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Gokalp G, Nalbant T, Berksoy E, Bardak S, Demir G, Demir S, Sahin O, Hocaoglu N. Is hypoglycemia really observed in pediatric beta-blocker intoxications? A case-control study. Arch Pediatr 2021; 29:56-60. [PMID: 34848131 DOI: 10.1016/j.arcped.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/14/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Beta-blocker (BB) intoxications are common in both childhood and adulthood. In the case of poisoning, bradycardia, hypotension, ventricular dysrhythmias, mental status changes, seizures, hypoglycemia, and bronchospasm may occur. Effects on the cardiovascular system are commonly seen, but hypoglycemia is not frequently observed in clinical practice. In this study, we aimed to answer the question, "Is hypoglycemia more commonly observed in BB intoxications than in other intoxications?" METHOD This was a case-control study conducted in a pediatric emergency department of a university hospital. The case group (Group 1) consisted of cases with BB poisonings and the control group (Group 2) consisted of cases with selective serotonin receptor inhibitor (SSRI) poisonings. Data were obtained from patient files. We recorded the blood glucose levels (BGLs) of all patients on admission to the emergency department and at the 1-, 6-, and 24-h follow-up. The amounts of BBs received by the cases were compared with the specific toxic doses of each drug. The data obtained were analyzed using the Statistical Package for the Social Sciences 22 (SPSS.22) program. Mean and standard deviation for numerical values and frequency for categorical data are reported; at test, chi-square test, and ANOVA tests were used for the analysis. RESULTS The study comprised 40 patients (Group 1) and 40 controls (Group 2). The mean serum BGLs of patients in Group 1 at admission and at the 1-, 6-, and 24-h follow-up were 107.2 ± 46.3 mg/dl, 86.3 ± 20.1 mg/dl, 88.6 ± 28.4 mg/dl, and 86.5 ± 23.7 mg/dl, respectively. The mean values of Group 2 cases were 100 ± 39.5 mg/dl, 92.1 ± 30 mg/dl, 91±28 mg/dl, and 127.8 ± 60.7 mg/dl, respectively, at admission and at the 1-, 6-, and 24-h follow-up (p = 0.4, p < 0.001, p = 0.7, and p < 0.001, respectively). The mean BGLs of patients who were exposed to propranolol at admission and at the 1-, 6-, and 24-h follow-up were significantly lower than those of the patients who had taken different BBs in Group 1. No linear correlation was found between the percentage of exposure to BB toxic doses and BGLs. CONCLUSION Our study showed that the BGLs of patients receiving BBs could be lower, but they were not at a level that would have serious consequences. Nevertheless, the BGLs of all cases of intoxication should be monitored closely.
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Affiliation(s)
- Gamze Gokalp
- Izmir Katip Celebi University Faculty of Medicine: Izmir Katip Celebi Universitesi Tip Fakultesi, Turkey; Dokuz Eylül University: Dokuz Eylul Universitesi Institute of Health Servises, Medical Pharmacology Depatment, Toxicology Devision, Turkey.
