Hypoglycemia and propranolol in pediatric behavioral disorders

Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents - assessment of adverse events in non-randomised studies

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood. The psychostimulant methylphenidate is the most frequently used medication to treat it. Several studies have investigated the benefits of methylphenidate, showing possible favourable effects on ADHD symptoms, but the true magnitude of the effect is unknown. Concerning adverse events associated with the treatment, our systematic review of randomised clinical trials (RCTs) demonstrated no increase in serious adverse events, but a high proportion of participants suffered a range of non-serious adverse events.

OBJECTIVES

To assess the adverse events associated with methylphenidate treatment for children and adolescents with ADHD in non-randomised studies.

SEARCH METHODS

In January 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, 12 other databases and two trials registers. We also checked reference lists and contacted authors and pharmaceutical companies to identify additional studies.

SELECTION CRITERIA

We included non-randomised study designs. These comprised comparative and non-comparative cohort studies, patient-control studies, patient reports/series and cross-sectional studies of methylphenidate administered at any dosage or formulation. We also included methylphenidate groups from RCTs assessing methylphenidate versus other interventions for ADHD as well as data from follow-up periods in RCTs. Participants had to have an ADHD diagnosis (from the 3rd to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders or the 9th or 10th edition of theInternational Classification of Diseases, with or without comorbid diagnoses. We required that at least 75% of participants had a normal intellectual capacity (intelligence quotient of more than 70 points) and were aged below 20 years. We excluded studies that used another ADHD drug as a co-intervention.

DATA COLLECTION AND ANALYSIS

Fourteen review authors selected studies independently. Two review authors assessed risk of bias independently using the ROBINS-I tool for assessing risk of bias in non-randomised studies of interventions. All review authors extracted data. We defined serious adverse events according to the International Committee of Harmonization as any lethal, life-threatening or life-changing event. We considered all other adverse events to be non-serious adverse events and conducted meta-analyses of data from comparative studies. We calculated meta-analytic estimates of prevalence from non-comparative cohorts studies and synthesised data from patient reports/series qualitatively. We investigated heterogeneity by conducting subgroup analyses, and we also conducted sensitivity analyses.

MAIN RESULTS

We included a total of 260 studies: 7 comparative cohort studies, 6 of which compared 968 patients who were exposed to methylphenidate to 166 controls, and 1 which assessed 1224 patients that were exposed or not exposed to methylphenidate during different time periods; 4 patient-control studies (53,192 exposed to methylphenidate and 19,906 controls); 177 non-comparative cohort studies (2,207,751 participants); 2 cross-sectional studies (96 participants) and 70 patient reports/series (206 participants). Participants' ages ranged from 3 years to 20 years. Risk of bias in the included comparative studies ranged from moderate to critical, with most studies showing critical risk of bias. We evaluated all non-comparative studies at critical risk of bias. The GRADE quality rating of the evidence was very low.Primary outcomesIn the comparative studies, methylphenidate increased the risk ratio (RR) of serious adverse events (RR 1.36, 95% confidence interval (CI) 1.17 to 1.57; 2 studies, 72,005 participants); any psychotic disorder (RR 1.36, 95% CI 1.17 to 1.57; 1 study, 71,771 participants); and arrhythmia (RR 1.61, 95% CI 1.48 to 1.74; 1 study, 1224 participants) compared to no intervention.In the non-comparative cohort studies, the proportion of participants on methylphenidate experiencing any serious adverse event was 1.20% (95% CI 0.70% to 2.00%; 50 studies, 162,422 participants). Withdrawal from methylphenidate due to any serious adverse events occurred in 1.20% (95% CI 0.60% to 2.30%; 7 studies, 1173 participants) and adverse events of unknown severity led to withdrawal in 7.30% of participants (95% CI 5.30% to 10.0%; 22 studies, 3708 participants).Secondary outcomesIn the comparative studies, methylphenidate, compared to no intervention, increased the RR of insomnia and sleep problems (RR 2.58, 95% CI 1.24 to 5.34; 3 studies, 425 participants) and decreased appetite (RR 15.06, 95% CI 2.12 to 106.83; 1 study, 335 participants).With non-comparative cohort studies, the proportion of participants on methylphenidate with any non-serious adverse events was 51.2% (95% CI 41.2% to 61.1%; 49 studies, 13,978 participants). These included difficulty falling asleep, 17.9% (95% CI 14.7% to 21.6%; 82 studies, 11,507 participants); headache, 14.4% (95% CI 11.3% to 18.3%; 90 studies, 13,469 participants); abdominal pain, 10.7% (95% CI 8.60% to 13.3%; 79 studies, 11,750 participants); and decreased appetite, 31.1% (95% CI 26.5% to 36.2%; 84 studies, 11,594 participants). Withdrawal of methylphenidate due to non-serious adverse events occurred in 6.20% (95% CI 4.80% to 7.90%; 37 studies, 7142 participants), and 16.2% were withdrawn for unknown reasons (95% CI 13.0% to 19.9%; 57 studies, 8340 participants).

