Background Phaeochromocytoma is a tumour arising from adrenomedullary chromaffin cells. Five-year survival with malignant phaeochromocytoma is less than 50%. Difficulty arises when prescribing for patients, given the potential to precipitate catecholamine crisis, a life-threatening emergency.
Case Presentation A 60 year-old female presented with abdominal fullness and discomfort. Imaging revealed a left adrenal mass with extensive hepatic metastatic disease. Liver biopsy confirmed phaeochromocytoma. The patient represented with a hypertensive crisis necessitating admission to the intensive care unit and alpha blockade. Contrast administration and morphine administration were identified as potential triggers. The palliative medicine team were consulted to aid managing her symptoms.
Management and Outcomes The patient experienced upper and lower abdominal pain described as ‘dragging’ and ‘sharp’ in nature. It was thought to be nociceptive pain. The Endocrine Society Clinical Practice guideline for management of phaeochromocytoma, recommends avoidance of morphine and codeine. Subcutaneous fentanyl was tolerated with good effect, and a continuous subcutaneous infusion was commenced while her pain was unstable to allow for rapid titration. She was transitioned to a fentanyl patch and her pain was reported to be 0/10. She was subsequently discharged and is undergoing chemotherapy.
Discussion/Learning Points While morphine administration is contraindicated in phaeochromocytoma, there is evidence in the literature to support the safe use of fentanyl, as is supported in this case. Tricyclic antidepressants, dopamine antagonists such as metoclopramide and prochlorperazine, corticosteroids, serotonin reuptake inhibitors and monoamine oxidase inhibitors are thought to precipitate a crisis. The authors have not found evidence to preclude the avoidance of cyclizine or ondansetron.
Conclusion Symptom control in patients with phaeochromocytoma remains challenging. There is a lack of published research to support the safe prescribing of medications for these patients.
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