Diagnostic use of metoclopramide in hypertension caused by pheochromocytoma

Biochemical Assessment of Pheochromocytoma and Paraganglioma

Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.

Adverse drug reactions in patients with phaeochromocytoma: incidence, prevention and management

The dangers of phaeochromocytomas are mainly due to the capability of these neuroendocrine tumours to secrete large quantities of vasoactive catecholamines, thereby increasing blood pressure and causing other related adverse events or complications. Phaeochromocytomas are often missed, sometimes only becoming apparent during therapeutic interventions that provoke release or interfere with the disposition of catecholamines produced by the tumours. Because phaeochromocytomas are rare, evidence contraindicating use of specific drugs is largely anecdotal or based on case reports. The heterogeneous nature of the tumours also makes adverse reactions highly variable among patients. Some drugs, such as dopamine D(2) receptor antagonists (e.g. metoclopramide, veralipride) and beta-adrenergic receptor antagonists (beta-blockers) clearly carry high potential for adverse reactions, while others such as tricyclic antidepressants seem more inconsistent in producing complications. Other drugs capable of causing adverse reactions include monoamine oxidase inhibitors, sympathomimetics (e.g. ephedrine) and certain peptide and corticosteroid hormones (e.g. corticotropin, glucagon and glucocorticoids). Risks associated with contraindicated medications are easily minimised by adoption of appropriate safeguards (e.g. adrenoceptor blockade). Without such precautions, the state of cardiovascular vulnerability makes some drugs and manipulations employed during surgical anaesthesia particularly dangerous. Problems arise most often when drugs or therapeutic procedures are employed in patients in whom the tumour is not suspected. In such cases, it is extremely important for the clinician to recognise the possibility of an underlying catecholamine-producing tumour and to take the most appropriate steps to manage and treat adverse events and clinical complications.

Pheochromocytoma in pregnancy manifesting hypertensive crisis induced by metoclopramide

Pheochromocytoma is a rare disease that may occur during pregnancy. Antenatal diagnosis is essential to improve fetal and maternal mortality and morbidity, but is difficult. A hypertensive crisis was induced by metoclopramide, a widely used anti-emetic, in a pregnant normotensive woman. Biochemical measurements of plasma and urine catecholamines and magnetic resonance imaging (MRI) established the diagnosis of pheochromocytoma. She was medically treated with prazocin and electively delivered by cesarean section simultaneously with tumor resection.

High-performance liquid chromatographic analysis with electrochemical detection of biogenic amines using microbore columns

High-performance liquid chromatography with electrochemical detection (HPLC-ED) is a popular method for measuring biogenic amines, owing to its simplicity, versatility, sensitivity, and specificity. Recent developments in microbore column HPLC-ED have been facilitated by miniaturization of solvent delivery, column packing, sample injection and micro-flow cell construction. The aim of this paper is to present an overview of recent developments in microbore column HPLC-ED, in terms of advantages and limitations. This paper covers the recent advancements and important factors of HPLC-ED analysis of biogenic amines using microbore columns. Particular emphasis is placed on applying this technique to microdialysis, for which great sensitivity is required. Its potential in future biomedical applications is also discussed.