Pheochromocytoma Surgery Preparation: Alpha Blockers Guide | QuickRx

If you’ve been diagnosed with pheochromocytoma, you probably know that surgery to remove the tumor is the goal. But here’s something critical that many patients don’t initially realize: you can’t just go straight to surgery. “If you’ve been diagnosed with pheochromocytoma, you probably know that surgery is the goal. But pheochromocytoma surgery preparation is just as critical as the operation itself — and it could save your life.”

The weeks before your operation are just as important as the surgery itself. Without proper preparation, pheochromocytoma surgery carries serious — even life-threatening — risks.

“Patients sometimes want to rush to surgery once they’re diagnosed, which is understandable,” says Julia Kravtsova, PharmD, Head Patient Navigator at QuickRx Specialty Pharmacy. “But the pre-surgical blocking period is not optional. It’s what makes the difference between a safe surgery and a dangerous one.”

Why Pre-Surgical “Blocking” is Critical

The Danger of Operating Without Blocking

Pheochromocytomas produce massive amounts of catecholamines — the same hormones your body releases during a “fight or flight” response. During surgery, when the tumor is manipulated or removed:

• Large surges of catecholamines can be released into the bloodstream
• Blood pressure can spike to extreme, dangerous levels (hypertensive crisis)
• Heart rate can become dangerously fast or irregular
• Risk of stroke, heart attack, or cardiac arrest increases dramatically

Before blocking medications became standard, pheochromocytoma surgery had very high complication and mortality rates. Today, with proper preparation, these risks are dramatically reduced.

What “Blocking” Accomplishes

Pre-surgical blocking serves several purposes:

• Blocks hormone effects: Alpha and beta blockers prevent catecholamines from affecting blood vessels and the heart
• Normalizes blood pressure: Gets hypertension under control before surgery
• Restores blood volume: Chronic catecholamine excess causes blood vessel constriction and reduced blood volume; blocking allows this to normalize
• Reduces surgical risks: Makes intraoperative blood pressure swings more manageable

Understanding Alpha Blockers: The First Step

Alpha blockers are always the FIRST medication started in pheochromocytoma preparation. Starting them before beta blockers is critical.

How Alpha Blockers Work

Catecholamines cause blood vessel constriction by activating alpha receptors. Alpha blockers:

• Block these receptors, preventing vessel constriction
• Allow blood vessels to relax and dilate
• Lower blood pressure
• Allow blood volume to expand to normal levels

Common Alpha Blockers Used

• Phenoxybenzamine (Dibenzyline): Non-selective, long-acting alpha blocker; traditional first choice
• Doxazosin (Cardura): Selective alpha-1 blocker; taken once daily
• Prazosin (Minipress): Selective alpha-1 blocker; taken multiple times daily
• Terazosin (Hytrin): Selective alpha-1 blocker

What to Expect from Alpha Blockers

• Blood pressure reduction: Your high blood pressure should improve
• Nasal congestion: A common side effect due to blood vessel dilation
• Dizziness or lightheadedness: Especially when standing up quickly (orthostatic hypotension)
• Fatigue: You may feel more tired as blood pressure normalizes
• Reflex tachycardia: Heart rate may increase — this is why beta blockers are added later

Important: Start Slow, Go Slow

Alpha blockers are typically started at low doses and gradually increased. This allows your body to adjust and helps minimize side effects. Your doctor will guide the dose escalation based on your blood pressure response.

Adding Beta Blockers: The Second Step

Once alpha blockade is established (usually after several days to a week), beta blockers may be added.

Why Beta Blockers are Needed

• Alpha blockers can cause reflex tachycardia (increased heart rate)
• Catecholamines also directly increase heart rate through beta receptors
• Beta blockers control heart rate and help manage arrhythmias

Common Beta Blockers Used

• Propranolol (Inderal): Non-selective beta blocker
• Atenolol (Tenormin): Cardioselective beta blocker
• Metoprolol (Lopressor): Cardioselective beta blocker

What to Expect from Beta Blockers

• Slower heart rate
• Possible fatigue or exercise intolerance
• Cold hands or feet
• Better blood pressure control in combination with alpha blockers

Metyrosine (Demser): Reducing Catecholamine Production

In some cases, your doctor may also prescribe metyrosine (brand name Demser) as part of your pre-surgical preparation.

How Metyrosine Works

Unlike alpha and beta blockers, which block the effects of catecholamines, metyrosine works differently:

• Inhibits tyrosine hydroxylase, an enzyme needed to produce catecholamines
• Reduces the amount of catecholamines the tumor produces
• Decreases the “hormone load” that could be released during surgery

When Metyrosine is Used

Metyrosine may be added to alpha and beta blockade when:

• Blood pressure remains difficult to control with blockers alone
• The tumor produces very high levels of catecholamines
• Surgery is expected to be particularly challenging
• For long-term management if surgery isn’t possible

What to Expect from Metyrosine

Metyrosine can have significant side effects because it affects catecholamine production throughout the body:

• Sedation and drowsiness: Common, especially at higher doses
• Anxiety or depression: Can occur in some patients
• Diarrhea: Relatively common
• Crystalluria: Crystals in urine — maintain good hydration
• Extrapyramidal symptoms: Movement-related side effects (rare)

Your medical team will weigh the benefits against side effects when deciding whether metyrosine is right for your preparation.

