What medication would you give to control hypertension (HTN) in a patient with a suprarenal mass, presenting with sweating, dyspnea, palpitations, and headache, despite taking antihypertensive medication?

Management of Hypertension in a Patient with Suprarenal Mass

Alpha-blockers are the first-line medication of choice for controlling hypertension in a patient with a suprarenal mass presenting with sweating, dyspnea, palpitations, and headache, as these symptoms strongly suggest pheochromocytoma. 1

Clinical Reasoning

The patient's presentation with:

• Sweating
• Dyspnea
• Palpitations
• Headache
• Uncontrolled hypertension despite medication
• Suprarenal mass on imaging

This constellation of symptoms is highly suggestive of pheochromocytoma, a catecholamine-secreting tumor of the adrenal medulla. Pheochromocytoma is a rare cause of secondary hypertension (0.2-0.4% of all hypertension cases) 1, but requires specific management to prevent potentially life-threatening complications.

Treatment Algorithm

1. First-line: Alpha-blocker (Option B)

   • Alpha-blockers are essential to control hypertension in pheochromocytoma by blocking alpha-adrenergic receptors, preventing catecholamine-induced vasoconstriction
   • Examples include phenoxybenzamine (non-selective, irreversible) or selective alpha-1 blockers (doxazosin, prazosin, terazosin)
   • Phenoxybenzamine is specifically indicated "in the treatment of pheochromocytoma, to control episodes of hypertension and sweating" 2

2. Second-line: Add beta-blocker

   • Only after adequate alpha-blockade is established
   • Controls tachycardia and other arrhythmias
   • Never start beta-blockers before alpha-blockers as this can worsen hypertension due to unopposed alpha-stimulation 3

3. Third-line: Consider calcium channel blockers (CCBs)

   • Can be added as supplementary therapy if blood pressure remains uncontrolled
   • Nicardipine or clevidipine are preferred in acute management 1

Why Other Options Are Not First-Line:

• CCBs (Option A): While effective for hypertension management, they are not first-line for pheochromocytoma. They may be used as adjunctive therapy but lack the specific alpha-blocking effects needed to counteract high catecholamine states 1.

• ACE inhibitors (Option C): Not recommended as first-line therapy for pheochromocytoma. They do not directly address the catecholamine excess that is causing the hypertension 1.

• Beta-blockers (Option D): Should never be started first in pheochromocytoma as blockade of vasodilatory peripheral β-adrenergic receptors with unopposed α-adrenergic receptor stimulation can lead to further elevation of BP and hypertensive crisis 3.

Important Clinical Considerations

• Diagnosis should be confirmed with plasma or urinary catecholamines or their metabolites 1
• Surgical removal is the definitive treatment for pheochromocytoma
• Preoperative preparation with alpha-blockers for 1-2 weeks is essential to prevent intraoperative hypertensive crisis 4
• Volume expansion is often needed alongside alpha-blockade due to chronic vasoconstriction
• Monitor for orthostatic hypotension, which is a common side effect of alpha-blockers 5

Monitoring and Follow-up

• Regular blood pressure monitoring
• Assess for symptoms of catecholamine excess
• Monitor for side effects of alpha-blockers (orthostatic hypotension, nasal congestion, dizziness)
• Prepare for definitive surgical management once blood pressure is adequately controlled

In conclusion, alpha-blockers represent the cornerstone of medical management for patients with suspected pheochromocytoma, directly addressing the pathophysiological mechanism of hypertension in these patients.