Skip to main content

Main menu

  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us

Clinical Medicine Journal

  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

User menu

  • Log in

Search

  • Advanced search
RCP Journals
Home
  • Log in
  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us
Advanced

Clinical Medicine Journal

clinmedicine Logo
  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

Established endocrine practice

Sam M O’Toole, Morris J Brown and William M Drake
Download PDF
DOI: https://doi.org/10.7861/clinmedicine.19-1-91a
Clin Med January 2019
Sam M O’Toole
St Bartholomew’s Hospital, London, UK
Roles: Specialist registrar in Endocrinology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Morris J Brown
Queen Mary University of London, London, UK
Roles: Professor of endocrine hypertension
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
William M Drake
St Bartholomew’s Hospital, London, UK
Roles: Professor of endocrinology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
Loading

Editor – Pre-operative preparation with alpha receptor antagonists before phaeochromocytoma resection is established endocrine practice.1 We therefore read with great interest the report by Faloon et al2 detailing circumstances which precluded this. We congratulate them on the successful outcome of the case and for highlighting the ongoing absence of parenteral preparations of alpha blockers in the UK. This has significant implications for the management of a phaeochromocytoma crisis given the uniformity with which these agents are recommended in society guidelines.1,3

The established mantra of alpha followed by beta blockade, whilst correct and widely held, is not achievable in the situation described. A range of alternative intravenous anti-hypertensive agents have been used in the management of phaeochromocytoma. Indeed, some units do not use alpha blockers even when available, but utilise the dihydropyridine calcium-channel blocker nicardipine4 which acts by preventing catecholamine-stimulated calcium influx into arterial smooth muscle. The combined α1 and β antagonist labetalol has also been used5 and has the advantages of familiarity with acute care physicians and accessibility in the emergency department. However, like all beta blockers, concerns exist regarding the risk of paradoxical hypertension in spite of its α1 activity and adverse events have been reported.6 Other drugs that also have a role are magnesium,7 sodium nitroprusside and glyceryl trinitrate.

Use of these agents may be limited by profound hypotension as they were in this case and this serves as an important reminder that patients with phaeochromocytoma are severely volume contracted due to alpha-mediated vasoconstriction. Volume expansion is therefore a key component to acute management and significant hypotension may follow successful tumour (and therefore catecholamine) removal.

We would like to remind readers that alternative parenteral treatment agents for this rare but life-threatening clinical situation are available in the UK.

  • © Royal College of Physicians 2019. All rights reserved.

References

  1. ↵
    1. Lenders JWM
    , Duh Q-Y, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2014;99:1915–42.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Faloon S
    , Venkataraman H, Skordilis K, et al. Lesson of the month 2: Blunt abdominal trauma: atypical presentation of phaeochromocytoma. Clin Med 2018;18:345–7.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Whelton PK
    , Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the ­prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College Of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 2018;71:1269–324.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Lebuffe G
    , Dosseh ED, Tek G, et al. The effect of calcium channel blockers on outcome following the surgical treatment of phaeochromocytomas and paragangliomas. Anaesthesia 2005;60:439–44.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Poopalalingam R
    , Chin EY. Rapid preparation of a patient with pheochromocytoma with labetolol and magnesium sulfate. Can J Anaesth 2001;48:876–80.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Kuok C-H
    , Yen C-R, Huang C-S, Ko Y-P, Tsai P-S. Cardiovascular collapse after labetalol for hypertensive crisis in an undiagnosed pheochromocytoma during cesarean section. Acta Anaesthesiol Taiwanica 2011;49:69–71.
    OpenUrl
  7. ↵
    1. James MF
    . Use of magnesium sulphate in the anaesthetic ­management of phaeochromocytoma: a review of 17 anaesthetics. Br J Anaesth 1989;62:616–23.
    OpenUrlCrossRefPubMed
Back to top
Previous articleNext article

Article Tools

Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Established endocrine practice
Sam M O’Toole, Morris J Brown, William M Drake
Clinical Medicine Jan 2019, 19 (1) 91; DOI: 10.7861/clinmedicine.19-1-91a

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Established endocrine practice
Sam M O’Toole, Morris J Brown, William M Drake
Clinical Medicine Jan 2019, 19 (1) 91; DOI: 10.7861/clinmedicine.19-1-91a
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • References
  • Info & Metrics

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • JAK-inhibition as a therapeutic strategy for refractory primary systemic vasculitides
  • Response
  • Functional disorders and chronic pain
Show more Letters to the editor

Similar Articles

Navigate this Journal

  • Journal Home
  • Current Issue
  • Ahead of Print
  • Archive

Related Links

  • ClinMed - Home
  • FHJ - Home
clinmedicine Footer Logo
  • Home
  • Journals
  • Contact us
  • Advertise
HighWire Press, Inc.

Follow Us:

  • Follow HighWire Origins on Twitter
  • Visit HighWire Origins on Facebook

Copyright © 2021 by the Royal College of Physicians