| | - Tugce Nalbant
- Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir, Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Emel Berksoy
- Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir, Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Sefika Bardak
- Izmir Tepecik Egitim ve Arastirma Hastanesi: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik, Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Gulsah Demir
- Izmir Tepecik Egitim ve Arastirma Hastanesi: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik, Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Sule Demir
- Izmir Tepecik Egitim ve Arastirma Hastanesi: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik, Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Orhan Sahin
- Dokuz Eylül University: Dokuz Eylul Universitesi Institute of Health Servises, Medical Pharmacology Depatment, Toxicology Devision, Turkey
| | - Nil Hocaoglu
- Dokuz Eylül University: Dokuz Eylul Universitesi Institute of Health Servises, Medical Pharmacology Depatment, Toxicology Devision, Turkey; Dokuz Eylul University: Dokuz Eylul Universitesi, Faculty of Medicine, Pharmacology Depatment, Medical Toxicology Devision, Turkey
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Frongia G, Byeon JO, Arnold R, Mehrabi A, Günther P. Cardiac diagnostics before oral propranolol therapy in infantile hemangioma: retrospective evaluation of 234 infants. World J Pediatr 2018; 14:254-258. [PMID: 29796952 DOI: 10.1007/s12519-018-0137-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/07/2017] [Accepted: 06/07/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The indication and extent of cardiac screening before oral propranolol therapy (OPT) in patients with infantile hemangioma (IH) has been challenged. In this study, we evaluated pre-OPT cardiac diagnostics in a pediatric IH cohort in our department. METHODS Retrospective chart review of infants ≤ 12 months old with IH undergoing OPT. The diagnostics prior to OPT, occurrence of complications, and outcome were recorded. RESULTS A total of 234 patients were evaluated. The mean age at the onset of OPT was 4.2 ± 0.3 months, the average duration of OPT was 6.1 ± 0.1 months, and the average follow-up was 12.3 ± 0.7 months. Echocardiograms and electrocardiograms were performed prior to OPT in all patients. One hundred and three (44.0%) echocardiograms revealed pathological findings, 19 (8.1%) of which were minor (including atrial septal defects, pulmonary stenosis, and patent ductus arteriosus). Pathological findings were observed in 17 (7.3%) of electrocardiograms, only one (0.4%) of which was minor (suspected cardiac arrhythmia, subsequently excluded by long-term electrocardiogram analysis). These findings did not contraindicate OPT and no severe adverse events associated with OPT occurred during the follow-up period. CONCLUSIONS Routine cardiac screening by electrocardiogram and echocardiogram before OPT is debatable and not routinely indicated in children with IH. Further studies are necessary to draw definite conclusions on the reasonable indication and extent of this diagnostic approach.
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Affiliation(s)
- Giovanni Frongia
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Ji-Oun Byeon
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Raoul Arnold
- Department of Pediatric Cardiology, Center for Pediatrics and Adolescent Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Pharmacological therapies for infantile hemangiomas: A clinical study in 853 consecutive patients using a standard treatment algorithm. Sci Rep 2016; 6:21670. [PMID: 26876800 PMCID: PMC4753681 DOI: 10.1038/srep21670] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 01/27/2016] [Indexed: 11/20/2022] Open
Abstract
Infantile hemangiomas are the most common infantile benign vascular tumor. While most infantile hemangiomas proliferate then involute, some may persist and require treatment for reasons including risk of disfigurement or functional impairment. Treatments currently include observation, pharmacological therapy, laser, cryosurgery, surgery and radiotherapy. Although pharmacological therapy is a well accepted treatment option, limited studies have evaluated the efficacy of different drug therapies. In this study, we compare different pharmacological modalities in the management of infantile hemangiomas. The study included 853 infants with proliferative infantile hemangiomas who were treated with topical timolol, oral propranolol, intralesional pingyangmycin, or intravenous vincristine from 2009 to 2012. Treatment stratification was based on clinical severity of the tumor. Response to the treatment was clinically evaluated and graded as: excellent, good, poor, or no response. Response to pharmacological therapies was excellent in almost all infantile hemangiomas. In addition, patients younger than 8 months responded highly to pharmacological treatment (89.1%), while patients older than 8 months were less responsive to treatment (36.3%). There were no instances of life-threatening complications. Overall, these findings support the efficacy of timolol, propranolol, pingyangmycin and vincristine in the treatment of infantile hemangiomas, especially in the youngest patient cohort (8 months or younger).
