Incidentaloma medical therapy
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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 medical management of patients with subclinical Cushing's syndrome
There are two approcaches tp deal with cases of Cushing's syndrome:
- Patients do not require glucocorticoid therapy during surgery. Such patients can safely undergo surgical resection of their tumor and have their cortisol levels measured postoperatively. This would provide an early evaluation of surgical success. Hydrocortisone may be given to the patient 30 mg in the morning and 10 mg in the afternoon until the result of the cortisol level becomes available (73).
- Another approach would be to cover all patients with glucocorticoids perioperatively. (71, 74).
Preoperative medical management of patients with pheochromocytoma
- 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]
Preoperative medical management of patients with aldosteronoma
Preoperative management
- Medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery (44).
- Adrenalectomy in patients with a documented unilateral source of primary aldosteronism is more cost effective compared with lifelong medical therapy.
- Laparoscopic adrenalectomy compared to an open procedure is associated with a shorter hospital stay, fewer complications, and faster recovery.
- Resection of the adrenal tumor 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 postoperatively with close monitoring of serum potassium.
- A temporary state of hypoaldosteronism may also develop in some patients with primary aldosteronism postoperatively and can be managed by increasing salt intake.