AUTHORS' CONCLUSIONS

Our findings suggest that methylphenidate may be associated with a number of serious adverse events as well as a large number of non-serious adverse events in children and adolescents, which often lead to withdrawal of methylphenidate. Our certainty in the evidence is very low, and accordingly, it is not possible to accurately estimate the actual risk of adverse events. It might be higher than reported here.Given the possible association between methylphenidate and the adverse events identified, it may be important to identify people who are most susceptible to adverse events. To do this we must undertake large-scale, high-quality RCTs, along with studies aimed at identifying responders and non-responders.

Recurrent hypoglycaemia in a toddler on β-blocker therapy

Hypoglycaemia is a well-known side effect of Propranolol. We described the case of a child presenting severe and recurrent Propranolol-induced hypoglycaemia. Those episodes were not related to prolonged fasting and were associated with only mild ketosis. Thus, therapy with β blockers may not only aggravate classical ketotic hypoglycaemia but also interfere with glucose metabolism.

Pilot study of propranolol premedication to reduce FDG uptake in brown adipose tissue on PET scans of adolescent and young adult oncology patients

OBJECTIVE

Physiologic uptake of ¹⁸F-fluorodeoxyglucose (FDG) in brown adipose tissue (adipose tissue) of cancer patients may confound interpretation of positron emission tomography (PET) scans. Uptake in adipose tissue occurs in up to half of pediatric oncology patients undergoing PET scans, and is especially common in adolescents. adipose tissue is innervated by the sympathetic nervous system, and beta blockers such as propranolol have shown efficacy in reducing adipose tissue uptake on PET scans done in older adult oncology patients.

PARTICIPANTS

Because propranolol may cause hypoglycemia or other side effects in fasting patients, we prospectively assessed the safety of a single dose of 20 mg propranolol in adolescent and young adult oncology patients undergoing FDG-PET imaging.

METHODS

Ten patients (median age 18 years, range 14-24) received propranolol premedication prior to FDG-PET.

RESULTS

No adverse effects or clinically significant changes in serum glucose, heart rate, or blood pressure were observed. Five of the 10 patients had adipose tissue identified on previous PET scans. However, following propranolol administration only, one patient had persistent uptake in adipose tissue.

CONCLUSIONS

Propranolol was convenient and safe in fasting adolescent and young adult oncology patients undergoing PET scans. Larger studies are warranted to better define the effectiveness of this approach.

Frequency and severity of hypoglycemia in children with beta-blocker-treated long QT syndrome

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.

Propranolol therapy of infantile hemangiomas: efficacy, adverse effects, and recurrence

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.

Nonselective β-blocker propranolol for orbital and periorbital hemangiomas in infants: a new first-line of treatment?

Purpose

To determine the effectiveness and possible side effects of using propranolol for the treatment of orbital and periorbital infantile hemangiomas.

Methods

Infants with periorbital or orbital hemangiomas who had not received either local or systemic corticosteroids were recruited. The changes in tumor size, color, and texture, and any side effects of the drug were recorded.

Results

Fifteen infants with a mean age of 8.13 ± 4.7 months were treated according to the set protocol. A change in the color and texture of the hemangioma occurred in the first week following treatment. Mean duration of treatment was 7.67 ± 3.96 months. The size of hemangiomas decreased from a mean of 2.4 ± 0.9 cm to a mean of 1.6 ± 1.0 cm 3 months after treatment (P = 0.001). One patient had to stop the drug because of peripheral vascular ischemia. Another case had the dose reduced to control a mild hyperglycemia. Serious side effects were not observed. A single case of tumor regrowth (8.3%) was recorded.

Conclusion

Treatment of 1–2 mg/kg/day propranolol proved to be effective and associated with minimal side effects. It is likely to replace steroids as the first-line of treatment of hemangiomas in infants.

β-blockers for infantile hemangiomas: a single-institution experience

Propranolol has become first-line therapy for the treatment of infantile hemangiomas in many centers. Of 302 children with hemangiomas seen at the University of North Carolina from 2008 through 2010, 15.6% were treated with oral propranolol alone, 5.6% with topical timolol (a propranolol derivative) alone, and 2.3% with both. The use of these agents increased over time from 7% of patients seen in 2008 to 54% of patients first seen in 2010. Starting doses of propranolol ranged from 0.25 to 1 mg/kg/d, with target doses of 1 to 4 mg/kg/d. Serious side effects, noted in 6/54 (10.9%) patients, included somnolence, bradycardia, hypotension, hypoglycemia, and mottling of extremities.The authors confirm the variation in use of propranolol for vascular lesions and extend experience with timolol. They suggest daily home monitoring of patients for the first 2 weeks of initiating or increasing doses. Frequent feeding of infants and young children on this drug is recommended.