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Koponen M, Marjamaa A, Hiippala A, Happonen JM, Havulinna AS, Salomaa V, Lahtinen AM, Hintsa T, Viitasalo M, Toivonen L, Kontula K, Swan H. Follow-up of 316 molecularly defined pediatric long-QT syndrome patients: clinical course, treatments, and side effects. Circ Arrhythm Electrophysiol 2015; 8:815-23. [PMID: 26063740 DOI: 10.1161/circep.114.002654] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/26/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inherited long-QT syndrome (LQTS) is associated with risk of sudden death. We assessed the clinical course and the fulfillment of current treatment strategies in molecularly defined pediatric LQTS type 1 and (LQT1) and type 2 (LQT2) patients. METHODS AND RESULTS Follow-up data covering a mean of 12 years were collected for 316 genotyped LQT1 and LQT2 patients aged 0 to 18 years. No arrhythmic deaths occurred during the follow-up. Finnish KCNQ1 and KCNH2 founder mutations were associated with fewer cardiac events than other KCNQ1 and KCNH2 mutations (hazard ratio [HR], 0.33; P=0.03 and HR, 0.16; P=0.01, respectively). QTc interval ≥500 ms increased the risk of cardiac events compared with QTc <470 ms (HR, 3.32; P=0.001). Treatment with β-blocker medication was associated with reduced risk of first cardiac event (HR, 0.23; P=0.001). Noncompliant LQT2 patients were more often symptomatic than compliant LQT2 patients (18% and 0%, respectively; P=0.03). Treatment with implantable cardioverter defibrillator was rare (3%) and resulted in reinterventions in 44% of cases. CONCLUSIONS Severe cardiac events are uncommon in molecularly defined and appropriately treated pediatric LQTS mutation carriers. β-Blocker medication reduces the risk of cardiac events and is generally well tolerated in this age group of LQTS patients.
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Affiliation(s)
- Mikael Koponen
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.).
| | - Annukka Marjamaa
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Anita Hiippala
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Juha-Matti Happonen
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Aki S Havulinna
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Veikko Salomaa
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Annukka M Lahtinen
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Taina Hintsa
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Matti Viitasalo
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Lauri Toivonen
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Kimmo Kontula
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
| | - Heikki Swan
- From the Heart and Lung Center, Helsinki University Central Hospital (M.K., A.M., M.V., L.T., H.S.), Children's Hospital, Helsinki University Central Hospital (A.H., J.-M.H.), Department of Medicine, Helsinki University Central Hospital (A.M.L., K.K.), and Institute of Behavioural Sciences, Psychology (T.H.), University of Helsinki, Helsinki, Finland; and Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., V.S.)
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Poterucha JT, Bos JM, Cannon BC, Ackerman MJ. Frequency and severity of hypoglycemia in children with beta-blocker-treated long QT syndrome. Heart Rhythm 2015; 12:1815-9. [PMID: 25929701 DOI: 10.1016/j.hrthm.2015.04.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypoglycemia is a potential side effect of beta-blockers; however, no cases have been reported in children with long QT syndrome (LQTS). OBJECTIVE The purpose of this study was to determine the frequency and severity of hypoglycemia among children with beta-blocker-treated LQTS. METHODS A retrospective study was performed to identify children with LQTS evaluated from 2000 to 2014 who developed symptomatic hypoglycemia while being treated with a beta-blocker. RESULTS Nine children (3%; 7 boys; average corrected QT interval 486 ± 35 ms) developed 13 episodes (0.005 events per 100 treatment years) of beta-blocker-associated hypoglycemia (mean initial glucose 21 ± 7 mg/dL), including 3 of 157 patients with LQTS type 1 (LQT1; 1.9%) and 6 of 105 with LQTS type 2 (LQT2; 5.7%). The mean age at hypoglycemic event was 3.5 ± 2 years (range 7 months to 9 years), involving nadolol in 6 cases (mean dose 1.4 ± 0.2 mg/kg/d) and propranolol in 3 (mean dose 2.7±1 mg/kg/d). Hypoglycemic events were more frequent in patients with LQT2 than in those with LQT1 (10 vs. 3 events; P = .02). Hypoglycemia-triggered seizures were observed in 6 patients, fasting ketoacidosis in 5, and 7 patients required hospitalization (mean of 3 ± 2 days). Decreased caloric intake before the event was identified in all patients and a concomitant viral infection in 3. CONCLUSION This is the largest single-center case series of beta-blocker-induced hypoglycemia. Clinicians should be cognizant of hypoglycemia symptoms in younger children during periods of poor appetite and during viral illness, and parents of these children should be educated about the signs and symptoms of hypoglycemia. A potential LQT2-hypoglycemia genotype-phenotype relationship warrants further investigation.