The Pre-Surgery Timeline: What to Expect

Typical Preparation Schedule

While every patient is different, here’s a general timeline:

• Week 1-2: Start alpha blocker at low dose; gradually increase
• Week 2+: Once alpha blockade adequate, add beta blocker if needed
• If using metyrosine: May be added during this period
• 10-14 days minimum: Most protocols require at least this long for adequate preparation
• Final days before surgery: Ensure hydration, check blood pressure goals are met

Goals Before Surgery

Your medical team will want to see:

• Blood pressure controlled: Typically below 130/80 mmHg while seated
• No severe orthostatic hypotension: Blood pressure shouldn’t drop too much when standing
• Heart rate controlled: Usually 60-80 beats per minute
• No recent hypertensive episodes: Ideally no significant episodes for 24+ hours before surgery
• Adequate hydration: Blood volume should be restored

Lifestyle During Preparation

• Stay hydrated: Drink plenty of fluids (helps restore blood volume and prevents crystalluria if taking metyrosine)
• High-sodium diet: Often recommended to help restore blood volume (opposite of typical hypertension advice!)
• Avoid triggers: Don’t provoke episodes with known triggers
• Take medications as prescribed: Don’t skip doses or adjust on your own
• Monitor blood pressure: Your doctor may want regular readings at home

What Happens During Surgery

The Surgical Approach

• Laparoscopic adrenalectomy: Minimally invasive surgery preferred when possible
• Open surgery: May be needed for larger tumors or difficult cases
• Specialized anesthesia team: Anesthesiologists experienced with pheo are essential

Managing Intraoperative Challenges

Even with excellent preparation, blood pressure can fluctuate during surgery:

• Anesthesia team has medications ready to manage blood pressure spikes
• Once tumor blood supply is controlled and tumor removed, catecholamine release stops
• Blood pressure may drop after tumor removal — this is expected and managed with fluids and medications

After Surgery: Recovery

Immediate Post-Operative Period

• Blood pressure monitoring: Close monitoring continues
• Hypoglycemia watch: Blood sugar may drop after catecholamine removal
• Fluid management: Important to maintain blood pressure
• Stopping preoperative medications: Alpha and beta blockers typically discontinued gradually

Recovery Timeline

• Hospital stay: Typically a few days for laparoscopic surgery
• Return to normal activities: Usually within 2-4 weeks
• Full recovery: Several weeks to months

Long-Term Follow-Up

• Regular monitoring for tumor recurrence
• Catecholamine/metanephrine testing periodically
• Genetic counseling and family screening if applicable
• Lifelong surveillance recommended

Frequently Asked Questions

How long do I need to take alpha blockers before surgery?

Typically 10-14 days minimum, though this varies by patient. Your endocrinologist and surgical team will determine when you’ve achieved adequate blockade based on blood pressure control and other factors.

Why can’t I just have surgery right away?

Operating on an “unblocked” pheochromocytoma is extremely dangerous. Manipulation of the tumor during surgery can release massive amounts of catecholamines, causing potentially fatal blood pressure spikes, heart attacks, or strokes. Proper blocking makes surgery much safer.

What if my blood pressure is still high even with medications?

Your doctor may increase medication doses, add additional medications (like metyrosine), or extend the blocking period. Achieving blood pressure control before surgery is critical and shouldn’t be rushed.

Will I need blood pressure medications after surgery?

Most patients with benign pheos that are completely removed will have normal blood pressure after surgery and won’t need long-term blood pressure medications. However, some patients may have residual hypertension that requires treatment.

Is pheochromocytoma surgery dangerous?

With proper pre-surgical preparation and an experienced surgical team, pheochromocytoma surgery is much safer than it once was. However, it still carries risks and should be performed at centers with expertise in pheo management. The preparation period is what makes modern outcomes so much better than historical ones.

What if I can’t have surgery?

For patients who cannot undergo surgery (due to other health conditions or metastatic disease), long-term medical management with alpha blockers, beta blockers, and metyrosine can help control symptoms. Other treatments may be options depending on the situation.

References

1. Endocrine Society. Pheochromocytoma.
2. National Organization for Rare Disorders (NORD). Pheochromocytoma.
3. National Cancer Institute. Pheochromocytoma and Paraganglioma Treatment (PDQ).
4. Mayo Clinic. Pheochromocytoma Diagnosis and Treatment.
5. MedlinePlus. Metyrosine.

This information is not intended to replace professional medical advice. Always follow your medical team’s specific instructions for pheochromocytoma preparation and surgery. For questions about medication copay assistance, contact QuickRx Specialty Pharmacy at (917) 830-2525.