Prevention and Management of Peptide Receptor Radionuclide Therapy-Induced Hypertensive Crisis in a Patient With Metastatic Pheochromocytoma

<h2>Abstract</h2> Background/Objective: While peptide receptor radionuclide therapy (PRRT) with lutetium-177 DOTATATE has been increasingly used for metastatic pheochromocytoma management, PRRT-induced hypertensive crisis has been documented in prior reports. A case is reported here to demonstrate the prevention and management of PRRT-induced hypertensive crisis. <h3>Case Report</h3> A 75-year-old male developed PRRT-induced hypertensive crisis. He had known progressive metastatic pheochromocytoma. Despite scheduled daily alpha and beta blockade, he developed symptomatic hypertensive crisis shortly after completion of lutetium-177 DOTATATE infusion in the first two treatments, which was managed with as-needed oral alpha blockade. Additional alpha blocker was given right before the initiation of lutetium-177 DOTATATE infusion in the third and fourth treatments. Hypertensive crisis still occurred in the third but not in the fourth treatment. He required the 5th treatment due to tumor progression but he developed another hypertensive crisis despite additional alpha blockade right before treatment. The patient became very concerned for potential hypertensive crisis in the 6th treatment. He was treated with escalating dose of metyrosine for 4 days before the treatment and did not develop hypertensive crisis. No additional alpha blockade was given. <h3>Discussion</h3> PRRT may directly stimulate catecholamine release or cause tumor lysis in patients with metastatic pheochromocytoma, resulting in hypertensive crisis. <h3>Conclusion</h3> PRRT-induced hypertensive crisis can happen in patients treated for metastatic pheochromocytoma. If hypertensive crisis occurs, caution should be taken on the subsequent treatments. Additional alpha blockade right before lutetium-177 DOTATATE infusion may help; in challenging cases, short-term metyrosine use may prevent PRRT-induced hypertensive crisis.