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Affiliation(s)
- Joseph T Poterucha
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - J Martijn Bos
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Bryan C Cannon
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael J Ackerman
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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Laranjo S, Costa G, Paramés F, Freitas I, Martins JD, Trigo C, Pinto FF. The role of propranolol in the treatment of infantile hemangioma. Rev Port Cardiol 2014; 33:289-95. [PMID: 24906291 DOI: 10.1016/j.repc.2013.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 10/10/2013] [Accepted: 10/19/2013] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Infantile hemangioma (IH) is one of the most common childhood tumors. There are various medical or surgical therapeutic options, all with suboptimal results. Recently, the successful use of propranolol for involution of IH was described. We report the results of a single-center experience with this therapeutic option. OBJECTIVE To prospectively assess the efficacy and safety of propranolol in children with infantile hemangioma. METHODS We performed a prospective analysis of clinical data of all patients with IH referred to a pediatric cardiology center for baseline cardiovascular assessment prior to propranolol therapy. Propranolol was given at a starting dose of 1 mg/kg/day and titrated to a target dose of 2-3 mg/kg/day according to clinical response. Efficacy was assessed through a photograph-based severity scoring scale. Safety was assessed by collecting data regarding significant side effects. RESULTS Starting in 2010, 30 patients (15 female) were referred for propranolol treatment of IH, at a median age of six months (1-63 months). The mean target propranolol dose was 2.8 mg/kg/day, with a mean duration of therapy of 12 months. All patients experienced significant reduction of IH size and volume. There were no side effects. CONCLUSIONS In our experience propranolol appears to be a useful and safe treatment option for severe or complicated IH, achieving a rapid and significant reduction in their size. No adverse effects were observed, although until larger clinical trials are completed, potential adverse events should be borne in mind and consultation with local specialists is recommended prior to initiating treatment.
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Affiliation(s)
- Sérgio Laranjo
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal.
| | - Glória Costa
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
| | - Filipa Paramés
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
| | - Isabel Freitas
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
| | - José Diogo Martins
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
| | - Conceição Trigo
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
| | - Fátima F Pinto
- Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
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Laranjo S, Costa G, Paramés F, Freitas I, Martins JD, Trigo C, Pinto FF. The role of propranolol in the treatment of infantile hemangioma. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2013.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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McSwiney E, Murray D, Murphy M. Propranolol therapy for cutaneous infantile haemangiomas initiated safely as a day-case procedure. Eur J Pediatr 2014; 173:63-8. [PMID: 23933667 DOI: 10.1007/s00431-013-2105-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 07/15/2013] [Indexed: 11/29/2022]
Abstract
Propranolol is emerging as the treatment of choice for high-risk infantile haemangiomas. Current protocols recommend overnight admission for initiation of propranolol as well as baseline investigations including electrocardiography (ECG) and echocardiography (ECHO). Our study examined the safety profile of propranolol for the treatment of infantile haemangiomas using a simplified day-case initiation protocol. We evaluated 20 consecutive patients commencing propranolol as a day case for the treatment of an infantile haemangioma over an 18-month period. Investigations were carried out according to our local protocol. Cardiac investigations were not routinely performed. Patients were observed for 2 h following administration of the first dose of propranolol (0.5 mg/kg orally). If no adverse effects were observed, patients were discharged on a daily dose of propranolol of 1 mg/kg, increased to 2 mg/kg on day 4. Patients were reviewed on the day ward on day 8. All haemangiomas requiring treatment were small to moderate in size (median maximum diameter 2.35 cm). Except for capillary blood glucose measurement, no patient required venepuncture for additional blood investigations. As all patients had a normal clinical examination, none required ECHO. An ECG was performed on just one patient. No adverse reactions were observed following administration of propranolol. All patients were discharged home on the same day. No serious adverse events were reported at follow-up. We demonstrate that with targeted cardiac screening, propranolol can be safely initiated on a day-case basis for the treatment of small- to moderate-sized infantile haemangiomas.