Adverse effects of propranolol when used in the treatment of hemangiomas: a case series of 28 infants

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.

Hypoglycemia as a result of propranolol during treatment of infantile hemangioma: a case report

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.

Initial Experience With a Multidisciplinary Strategy for Initiation of Propranolol Therapy for Infantile Hemangiomas

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.

Severe hypoglycemia during successful treatment of diffuse hemangiomatosis with propranolol

A 27-day-old male infant with diffuse hemangiomatosis of the skin and liver was treated with oral propranolol at a dosage of 2 mg/kg per day. Five months later skin and liver hemangiomas regressed almost completely. After 160 days of onset of propranolol, the patient presented with seizures on waking up. Laboratory examinations showed blood glucose of 15 mmol (n.v. 50-110) and increased ketone bodies. Propranolol was recommenced at a lower dosage the day after the crisis and then withdrawn when the baby was aged ten months. Hypoglycemia is the most frequent and insidious side effect of propranolol, mainly occurring in circumstances with diminished oral intake. Although the risk appears small, increased vigilance for hypoglycemia in children on chronic propranolol treatment who have decreased caloric intake for any reason seems prudent.

Hypoglycemia in infants and children

Our understanding of the many different causes of hypoglycemia has vastly expanded in recent years. Most hypoglycemic disorders in infants and children are due to defects in the metabolic systems involved in fasting adaptation or the hormone control of these systems. As a result of these defects, infants and children have an abnormal adaptation to fasting, which results in hypoglycemia. The "critical sample" allows one to assess the integrity of the fasting systems when hypoglycemic. An understanding of the pathophysiology of these disorders establishes a foundation for a rational approach in evaluating the etiology of the hypoglycemia and developing the most appropriate management plan.

Cardiovascular challenges in toxicology

The diagnoses and subsequent treatment of poisoned patients manifesting cardiovascular compromise challenges the most experienced emergency physician. Numerous drugs and chemicals cause cardiac and vascular disorders. Despite widely varying indications for therapeutic use, many agents share a common cardiovascular pharmacologic effect if taken in overdose. Standard advanced cardiac life support protocol care of these patients may not apply and may even result in harm if followed. This chapter discusses com-mon cardiovascular toxins and groups them into their common mechanisms of toxicity. Multiple agents exist that result in human cardiovascular toxicity. The management of the toxicity of each agent should follow a rationale approach. The first step in the care of all poisoned patients focuses on good supportive care.

Life-threatening isradipine poisoning in a child

Calcium channel blockers as a group are responsible for significant morbidity and mortality with toxic exposures. Isradipine, a cardioselective dihydropyridine calcium channel blocker, rarely has been implicated, with only two reports in the literature of significant toxic reactions, one in an adult and another in a child. To our knowledge, we describe the first case of life-threatening isradipine poisoning in a child and provide documentation of serum drug levels. On arrival at the hospital, a 5-year-old girl had abdominal distention and bradycardia that rapidly progressed to asystole. She received 73 minutes of cardiopulmonary resuscitation and transvenous cardiac pacing and survived with an intact neurologic recovery. Serum concentrations of isradipine were 30-100 times those found with therapeutic use.

Hypoglycemia and the ABC'S (sugar) of pediatric resuscitation

STUDY OBJECTIVE

The purpose of this study was to determine the prevalence of hypoglycemia and describe the clinical variables associated with hypoglycemia in children receiving resuscitation care.

METHODS

A cross-sectional study of consecutive children receiving resuscitation care in an emergency department was performed. Rapid glucose testing was prospectively established as one of the initial resuscitation steps, and clinical variables were obtained from a retrospective chart review. The setting was an urban children's hospital ED (Level II trauma center) with a census of 31, 000 per year and a 10% admission rate. The patient population consisted of children (birth to 20 years of age) receiving resuscitation care for altered consciousness, status epilepticus, respiratory failure, cardiac failure, and cardiopulmonary arrest.

RESULTS

Over a 1-year period, 49 nontrauma-related children received resuscitation care. Nine (18%; 95% confidence interval 8.7 to 32.2) were hypoglycemic (glucose level </=40 mg/dL). The median time from ED presentation to rapid glucose testing was 11 minutes (range, 0 to 65 minutes). Four of the hypoglycemic children had septic shock. The mortality rate was significantly greater (P =.015) in the hypoglycemic children.

CONCLUSION

Because hypoglycemia occurs often in children requiring resuscitation and clinical signs are often unspecific, routine rapid assessment of serum glucose is recommended. To increase physician awareness, adding "S" (sugar) to the popular mnemonic A (airway), B (breathing), and C (circulation): ABC'S is recommended. [Losek JD. Hypoglycemia and the ABC'S (sugar) of pediatric resuscitation. Ann Emerg Med. January 2000;35:43-46.]