From the Guidelines
Elevated catecholamines should be managed with alpha-blockers, such as phenoxybenzamine or doxazosin, prior to any therapeutic intervention, especially in patients with norepinephrine-producing tumors, to prevent hypertensive crisis and other cardiovascular complications. The management of elevated catecholamines depends on the underlying cause, and diagnosis typically involves 24-hour urine tests for catecholamines and their metabolites or plasma metanephrine testing 1. For pheochromocytoma, surgical removal of the tumor is recommended after proper preoperative preparation with alpha-blockers, followed by beta-blockers to control blood pressure 1.
Some key points to consider in the management of elevated catecholamines include:
- Alpha-blockade must precede beta-blockade to prevent hypertensive crisis 1
- Phenoxybenzamine and doxazosin are commonly used alpha-blockers, with phenoxybenzamine showing less intraoperative hemodynamic instability in a randomized controlled trial 1
- Metyrosine and calcium channel blockers can be used as adjunctive therapy to control refractory hypertension or as presurgical monotherapy in cases of normal to mildly elevated blood pressure levels 1
- Tachycardia is treated with either non-selective β- or β1-selective adrenoceptor blocker 1
In patients with dopamine-only producing tumors, management with alpha-adrenoceptor blockers before any type of treatment is not advised, as these tumors are unlikely to provoke significant hemodynamic effects 1. However, in patients with norepinephrine-producing tumors, preoperative adrenoceptor blockade can be considered to prevent hypertensive crisis and other cardiovascular complications 1.
Overall, the goal of management is to control the symptoms and signs of catecholamine excess, prevent complications of therapeutic interventions, and improve patient outcomes 1.
From the Research
Elevated Catecholamine
Elevated catecholamine levels can lead to various health issues, including hypertensive crises. The following points summarize the current understanding of elevated catecholamine and its management:
- Catecholamine-induced hypertensive crises can be complicated by tachyarrhythmias, hypotension, or life-threatening target organ damage 2
- Phaeochromocytomas and paragangliomas (PPGLs) release catecholamines, leading to catecholamine-induced hypertensive crises 2
- Biochemical diagnosis of a PPGL as a cause of a CIH crisis can be difficult to identify or confounded by comorbid conditions, potentially resulting in misdiagnosis 2
- Effective intervention with available drugs can mitigate consequent morbidity and mortality in patients with PPGL 2
Management of Elevated Catecholamine
The management of elevated catecholamine levels typically involves the use of alpha-blockers, such as phenoxybenzamine or doxazosin. Key points to consider:
- Phenoxybenzamine and doxazosin are commonly used alpha-blockers for the preoperative treatment of pheochromocytoma 3
- There is no evidently superior alpha-blocker for the pretreatment of patients with pheochromocytoma, with perioperative haemodynamics slightly better controlled with phenoxybenzamine, but at the cost of more pronounced postoperative hypotension 3
- Side effects, such as orthostatic hypotension, oedema, and complaints of a stuffy nose, occurred less often in the doxazosin group 3
- A significant shift away from phenoxybenzamine for preoperative blockade before resection of pheochromocytoma has been observed, with selective alpha blockers and calcium channel blockers increasingly used due to reduced costs 4
Catecholamine Therapy
Catecholamine therapy is often required to restore systemic circulation and avoid organ damage in cases of severe systemic hypotension. Important considerations:
- Catecholamine therapy should be limited to an initial measure until correction of the underlying abnormalities can be achieved 5
- Different etiologies of shock, as well as diseases requiring specific interventions, must be considered when administering catecholamine therapy 5
- First-line intervention consists of optimizing preload by fluid resuscitation and using dopamine as the primary catecholamine to increase contractility and blood pressure 5