Oral propranolol for infantile hemangiomas: a prospective study on the role of 48-hour Holter monitoring in additional safety assessment

Safety assessment of propranolol for infantile hemangioma: a study in an Asian population

OBJECTIVE

To evaluate the safety of initiating and maintaining propranolol therapy for infantile hemangioma (IH) and the safety of different doses.

METHODS

The retrospective analysis included 336 consecutive cases of infants with IH treated between January 2016 and October 2017. The patients were assessed in the hospital at the initiation of the therapy and later in outpatient settings during the therapy. The monitoring included blood pressure (BP), heart rate (HR), blood glucose, hepatic and renal function, myocardial enzymes and serum lipids. Cardiac examinations in the outpatient follow-up included electrocardiography, ultrasound echocardiography, height, weight and head circumference.

RESULTS

Propranolol decreased BP and HR at the initiation of treatment. The incidences of sinus bradycardia and hypoglycemia increased with the time of administration. Mean height, weight and head circumference were not affected during the treatment. The incidence of PR prolongation was 0%-5.7%. The effect of propranolol on the cardiovascular system, metabolism and physical development was not affected by its dose.

CONCLUSION

Oral propranolol is a safe treatment for IH. Serious side effects were not observed. Attention should be paid to the side effects during clinical treatment.

Limited utility of repeated vital sign monitoring during initiation of oral propranolol for complicated infantile hemangioma

BACKGROUND

Initial propranolol recommendations for infantile hemangioma published in 2013 were intended as provisional best practices to be updated as evidence-based data emerged.

METHODS

A retrospective multicenter study was performed to evaluate utility of prolonged monitoring after first propranolol dose and escalation(s). Inclusion criteria included diagnosis of hemangioma requiring propranolol of greater than or equal to 0.3 mg/kg per dose, younger than 2 years, and heart rate monitoring for greater than or equal to 1 hour. Data collected included demographics, dose, vital signs, and adverse events.

RESULTS

A total of 783 subjects met inclusion criteria; median age at initiation was 112 days. None of the 1148 episodes of prolonged monitoring warranted immediate intervention or drug discontinuation. No symptomatic bradycardia or hypotension occurred during monitoring. Mean heart rate change from baseline to 1 hour was -8.19/min (±15.54/min) and baseline to 2 hours was -9.24/min (±15.84/min). Three preterm subjects had dose adjustments because of prescriber concerns about asymptomatic vital sign changes. No significant difference existed in pretreatment heart rate or in heart rate change between individuals with later adverse events during treatment and those without.

CONCLUSION

Prolonged monitoring for initiation and escalation of oral propranolol rarely changed management and did not predict future adverse events. Few serious adverse events occurred during therapy; none were cardiovascular.

Clinical Significance of Screening Electrocardiograms for the Administration of Propranolol for Problematic Infantile Hemangiomas

Objective

Low-dose nonselective β blockade is an effective treatment for problematic infantile hemangioma (PIH). Screening electrocardiograms (ECG) are performed prior to the initiation of propranolol to minimize the risk of exacerbating undiagnosed heart block. How ECG results affect subsequent propranolol usage and patient management remains unclear. We examined the value of ECG prior to propranolol therapy in a quaternary pediatric hospital.

Methods

A retrospective chart review was performed on all infants who received propranolol (2 mg/kg/day divided three times daily) to treat PIH at Arkansas Children's Hospital from Sept. 2008 to Sept. 2015. All available demographic, historical, and clinical data were obtained. ECGs and echocardiographic data were reviewed and summarized. A pediatric cardiologist read all ECGs.

Results

A total of 333 patients (75% female) received propranolol therapy. ECG information was available for 317 (95%). Abnormal findings were present on 44/317 (13.9%) of study ECGs. The most common abnormal finding was "voltage criteria for ventricular hypertrophy" (n = 35, 76.1%). Two patients had abnormal rhythms; one had first-degree atrioventricular (AV) block, and one had occasional premature atrial contractions. Of the 31 patients who underwent echocardiograms, 20 (35%) were abnormal. 2.9% of infants with PIH treated with propranolol required a follow-up with a cardiologist. No patient was precluded from taking propranolol due to the findings on screening ECG.

Conclusions

Screening ECGs prior to propranolol therapy are abnormal in nearly 14% of patients with PIH but are unlikely to preclude therapy. In the absence of prior cardiac history, this cohort offers further evidence suggesting that screening ECGs may be of limited value in determining the safety of propranolol in otherwise healthy infants with PIH.

