For my upcoming adrenalectomy, should I withhold any of the following medications: prazosin extended‑release, tamsulosin, rosuvastatin, the supplement giftofer, nutrico‑ba, magnesium supplement, potassium chloride, pancreatic enzyme preparation, metformin, amlodipine, or atenolol?

Preoperative Medication Management for Adrenalectomy

Continue all your medications except metformin (hold 24-48 hours before surgery) and ensure your alpha-blocker (prazosin) is optimized if you have a pheochromocytoma.

Critical Preoperative Considerations

Blood Pressure Medications – Continue All

• Prazosin XL (alpha-blocker), amlodipine (calcium channel blocker), and atenolol (beta-blocker) should all be continued through the morning of surgery 1, 2.
• Good preoperative blood pressure control with antihypertensive medications predicts better postoperative outcomes, with 53% of normotensive patients achieving complete resolution of hypertension versus only 24% of hypertensive patients 3.
• If your adrenalectomy is for pheochromocytoma, the alpha-blocker (prazosin) is essential and must be optimized preoperatively to prevent hypertensive crisis during tumor manipulation 2, 4.
• The beta-blocker (atenolol) should never be started before adequate alpha-blockade in pheochromocytoma, but if already established, continue it 2.

Tamsulosin (Tazloc) – Continue

• This alpha-blocker for urinary symptoms can be continued safely and does not interfere with adrenal surgery 1.

Metformin (Glycomet) – Hold 24-48 Hours Before Surgery

• Stop metformin 24-48 hours before surgery due to risk of lactic acidosis with anesthesia and potential perioperative renal impairment.
• This is standard perioperative practice for any major surgery requiring general anesthesia.

Rosuvastatin (Crevast) – Continue

• Continue your statin through surgery; cardiovascular protection is important given the metabolic stress of adrenalectomy 1.

Potassium Chloride (Potchlor) – Likely Discontinue Day of Surgery

• If you have primary hyperaldosteronism (Conn's syndrome), potassium supplementation is typically needed preoperatively but will be immediately unnecessary after tumor removal 5.
• All patients with preoperative hypokalemia have immediate resolution postoperatively and do not require continuation of potassium supplementation 5.
• Discuss with your surgeon, but generally hold the morning of surgery as your potassium will normalize rapidly after adrenal removal.

Spironolactone or Eplerenone – If Taking, Continue Until Surgery

• If you're on mineralocorticoid receptor blockers for aldosteronoma, these are typically continued preoperatively to control blood pressure and normalize potassium 2.
• These will be discontinued immediately postoperatively 5.

Supplements (Giftofer, Nutricoba, Magvion) – Continue

• Iron supplementation (giftofer), B-complex vitamins (nutricoba), and magnesium (magvion) can all be continued safely 1.
• Take with a small sip of water on the morning of surgery if instructed to take morning medications.

Pancreatic Enzymes (Pancare) – Continue

• These are safe to continue and should be taken with meals as usual 1.

Critical Perioperative Steroid Management

If You Have Cushing's Syndrome or Cortisol-Secreting Tumor

• You will receive hydrocortisone 100 mg IV at anesthetic induction, followed by continuous infusion of 200 mg over 24 hours 1, 6, 2.
• This prevents life-threatening adrenal crisis from sudden cortisol withdrawal 7.
• Postoperatively, stress-dose steroids continue until you can take oral medications, then are gradually tapered over 6-12 months 6, 2.

If You Have Aldosteronoma (Conn's Syndrome)

• You typically do NOT require postoperative steroid replacement unless you have bilateral disease 6, 2.
• Your contralateral adrenal gland maintains normal cortisol production 2.

If You Have Bilateral Adrenalectomy

• You will require lifelong glucocorticoid and mineralocorticoid replacement (hydrocortisone 15-25 mg daily plus fludrocortisone 0.05-0.2 mg daily) 6.

Common Pitfalls to Avoid

• Never stop alpha-blockers abruptly before pheochromocytoma surgery – this can precipitate hypertensive crisis 2.
• Do not assume you can stop all blood pressure medications immediately after surgery – 69% of patients still require some antihypertensive medications postoperatively, though usually fewer 8, 5.
• Ensure you are scheduled as the first case of the day to minimize fasting time and facilitate close postoperative monitoring 1.
• Bring a steroid emergency card and medical alert identification if you will have adrenal insufficiency postoperatively 7, 6.

Postoperative Expectations

• 90% of patients achieve at least a 20 mmHg reduction in systolic blood pressure within 6 months 5.
• Metabolic abnormalities (hypokalemia, hyperaldosteronism) resolve immediately after tumor removal 5.
• Complete resolution of hypertension occurs in 31-39% of patients, with higher rates in those with good preoperative blood pressure control 3, 5.
• Weight is a critical factor – lower body mass index predicts better blood pressure outcomes 5.