensive crisis in a patient with pheochromocytoma. The typical dose is 5-10 mg given intravenously, which can be repeated as needed to control blood pressure [ 1 ]. Alternatively, other alpha-1-blockers such as doxazosin or terazosin, or labetalol, which has alpha-blocker properties, may be used [ 1 ]. These medications work by blocking alpha-adrenergic receptors, counteracting the effects of the excessive catecholamines (epinephrine and norepinephrine) released by the pheochromocytoma tumor.

It's crucial to use alpha-blockers first before introducing any beta-blockers, as using beta-blockers alone can worsen hypertension by leaving alpha-mediated vasoconstriction unopposed [ 1 ]. Other medications that may be considered include nicardipine or clevidipine (calcium channel blockers) if additional blood pressure control is needed [ 1 ]. Close monitoring in an intensive care setting with continuous blood pressure monitoring is essential during treatment of a hypertensive crisis in these patients, as rapid fluctuations in blood pressure can occur.

Some key points to consider when managing hypertensive crisis in patients with pheochromocytoma include:

• Identifying and treating the underlying cause of the crisis
• Using alpha-blockers as the initial treatment
• Avoiding beta-blockers until alpha-blockade is established
• Monitoring blood pressure closely and adjusting treatment as needed
• Considering alternative medications, such as calcium channel blockers, if additional blood pressure control is needed [ 1 ].

From the FDA Drug Label

The reconstituted solution should be used upon preparation and should not be stored. 1. Prevention or control of hypertensive episodes in the patient with pheochromo-cytoma. Phentolamine Mesylate for Injection is indicated for the prevention or control of hypertensive episodes that may occur in a patient with pheochromocytoma as a result of stress or manipulation during preoperative preparation and surgical excision.

Phentolamine (IV) is recommended to manage hypertensive crisis in a patient with pheochromocytoma 2 2.

• The dose for adults is 5 mg; for children, 1 mg.
• It can be administered intravenously to help prevent or control paroxysms of hypertension.

From the Research

Management of Hypertensive Crisis in Pheochromocytoma

• The management of hypertensive crisis in patients with pheochromocytoma requires careful consideration of the patient's condition and the potential risks associated with different treatment options 3, 4.
• Phentolamine is a recommended drug for managing hypertensive crisis in patients with pheochromocytoma, as it has been shown to be effective in controlling blood pressure and heart rate in these patients 3.
• The use of selective α1-adrenergic blocking agents, such as doxazosin, prazosin, or terazosin, is also recommended for the management of hypertension in patients with pheochromocytoma, followed by β-adrenergic blockade with agents such as propranolol or atenolol 4.
• Vasodilators, such as calcium channel blockers, may also be used to control blood pressure in patients with pheochromocytoma, but oral and sublingual short-acting nifedipine are not recommended due to the risk of potentially dangerous side effects 4.

Preoperative Management

• Preoperative management of patients with pheochromocytoma is crucial to minimize the risk of catecholamine-related complications during surgery 5, 6.
• Patients with pheochromocytoma should be prepared for surgery with α-adrenergic blockade, followed by β-adrenergic blockade, and should be closely monitored for blood pressure, heart rate, and arrhythmias 5, 6.

Emergency Department Management

• In the emergency department, patients with pheochromocytoma crisis require prompt and careful management to prevent multi-organ failure and cardiopulmonary collapse 7.
• Emergency providers should be aware of the potential for pheochromocytoma crisis in patients presenting with severe hypertension and should be prepared to manage these patients with the appropriate medications and supportive care 7.