Hemangiol in infantile haemangioma: A paediatric post-marketing surveillance drug study

AIM

Infantile haemangioma (IH) is the most common benign tumour in children. Since 2014, propranolol has become the first-choice therapy and currently Hemangiol is the only approved drug for complicated haemangioma. This post-marketing study reports the use of Hemangiol for IH in paediatric practice.

METHOD AND RESULTS

From January 2014 to November 2018, 94 children (median age 4 [0; 21] months; 75% female) treated with Hemangiol for proliferative IH were enrolled in the study. The systematic paediatric cardiology consultation never contraindicated beta-blockers. Two Hemangiol initiation protocols were used: a conventional ambulatory 3-week titration phase protocol (n = 76, 80.9%), and a rapid initiation protocol with a 48-hour dose escalation in conventional hospitalization for severe proliferative or ulcerated IH (n = 18, 19.1%). In both protocols, the haemodynamic tolerance was good. The mean maintenance dose of Hemangiol was 2.7 ± 0.8 mg/kg/day, with a median treatment duration of 7 [1.5; 19] months. Adverse events (AEs) have been found in 25 (26,6%) patients, including 8 (8.5%) patients with serious AEs (uncontrolled bronchial hyperreactivity, n = 5; serious hypoglycaemia, n = 3). Some patients had one or more AEs, a total of 24 nonserious AEs was reported in 19 patients (sleep disturbances, n = 9; respiratory disorders, n = 5; digestive disorders, n = 6). No cardiac adverse event was reported.

CONCLUSION

This post-marketing surveillance drug study supports the good tolerance of Hemangiol in children with IH. A rapid initiation protocol is of interest when treatment is urgent. The pretherapeutic paediatric cardiology consultation should not be systematic but only indicated for specific patients. CLINICALTRIALS.GOV: NCT04105517.

Evaluating the Safety of Oral Propranolol Therapy in Patients With PHACE Syndrome

Importance

Oral propranolol is widely considered to be first-line therapy for complicated infantile hemangioma, but its use in patients with PHACE (posterior fossa malformations, hemangioma, arterial anomalies, cardiac defects, eye anomalies) syndrome has been debated owing to concerns that the cardiovascular effects of the drug may increase the risk for arterial ischemic stroke.

Objective

To assess the incidence of adverse events among patients with PHACE syndrome receiving oral propranolol for infantile hemangioma.

Design, Setting, and Participants

This multicenter retrospective cohort study assessed the incidence of adverse events among 76 patients with PHACE syndrome receiving oral propranolol for infantile hemangioma at 11 tertiary care, academic pediatric dermatology practices. Medical records from January 1, 2010, through April 25, 2017, were reviewed.

Exposures

Patients received oral propranolol, 0.3 mg/kg/dose or more.

Main Outcomes and Measures

The main outcome was the rate and severity of adverse events occurring throughout the course of treatment with oral propranolol, as documented in the medical records. Adverse events were graded from 1 to 5 using a scale derived from the Common Terminology Criteria for Adverse Events and were considered to be serious if they were grade 3 or higher.

Results

A total of 76 patients (59 girls and 17 boys; median age at propranolol initiation, 56 days [range, 0-396 days]) met the inclusion criteria. There were no reports of serious adverse events (ie, stroke, transient ischemic attack, or cardiovascular events) during treatment with oral propranolol. A total of 46 nonserious adverse events were reported among 29 patients (38.2%); the most commonly reported nonserious adverse events were sleep disturbances and minor gastrointestinal tract and respiratory tract symptoms. In a comparison with 726 infants who received oral propranolol for hemangioma but did not meet criteria for PHACE syndrome, there was no significant difference in the rate of serious adverse events experienced during treatment (0 of 76 patients with PHACE syndrome and 3 of 726 patients without PHACE syndrome [0.4%]).

Conclusions and Relevance

This study found that oral propranolol was used to treat infantile hemangioma in 76 patients with PHACE syndrome and that no serious adverse events were experienced. These data provide support for the safety of oral propranolol in this patient population.

Propranolol Treatment for Infantile Hemangiomas: Short-Term Adverse Effects and Follow-Up to Age Two

Objective

To analyse the short-term adverse effects (AEs) of propranolol in the treatment of infantile hemangiomas (IHs) and their relevant factors, as well as the relationship between child growth and propranolol.

Methods

A total of 506 patients with confirmed or suspected IHs were enrolled, and a total of 439 cases were included in the study. Short-term AEs were analysed using single-factor analysis and binary logistic regression. Out of 439 patients, 292 were enrolled to examine the effect of propranolol on 2-year-olds' height and body weight (BW), by comparison with reference range and among groups. Spearman rank correlation analysis was used to determine the relationship between BW, height, and duration of propranolol treatment.