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Affiliation(s)
- Edward McSwiney
- Department of Paediatrics, Cork University Hospital, Cork, Ireland,
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Puttgen KB, Summerer B, Schneider J, Cohen BA, Boss EF, Bauman NM. Cardiovascular and blood glucose parameters in infants during propranolol initiation for treatment of symptomatic infantile hemangiomas. Ann Otol Rhinol Laryngol 2013; 122:550-4. [PMID: 24224397 DOI: 10.1177/000348941312200903] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We sought to determine the effect of propranolol on cardiovascular and blood glucose parameters in infants with symptomatic infantile hemangiomas who were hospitalized for initiation of treatment, and to analyze adverse effects of propranolol throughout the course of inpatient and outpatient treatment. METHODS A retrospective cohort analysis was performed on 50 infants (age less than 12 months) with symptomatic infantile hemangiomas who were hospitalized for propranolol initiation between 2008 and 2012. Demographic data and disease characteristics were recorded. Systolic and diastolic blood pressures, heart rate, blood glucose values, and adverse events recorded during hospitalization were analyzed. An additional cohort of 200 consecutively treated children was also assessed for adverse events associated with outpatient propranolol use. RESULTS The median age among the inpatient cohort was 3.4 months (range, 0.8 to 12.0 months). Infants older than 6 months were more likely to exhibit bradycardia than were younger infants (p < 0.001). Hypotensive and/or bradycardic periods were infrequent and were not associated with observable clinical symptoms. The mean systolic and diastolic blood pressures and the mean heart rate decreased significantly from day 1 of hospitalization to day 2 (p = 0.004; p = 0.008; p < 0.001), but not from day 2 to day 3, when the propranolol dose was increased to target. Hypoglycemia was rare (0.3% incidence.) Among the 250 outpatients, 2 infants developed lethargy and hypoglycemia during a viral illness and recovered without sequelae. One infant experienced recurrent bronchospasm with viral illnesses and required concomitant bronchodilator therapy. CONCLUSIONS Frequent deviations from normal ranges of blood pressure and heart rate occur upon initiation of propranolol, but are clinically asymptomatic. These findings support that outpatient initiation of propranolol in healthy, normotensive infants appears to be a relatively safe alternative to inpatient initiation. Hypoglycemia is rare, but can occur throughout the treatment period; parent counseling is of paramount importance.
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Affiliation(s)
- Katherine B Puttgen
- Department of Dermatology, Johns Hopkins University School of Medicine, 200 N Wolfe St, Unit 2107, Baltimore, MD 21287, USA
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Xiao Q, Li Q, Zhang B, Yu W. Propranolol therapy of infantile hemangiomas: efficacy, adverse effects, and recurrence. Pediatr Surg Int 2013; 29:575-81. [PMID: 23519547 PMCID: PMC3657346 DOI: 10.1007/s00383-013-3283-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2013] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the efficacy, adverse effects, and recurrence of oral propranolol for treatment of infantile hemangioma. METHODS Participants were treated with oral propranolol three times daily, with inpatient monitoring of adverse effects. The starting dosage was 2 mg/kg per day, which had been for the remaining duration of treatment. Therapy duration was planned for 4-6 months; if there was significant relapse, the period of treatment was extended. A photograph based severity scoring assessment was performed by three observers to evaluate efficacy by visual analog scale (VAS). RESULTS Sixty-one infants [median age 3.3 (1.2-8.1) months] were included in the study. The median follow-up-time was 15 (6-20) months and 53 patients completed treatment at a median age of 10.3 (8.4-18.1) months, after a duration of 8.5 (4.5-14) months. In all patients, there was significant fading of color [with a VAS of -9 (-6 to -9) after 6 months] and significant decrease in size of the infantile hemangiomas [with a VAS of -8 (-3 to -10) after 6 months]. We did not observe any life-threatening adverse effects. The therapy was interrupted due to temporary aggravation of pre-existing bronchial asthma in one child. Four cases presented partial recurrences. CONCLUSIONS Oral propranolol 2 mg/kg per day was a well-tolerated and effective treatment, mild adverse effects, and low recurrence for infantile hemangiomas. Propranolol should now be used as a first-line treatment in hemangiomas when intervention is required. Also, prospective studies should be needed in determining the most effective treatment dosage, optimum treatment duration, and exact mechanism of action of propranolol in future.
