Table 1.

Outpatient pre-procedural medical management.

Class of Medication	Medication Name	Approach to Titration	Dosing	Monitoring/Goals of Therapy	Side Effects and Counseling
Alpha-adrenergic blockade	Phenoxybenzamine Doxazosin	Start at least 10–14 days prior to procedure. Titrate daily based on orthostatic blood pressure.	Starting dose: usually 10 mg once or twice daily, gradually increased. Final dose varies (60–120 mg total daily dose in divided doses). Starting dose: usually 1 mg once or twice daily, or 4 mg once daily, gradually increased. Final dose varies (6–40 mg) * total daily dose in divided doses.	Monitoring includes: daily orthostatic vitals, side effects. The goal is low normal blood pressure.	Fatigue, lightheadedness, tachycardia, nasal congestion, diarrhea Counseling: Optimal hydration Increase salt intake. Avoid driving if lightheaded.
Beta-adrenergic blockade	Propranolol Metoprolol succinate Atenolol	Start 3–7 days prior to procedure. Start after alpha-adrenergic blockade. Titrate daily based on heart rate.	Starting dose: 10 mg every 6–8 h, gradually increased. Final dose varies (30-90 mg total daily dose). Starting dose: 25 mg daily. Final dose varies (50–200 mg) daily in divided doses. Starting dose: 25 mg daily. Final dose varies.	Absence of tachycardia, with a baseline heart rate <80–90 beats/minute	Usually none if started after alpha-adrenergic blockade and close monitoring as well as treatment of short duration.
Calcium channel blockade	Amlodipine	Usually used as an additive agent when blood pressure is uncontrolled with alpha- and beta-blockade.	Starting dose: 5 mg, increase to 10 mg if needed.	Monitoring includes blood pressure measurements.	Usually none with close monitoring and treatment of short duration.
Catecholamine synthesis inhibitor	Metyrosine	Usually used when inadequate or intolerant to alpha blockade, when difficult resection is anticipated. Titrated based on the Mayo Clinic protocol. Day 1: 250 mg every 6 h Day 2: 500 mg every 6 h Day 3: 500 mg every 6 h Day 4: 750 mg every 6 h Day 5: 1000 mg every 6 h, last dose of 1000 mg on the morning of procedure		Monitor for side effects	Fatigue Sedation Dizziness Depressed mood Diarrhea, anorexia Extrapyramidal side effects Counseling: Optimal hydration. Avoid driving. Contact physician if extra-pyramidal side effects occur.

* Forty mg is a very high dose of doxazosin that is not usually employed except in rare cases. In most settings, the maximal dosage of doxazosin employed is 16 mg, and calcium-channel blockers or metyrosine are employed if control is still inadequate. On the other hand, in some patients a final dose lower than 6 mg (e.g., 2 mg or 4 mg) is sufficient to reach the blood pressure target.