Propranolol in use for treatment of complex infant hemangiomas: literature review regarding current guidelines for preassessment and standards of care before initiation of therapy

Immediate possible adverse event rates in infants treated with oral propranolol for infantile haemangiomas at an Australian urban tertiary hospital between 2016 and 2019

BACKGROUND/OBJECTIVES

Infantile haemangiomas (IH) are common benign tumours of childhood. The current guideline recommended treatment is oral propranolol, the use of which for IH is relatively recent and there are no safety audits in Australian children published. As a result, it is a primarily inpatient initiated treatment. The aim of this study was to examine the short-term complication rates in infants treated with oral propranolol for IH.

METHODS

Retrospective case note review of IH patients initiated on oral propranolol admitted to the day-unit of tertiary metropolitan hospital in an Australia capital city, from January 2016 to December 2019.

RESULTS

Overall, 72 children were included in the study. Mean age at time of admission was 3.8 ± 2 months. Eight patients (11.1%) experienced complications during their initiation admission. Pulmonary complications (oxygen desaturation, wheeze, increased respiratory rate) was the most common type. No children required high-dependency or intensive care unit admission. The children who experienced complications had a mean age of 2.4 ± 1.2 months; t-test of equality of means found a relationship between propranolol-associated complication rate and age (p = 0.007). All other patient or admission characteristics were not associated with complication events (all p > 0.05).

CONCLUSIONS

Propranolol is a safe, effective and well-tolerated treatment in Australian children with IH. This study demonstrates younger infants will most likely benefit from inpatient initiation. More research needs to be done to characterise the risk profile of propranolol initiation for IH.

Management of Head and Neck Hemangiomas in Adults: Oral Propranolol Versus Oral Itraconazole in Conjugation with Injection Sodium Tetra Decyl Sulphate

Management of head and neck hemangiomas with oral propranolol versus oral itraconazole in conjugation with injection sodium tetra decyl sulphate. This prospective parallel clinical trial was done to check for the effectiveness of oral propranolol and oral itraconazole when used in conjugation with inj. sodium tetra decyl sulphate in treatment of head and neck haemangiomas in adult patients visiting department of ENT and head and neck surgery, VIMSAR, Burla. All the patients visiting the department with hemangioma (diagnosed clinically and by FNAC) were considered and only those who gave written informed consent and were according to our inclusion and exclusion criteria were included into the study as subjects. Dimension (length, width and hemi-circumference) of the haemangiomas were measured using disposable paper taper measures. Depth of the hemangioma was calculated based on formula and using that volume was calculated both at baseline and after 8 weeks of drug administration. Data so collected was entered into Microsoft Office Excel 2013 and statistical analysis was performed using SPSS Version 20.0. Descriptive statistics was calculated and student's t test (paired and unpaired) was used to compare within the group (before and after) and between the groups respectively. Statistical significance was set at p ≤ 0.05. Both the groups showed statistically significant volume reduction in the lesions [p < 0.018 (propranolo + sodium tetra decyl sulphate), p < 0.025 (itraconazole + sodium tetra decyl sulphate)]. The mean decrease in volume in propranolol group was 91.92% and that in itraconazole group was 88.97%. There was no statistical difference between the final outcome of both the groups (p < 0.766) but 3 patients on propranolol had complete resolution while 1 patient on itraconazole had complete resolution of the lesion. Oral propranolol and itraconazole are both effective and safe in hemangioma in adults. The combination with inj. sodium tetra decyl sulphate has a (1) favorable impact on decreasing the overall duration of treatment. (2) Aiding in complete resolution of lesions (especially < 3 cm). Propranolol has an edge over itraconazole (more no of tumors had complete resolution).

Deep coma in a child treated with propranolol for infantile hemangioma

Background

Propranolol hydrochloride is the first-line agent recommended for the treatment of infantile hemangiomas (IH). Serious adverse effects of propranolol therapy for hemangiomas are infrequent.

Case presentation

We report a case presented in deep hypoglycemic coma during his treatment with propranolol for IH. Through our case report and the review of the literature, we aimed to underline the importance of recognizing adverse effects during propranolol therapy. Although propranolol has a long history of safe and effective use in infants and children, pediatricians should be aware that life-threatening adverse effects can happen during propranolol therapy for IH.

Conclusion

Early identification of these adverse effects can be of great importance for patient management and prognosis. It must certainly be noted that not just early identification among doctors, but education for parents is crucial.

