Incidentaloma medical therapy: Difference between revisions
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* This would provide an early and accurate evaluation of surgical success in patients with underlying Cushing’s syndrome or SCS. | * This would provide an early and accurate evaluation of surgical success in patients with underlying Cushing’s syndrome or SCS. | ||
* Another approach would be to cover all patients with glucocorticoids perioperatively and evaluate their HPA axis at a later date (71, 74). | * Another approach would be to cover all patients with glucocorticoids perioperatively and evaluate their HPA axis at a later date (71, 74). | ||
=== Preoperative medical therapy === | |||
* All patients undergoing surgery need preoperative treatment to control [[hypertension]] during surgery and [[hypotension]] after it. | |||
* According to Endocrine Society’s 2014 Clinical Practice Guidelines, there are three medical regimens for preoperative management of pheochromocytoma:<sup>[[Pheochromocytoma medical therapy#cite note-pmid248931352-1|[1]]][[Pheochromocytoma medical therapy#cite note-pmid14766711-2|[2]]]</sup> | |||
** Combined [[Alpha blocker|alpha]] and [[beta-adrenergic blockers]] | |||
** [[Calcium channel blocker|Calcium channel blockers]] | |||
** [[Metyrosine]] | |||
==== [[Alpha blocker|Aalpha adrenoceptor blocker]] ==== | |||
* It is used to counteract [[hypertension]] and the [[Beta blockers|beta-1 adrenoceptor antagonist]] [[atenolol]] to reduce [[cardiac output]]. They can block the sudden release of [[adrenaline]] during surgical stress and prevent [[hypertensive crisis]]. The patient is ready for surgery after 10 to 14 days of initiation of [[Alpha-adrenergic blocking agent|alpha-adrenergic blockade]]. Patients should take high [[sodium]] diet to prevent [[orthostatic hypotension]] due to [[Alpha blocker|alpha blockers]]. After adequate [[Alpha-adrenergic blocker|alpha-adrenergic blockade]] has been achieved, a [[beta-adrenergic blocker]] is initiated 3 days before surgery. | |||
'''[[Beta blockers|Beta-adrenergic blocker]]''' | |||
* It should never be started first because unopposed [[Alpha-adrenergic agonist|alpha-adrenergic]] receptor stimulation can lead to the brisk increase in [[blood pressure]]. It should be used with caution due to the risk of [[heart failure]], [[pulmonary edema]], and [[asthma]]. | |||
==== [[Calcium channel blocker]] ==== | |||
* It is used to control [[blood pressure]] preoperatively and an [[intravenous injection]] is given intraoperatively. | |||
* Its main use is controlling [[blood pressure]] in case of failed [[Alpha blocker|alpha]] and [[beta blockers]] regimen or unaccepted side effects in that regimen.<sup>[[Pheochromocytoma medical therapy#cite note-pmid15819762-3|[3]]]</sup> | |||
==== [[Metyrosine]] ==== | |||
* It is the last medical line of treatment. It inhibits [[catecholamine]] synthesis. | |||
* It is used in case of failure of other medical lines of treatment or in patients who cannot tolerate them. | |||
* Clinicians use combined treatment in difficult cases and if [[radiofrequency ablation]] for [[metastatic]] foci will be used. [[Metyrosine]] side effects include [[Crystalluria|crystalluria,]] [[Extrapyramidal symptom|extrapyramidal]]<nowiki/>manifestations, and high cost.<sup>[[Pheochromocytoma medical therapy#cite note-pmid9129550-4|[4]]]</sup> | |||
===Aldosteronoma=== | ===Aldosteronoma=== | ||
Revision as of 23:34, 29 August 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
The mainstay of treatment for [disease name] is [therapy].
Medical Therapy
Perioperative management of patients with SCS
- Patients with Cushing’s syndrome or SCS have adequate circulating glucocorticoids and therefore do not require glucocorticoid therapy during surgery.
- Such patients can safely undergo surgical resection of their tumor, have their cortisol levels measured in the morning of postoperative d 1
- be started on hydrocortisone 30 mg in the morning and 10 mg in the early afternoon until the result of the cortisol level becomes available (73).
- This would provide an early and accurate evaluation of surgical success in patients with underlying Cushing’s syndrome or SCS.
- Another approach would be to cover all patients with glucocorticoids perioperatively and evaluate their HPA axis at a later date (71, 74).
Preoperative medical therapy
- All patients undergoing surgery need preoperative treatment to control hypertension during surgery and hypotension after it.
- According to Endocrine Society’s 2014 Clinical Practice Guidelines, there are three medical regimens for preoperative management of pheochromocytoma:[1][2]
- Combined alpha and beta-adrenergic blockers
- Calcium channel blockers
- Metyrosine
Aalpha adrenoceptor blocker
- It is used to counteract hypertension and the beta-1 adrenoceptor antagonist atenolol to reduce cardiac output. They can block the sudden release of adrenaline during surgical stress and prevent hypertensive crisis. The patient is ready for surgery after 10 to 14 days of initiation of alpha-adrenergic blockade. Patients should take high sodium diet to prevent orthostatic hypotension due to alpha blockers. After adequate alpha-adrenergic blockade has been achieved, a beta-adrenergic blocker is initiated 3 days before surgery.
- It should never be started first because unopposed alpha-adrenergic receptor stimulation can lead to the brisk increase in blood pressure. It should be used with caution due to the risk of heart failure, pulmonary edema, and asthma.
Calcium channel blocker
- It is used to control blood pressure preoperatively and an intravenous injection is given intraoperatively.
- Its main use is controlling blood pressure in case of failed alpha and beta blockers regimen or unaccepted side effects in that regimen.[3]
Metyrosine
- It is the last medical line of treatment. It inhibits catecholamine synthesis.
- It is used in case of failure of other medical lines of treatment or in patients who cannot tolerate them.
- Clinicians use combined treatment in difficult cases and if radiofrequency ablation for metastatic foci will be used. Metyrosine side effects include crystalluria, extrapyramidalmanifestations, and high cost.[4]
Aldosteronoma
Preoperative management
- The majority of patients with primary aldosteronism need to proceed with bilateral adrenal venous sampling to confirm the presence of a unilateral source for hyperaldosteronism.
- Some experts recommend adrenal vein sampling in all patients with primary aldosteronism older than 40 yr due to the increased prevalence of adrenal incidentaloma in such a population (118).
- Adrenalectomy in patients with a documented unilateral source of primary aldosteronism is more cost effective compared with lifelong medical therapy.
- Medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery (44).
- Laparoscopic adrenalectomy compared to an open procedure is associated with a shorter hospital stay, fewer complications, and faster recovery.
- Resection of the adrenal tumor in a patient with APA will result in resolution of hypokalemia and improvement in hypertension in almost all patients.
Postoperative management
- Potassium supplementation and mineralocorticoid receptor antagonists should be stopped on postoperative day1
- Close monitoring of serum potassium.
- A temporary state of hypoaldosteronism may also develop in some patients with primary aldosteronism postoperatively.
- In the majority of cases, this condition can be managed by increasing salt intake.