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Affiliation(s)
- Qiang Xiao
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
| | - Qin Li
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
| | - Bin Zhang
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
| | - Wenlin Yu
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
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Meyers RS, Siu A. Pharmacotherapy Review of Chronic Pediatric Hypertension. Clin Ther 2011; 33:1331-56. [DOI: 10.1016/j.clinthera.2011.09.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/31/2011] [Accepted: 09/05/2011] [Indexed: 12/16/2022]
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Adverse effects of propranolol when used in the treatment of hemangiomas: a case series of 28 infants. J Am Acad Dermatol 2011; 65:320-327. [PMID: 21601311 DOI: 10.1016/j.jaad.2010.06.048] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 06/11/2010] [Accepted: 06/13/2010] [Indexed: 01/01/2023]
Abstract
BACKGROUND Infantile hemangioma (IH) is a frequently encountered tumor with a potentially complicated course. Recently, propranolol was discovered to be an effective treatment option. OBJECTIVE To describe the effects and side effects of propranolol treatment in 28 children with (complicated) IH. METHODS A protocol for treatment of IH with propranolol was designed and implemented. Propranolol was administered to 28 children (21 girls and 7 boys, mean age at onset of treatment: 8.8 months). RESULTS All 28 patients had a good response. In two patients, systemic corticosteroid therapy was tapered successfully after propranolol was initiated. Propranolol was also an effective treatment for hemangiomas in 4 patients older than 1 year of age. Side effects that needed intervention and/or close monitoring were not dose dependent and included symptomatic hypoglycemia (n = 2; 1 patient also taking prednisone), hypotension (n = 16, of which 1 is symptomatic), and bronchial hyperreactivity (n = 3). Restless sleep (n = 8), constipation (n = 3) and cold extremities (n = 3) were observed. LIMITATIONS Clinical studies are necessary to evaluate the incidence of side effects of propranolol treatment of IH. CONCLUSIONS Propranolol appears to be an effective treatment option for IH even in the nonproliferative phase and after the first year of life. Potentially harmful adverse effects include hypoglycemia, bronchospasm, and hypotension.
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Breur JMPJ, de Graaf M, Breugem CC, Pasmans SGMA. Hypoglycemia as a result of propranolol during treatment of infantile hemangioma: a case report. Pediatr Dermatol 2011; 28:169-71. [PMID: 20738795 DOI: 10.1111/j.1525-1470.2010.01224.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Propranolol is a new and promising treatment for hemangiomas of infancy. We report of a patient in whom steroid maintenance therapy is successfully tapered after introduction of propranolol. This patient, however, developed symptomatic hypoglycemic events presumably because of a concurrent deficiency of epinephrine and cortisol as a direct result of both beta-blockage by propranolol and adrenal insufficiency as a result of prednisone use. Extreme care should be taken in patients treated with both propranolol and prednisone as they are at increased risk of hypoglycemia.