Propranolol pharmacokinetics in infants treated for Infantile Hemangiomas requiring systemic therapy: Modeling and dosing regimen recommendations

Propranolol has become the first choice therapy for complicated Infantile Hemangiomas (IH). The pharmacokinetics of propranolol were evaluated after repeated oral administration of a new pediatric solution of propranolol at 3 mg kg⁻¹ day⁻¹ given twice daily (BID) in infants (77‐243 days) with IH. A population model was built to describe the pharmacokinetics of propranolol in infants and to simulate different dosing regimens. One hundred and sixty‐seven plasma concentrations from 22 infants were used in the population analysis. Weight effect was tested on apparent clearance and volume of distribution. Monte‐Carlo simulations were performed for 4 dosing regimens: BID dosing with irregular or strict 12‐hour intervals and 2 different 3 time daily dosing (TID) regimens. The best model was a one‐compartment model with first‐order absorption and elimination rates. The weight affected the clearance but not the volume. Typical oral clearance was estimated at 3.06 L hour⁻¹ kg⁻¹ (95% CI: 1.14‐8.61 L hour⁻¹ kg⁻¹), close to adult clearance data. When regular BID dosing was compared to TID or irregular BID regimens, simulated median Cmin and Cmax were <20% different. To conclude, a model using a weight allometric function on clearance was established and confirmed that the dose in mg/kg should be used without adaptation by range of age in treatment of complicated IH. The simulations support the use of a BID dosing preferably to a TID dosing thanks to close Cmin and Cmax at steady state between both regimen and showed the possibility of irregular BID dosing, allowing early administration in the evening when needed.

Mesenteric infantile hemangioma: diagnostic work-up

A very rare localization of infantile hemangioma (IH) is mesentery. It may manifest with intra-luminal or intra-peritoneal bleeding. Here there is the case of a 45-day-old infant, presenting with anemia and poor growth, subsequently referred to an uncommon hemangioma of the mesentery. As well as for most of IH, conservative treatment with only propranolol resulted in the disappearance of the lesion. Here we analyze ultrasound and magnetic resonance (MR) features of this uncommon lesion, trying to underline main characteristics at imaging in order to monitor the response to therapy.

Successful management of extremely high-output refractory congenital chylothorax with chemical pleurodesis using 4% povidone-iodine and propranolol: a case report

First‐line therapy for congenital chylothorax is conservative treatment. However, surgical intervention or chemical pleurodesis is required for refractory cases. With all the concerns regarding its complications, povidone–iodin provided a successful management for a high‐output congenital chylothorax. However, renal and thyroid function must be monitored during treatment.

Blood Pressure Monitoring During the Induction and Maintenance Period of Propranolol Therapy for Complicated Infantile Hemangiomas: A Prospective Study of 109 Infants

BACKGROUND

Propranolol has become the first-line treatment for complicated infantile hemangiomas (CIHs) worldwide. Recommendations for monitoring infants undergoing propranolol therapy vary. Data on long-term blood pressure (BP) monitoring have not been reported before.

OBJECTIVE

The objective of the current study was to monitor BP in full-term infants during the induction and maintenance phase of propranolol therapy.

METHODS

BP was monitored prospectively in 109 infants (mean age 2.8 mos, range 1-5 mos) with CIHs during the induction (3-4 days in the hospital during up-dosing from 0.5 to 2.0 mg/kg/day) and maintenance (6 mos) phases of oral propranolol therapy.

RESULTS

Four children were excluded from the study because of sinus bradycardia (n = 2 [1.8%]) or lethargy (n = 2 [1.8%]). Mean systolic BP (SBP) decreased by 5 mmHg with the increase in propranolol dosage. Low (<5th percentile) SBP or diastolic BP (DBP) was observed in 2 of 105 children (1.9%) each. During the maintenance phase, 2 of 105 children (1.9%) had occasional SBP readings of less than 70 mmHg. No hypotension was observed after the third month of therapy. Low DBP (<36 mmHg) was recorded in 16 (15.2%) children after the first month, in 8.6% after the second, and in 2.9% during the third and fourth months of therapy. No patients exhibited clinical hypotension, bradycardia, or other known side effects of propranolol. Clinical response to therapy was excellent.

LIMITATIONS

Reference BP values were derived from published tables, not from an untreated control group.

CONCLUSIONS

In healthy full-term infants, propranolol (2 mg/kg/day divided in three doses) is well tolerated. No clinically significant hypotension was observed. We conclude that for otherwise healthy infants, BP monitoring during long-term propranolol therapy for CIHs is not necessary.

Retrospective follow up of gross motor development in children using propranolol for treatment of infantile haemangioma at Sydney Children's Hospital

Questions have been raised as to whether propranolol, which crosses the blood-brain barrier, when used early in life may have an adverse effect on gross motor development. A retrospective survey asking questions about gross motor development was sent to the families of children who had been prescribed oral propranolol for infantile haemangioma at Sydney Children's Hospital between 2008 and 2013. It was found that of the 84 patients surveyed, four were delayed in walking unassisted. There was a statistically significant influence if the child was taking other medications which included prednisolone, vincristine, omeprazole, ranitidine, salbutamol, Flixotide, Timoptol and antibiotics. This was not further analysed in this study because of the low numbers involved. There was no statistically significant influence of gestational age, birth weight or length of time on propranolol. This study adds to the retrospective data available; however large-scale prospective studies are needed to identify unexpected long-term side-effects.