Results

Among 439 patients, 70 (16.0%) experienced AEs. Among them, 48 had gastrointestinal (GI) symptoms, 23 had central nervous system (CNS) symptoms, 8 had both symptoms above, and 7 had other symptoms. Most of the AEs occurred on the starting day (day 0), and 6 children's AEs were transient. Starting age of no older than 3 months led to more CNS symptoms, and starting age of older than 3 months was a protective factor against CNS symptoms, with an OR value of 0.303 (0.117–0.783). Height and BW of 292 two-year-old children were no less than the reference levels, although those of 3 females and 1 male were less than the average −2 standard deviation (−2SD). The height and BW of the children at the age of two was not related to the length of time of propranolol treatment.

Conclusion

Oral propranolol has a good tolerance in the treatment of IHs. Oral propranolol exerts more adverse effects on the CNS of lower age children, and it has exhibited no effect on the growth of two-year-old children.

Successful treatment of cardiac haemangiomas with oral propranolol: a case series of two patients

BACKGROUND

Cardiac haemangiomas are extremely rare tumours with equivocal surgical outcomes. Haemangiomas appearing on other sites of the body have been successfully treated with oral propranolol. To the best of our knowledge, such treatment has not been tried to date for cardiac location of haemangiomas.

CASE SUMMARY

We report two cases of neonatal cardiac haemangiomas, and we describe their presentation and characteristics, as well as how these were successfully treated with oral propranolol, with complete regression of the tumours within the 1st year of life.

DISCUSSION

Despite the rarity of cardiac haemangiomas, their presentation and complications could be dramatic with side-effects spanning from intracardiac space occupying phenomena to Kasabach-Merritt syndrome. Propranolol therapy, having been established for long now in the treatment of skin haemangiomas, should also be considered in cases of cardiac haemangiomas, particularly in the neonatal and infantile population.

Infantile hemangiomas: what have we learned from propranolol?

PURPOSE OF REVIEW

Infantile hemangiomas are the most common vascular tumor of infancy. Treatment of infantile hemangiomas was revolutionized when propranolol, a nonselective β-blocker, was reported to be effective therapy. In this review, we highlight the lessons learned using propranolol to treat infantile hemangiomas. We also describe the ongoing effort to understand the mechanism of action of propranolol.

RECENT FINDINGS

Although the pathogenesis of infantile hemangiomas is not fully understood, maternal hypoxic stress and embolization of placental tissue are suggested to be critical components in their development. The mechanism of action of propranolol remains unclear, however various molecular mechanisms are detailed in this review. Propranolol treatment remains a well tolerated therapy, with low risk of adverse events or long-term neurocognitive effects. Dosing recommendations and optimal treatment duration vary among studies, and should be altered in patients with certain medical conditions such as Posterior fossa anomalies, Hemangioma, Arterial lesions, Cardiac abnormalities/coarctation of the aorta, Eye anomalies (PHACE) syndrome.

SUMMARY

Propranolol is a well tolerated and effective treatment for infantile hemangiomas. The efficacy of propranolol for infantile hemangiomas is clear, however questions pertaining to mechanism of action, pretreatment risk stratification, and optimal dosing remain unanswered. The guidelines for managing infantile hemangiomas with propranolol will continue to adapt as research catches up to clinical experience.

Effectiveness and safety of polidocanol for the treatment of hemangiomas and vascular malformations: A meta-analysis

A meta-analysis was conducted to investigate the efficacy and safety of polidocanol versus other conventional therapies in treating hemangiomas (HMs) and vascular malformations (VMs). Literature search was conducted in the Cochrane, Embase, PubMed, Web of Science, CNKI, CBM, VIP, and WanFang databases until March 5, 2017. A meta-analysis was conducted using Revman 5.3 software. A total of 19 randomized controlled trials (RCTs) involving 1,514 participants met the inclusion criteria. Regarding the effectiveness, statistically significant differences were observed between polidocanol and all the independent treatments (p = .006), but not between polidocanol and pingyangmycin (p = .16). Combination therapy of polidocanol with any other conventional treatments (p = .0001), pingyangmycin (p = .005) or hemoclip (p = .008) elicited a better response compared to treatment with these treatments independently. A meta-analysis on the risk of adverse events (AEs) showed a lower risk for polidocanol versus other treatments, for example, all the conventional treatments used independently (p < .00001) and pingyangmycin (p < .00001). Combination therapy of polidocanol with pingyangmycin also yielded a significantly lower risk of AEs (p < .00001). Polidocanol is at least as effective as other conventional therapies on HMs and VMs (especially venous malformations). The former is much safer. Combining its use with other treatments may produce excellent results. Our study provides strong evidence supporting the use of polidocanol for HMs and VMs.