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Affiliation(s)
- Johannes M P J Breur
- Department of Pediatric Cardiology, Centre for Congenital Vascular Anomalies Utrecht, University Medical Centre Utrecht/Wilhelmina Children's Hospital, Lundlaan, Utrecht, The Netherlands.
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Cushing SL, Boucek RJ, Manning SC, Sidbury R, Perkins JA. Initial Experience With a Multidisciplinary Strategy for Initiation of Propranolol Therapy for Infantile Hemangiomas. Otolaryngol Head Neck Surg 2010; 144:78-84. [DOI: 10.1177/0194599810390445] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives. To outline a safe, standardized protocol for outpatient initiation of propranolol therapy for infantile hemangiomas. Study Design. Retrospective review. Setting. Academic tertiary care pediatric hospital. Subjects and Methods. Forty-nine infantile hemangioma patients were offered propranolol therapy and included in the study. Any patients requiring hospital admission were excluded. Screening consisted of cardiology evaluation, including electrocardiography and, when indicated, echocardiography. Target initiation dose was 2 to 3 mg/kg/d divided into 3 doses. Blood pressure and heart rate were initially monitored at baseline and 1 and 2 hours in clinic following initial dosing. A 3-hour time point was later added. Families received standardized instructions regarding home heart rate monitoring, side effects, and fasting. Results. Outpatient propranolol therapy was safely initiated in 39 of 44 patients (89%). Five patients required brief admission: 1 with clinical signs/symptoms of heart failure, 3 having airway involvement, and 1 for social reasons. Propranolol administration transiently reduced blood pressure; the maximal decrease occurred at 2 hours, prompting addition of a 3-hour time point to ensure recovery. No patients exhibited symptomatic hypotension, bradycardia, or heart failure. Conclusions. In most children with infantile hemangiomas, propranolol therapy can be safely initiated as an outpatient. Careful cardiovascular evaluation by an experienced clinician is essential for pretreatment evaluation, inpatient admission (when necessary), blood pressure and heart rate monitoring following initial dosing, and parent education. This standardized multidisciplinary outpatient initiation plan reduces the cost of initiating therapy compared with inpatient strategies while still providing appropriate monitoring for potential treatment complications. Further evaluation of propranolol therapy efficacy at the current dosing and duration of treatment continues.
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Affiliation(s)
- Sharon L. Cushing
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, Washington, USA
- Department of Otolaryngology, Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Robert J. Boucek
- Division of Cardiology, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Scott C. Manning
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, Washington, USA
- Department of Otolaryngology, Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Robert Sidbury
- Division of Dermatology, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Jonathan A. Perkins
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, Washington, USA
- Department of Otolaryngology, Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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Love JN, Sikka N. Are 1–2 tablets dangerous? Beta-blocker exposure in toddlers. J Emerg Med 2004; 26:309-14. [PMID: 15028329 DOI: 10.1016/j.jemermed.2003.11.015] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2003] [Revised: 09/17/2003] [Accepted: 11/03/2003] [Indexed: 11/24/2022]
Abstract
The common use and wide availability of beta-adrenergic blocking agents make them frequent ingestants for small children. Yet, there are no clear guidelines in the literature to direct the care of the toddler with the history of ingesting 1-2 tablets. With 40 years of extensive clinical experience, not one documented case of death or serious cardiovascular morbidity as a direct result of a beta-blocker exposure is to be found in an English language review for children under 6 years of age. As with children on chronic beta-blocker therapy, several cases of symptomatic hypoglycemia associated with a single acute propranolol exposure suggest a vulnerability to this complication. Though the risk to the toddler exposed to 1-2 tablets appears to be extremely small, several factors mitigate the actual risk to the child and the need for triage to a health care facility.
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Affiliation(s)
- Jeffrey N Love
- Department of Emergency Medicine, Georgetown University Hospital, Washington, DC 20057, USA
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Affiliation(s)
- H Chavez
- Department of Pediatric Emergency Medicine, Children's Hospital, St Paul, MN 55102, USA
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