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

Effect of oral propranolol on periocular Capillary Hemangiomas of Infancy

BACKGROUND

To assess the safety and efficacy of oral propranolol in the management of periocular Capillary Hemangiomas of Infancy (CHI).

METHODS

Medical records of 21 infants diagnosed with periocular capillary hemangioma during a period of 5 years from 2009 to 2014 were retrospectively reviewed. The data collected included demographic details, clinical features and details of imaging studies and response to the therapy. All patients received oral propranolol under the supervision of a pediatrician. The initial dose was 0.2-1 mg/kg body weight, which was increased to 2 mg/kg body weight (3 divided doses) in 48 h if there was no adverse reaction to the initial dose. The response to the treatment was assessed clinically as well as by radiographic imaging. Photographic documentation was done periodically.

RESULTS

Out of 21 patients, 18 were females and remaining three were males. The median age at the time of presentation was 4 months. The most common presenting feature was lid mass (n = 17, 80%) followed by proptosis (n = 7, 33%). Reddish discoloration of face was seen in 2 (1%) patients. All patients showed reduction in the size of the lesion. None of the patients included in this study had any adverse reaction to propranolol or recurrence following cessation of the therapy.

CONCLUSION

Oral propranolol is highly effective and safe in the treatment of periocular capillary hemangiomas in infants.

Safety of Oral Propranolol for the Treatment of Infantile Hemangioma: A Systematic Review

BACKGROUND AND OBJECTIVES

Given the widespread use of propranolol in infantile hemangioma (IH) it was considered essential to perform a systematic review of its safety. The objectives of this review were to evaluate the safety profile of oral propranolol in the treatment of IH.

METHODS

We searched Embase and Medline databases (2007-July 2014) and unpublished data from the manufacturer of Hemangiol/Hemangeol (marketed pediatric formulation of oral propranolol; Pierre Fabre Dermatologie, Lavaur, France). Selected studies included ≥10 patients treated with oral propranolol for IH and that either reported ≥1 adverse event or effect (AE) or planned to capture AEs. Data capture was standardized and extracted study design, demographic characteristics, IH characteristics, intervention, and safety outcomes. AEs were assigned a system organ class and preferred term.

RESULTS

A total of 83 of 398 identified literature records met the inclusion criteria, covering 3766 propranolol-treated patients. The manufacturer's data for 3 pooled clinical trials (435 propranolol-treated patients) and 1 Compassionate Use Program (1661 patients) were included. AE data were reported for 1945 of 5862 propranolol-treated patients. The most frequently reported AEs included a range of sleep disturbances, peripheral coldness, and agitation. The most serious AEs (atrioventricular block, bradycardia, hypotension, bronchospasm/bronchial hyperreactivity, and hypoglycemia-related seizures) were managed by decreasing doses or temporary/permanent discontinuation of propranolol. Limitations included the variety of included study designs; monitoring, collection, and reporting of AE data; small sample sizes for some articles; and the wide scope of review.

CONCLUSIONS

Oral propranolol is well tolerated if appropriate pretreatment assessments and within-treatment monitoring are performed to exclude patients with contraindications and to minimize serious side effects during treatment.

Adverse Events in Young and Preterm Infants Receiving Topical Timolol for Infantile Hemangioma

BACKGROUND

The success of oral propranolol for treatment of infantile hemangiomas (IHs) has led practitioners to use topical β-blockers. In preterm infants, clinicians frequently turn to topical timolol, with the presumption that topical application will result in less systemic absorption. We used Holter monitoring to assess for drug-induced bradycardia in high-risk infants.

METHODS

We retrospectively reviewed the charts of 22 at-risk infants who received a Holter monitor to assess for association between timolol administration and development of significant bradycardia.

RESULTS

Four infants had episodic bradycardia detected by Holter monitoring. Two of these infants were full term; weighed more than 3,000 g; and had rare, brief, asymptomatic episodes unrelated to the timing of the timolol application. The other two infants had symptomatic bradycardia while on timolol and were the only two babies that weighed less than 2,500 g at initiation of therapy. Both were young (postmenstrual age [PMA] 34 and 37 wks) at initiation and had a timolol dose above the average exposure for the cohort.

CONCLUSION

In this cohort of at-risk infants, topical timolol appeared to provide safe treatment for IHs in full-term infants receiving a dose of less than 0.2 mg/kg/day, but infants with a PMA of less than 44 weeks and weight at treatment initiation of less than 2,500 g may be at risk of adverse events, including bradycardia, hypotension, apnea, and hypothermia. We recommend close monitoring of temperature, blood pressure, and heart rate in premature and low-birthweight infants with IHs at initiation of and during therapy with topical timolol.

Propranolol as first-line treatment in orbital infantile haemangiomas: a case series

PURPOSE

To highlight the importance of Magnetic Resonance Imaging (MRI) and the use of propranolol as both a final diagnostic tool and adequate treatment for orbital Infantile Haemangiomas (IHs).

METHODS

A retrospective study was conducted using a case series of 5 infants diagnosed with orbital IH. All patients presented with progressive unilateral proptosis and were at high risk of developing amblyopia, some had combined swelling of the eyelid, impaired eye movements or exposure keratopathy. Propranolol was administered in an initial dose of 0.6 mg/kg/day orally divided in three daily doses and increased in 4 days to 2.7 mg/kg/day. MRI was performed in all children.

RESULTS

Striking MR characteristics of an IH lesion were seen in each of our 5 cases, including the presence of flow voids, high contrast enhancement, hypo-intense T1W signal, iso- to hyper intense T2W signal, and lobulated appearance. All patients showed a quick clinical response to treatment, resulting in significant reduction in tumour size within a range of 1-3 weeks and almost complete regression of the lesion at the end of the treatment schedule.

CONCLUSIONS

Our study adds another 5 cases to the growing body of reports confirming the efficacy and safety - under controlled circumstances - of propranolol therapy in orbital IH management, in which we highlight the use of propranolol as both a final diagnostic tool and as an adequate treatment.

Treatment of periorbital infantile haemangiomas: a systematic literature review on propranolol or steroids

AIM

The aim of this study was to compare the efficacy and safety of propranolol versus corticosteroids for the treatment of periorbital infantile haemangiomas (IHs).

METHODS

A literature review using PubMed, Ovid Medline, EBSCO, Springer, Web of Knowledge, Cochrane Library, CNKI and associated references before 2 March 2013 was conducted. The main outcomes were distribution of locations, response rate, rebound growth rate, spherical and cylinder power before and after treatment, amblyopia rate and adverse events.

RESULTS

Thirty-one studies including 425 patients met the inclusion criteria. A total of 70.6% of patients were female, 89.6% of the periorbital IHs were located in the upper or lower eyelid area. The most common administration routes involved oral propranolol and intralesional injection of corticosteroids. The mean response rate was 94.0% for propranolol and 82.3% for corticosteroid (P = 0.001). The rebound growth rate was 13.9% for propranolol and 12.0% for steroids (P = 0.71). Astigmatism was reduced in both propranolol and steroid studies (P < 0.0001, P < 0.0001), but a significant reduction in spherical power was only demonstrated in propranolol studies (P = 0.005). A total of 31.1% of patients treated with corticosteroids developed post-operative amblyopia compared with 16.7% of patients treated with propranolol (P = 0.04). Oral propranolol seemed to induce more temporary adverse events than intralesional corticosteroids administration (24.0% vs. 9.6%, P = 0.006).

CONCLUSION

Propranolol may represent an effective therapy for periorbital IHs compared with the use of corticosteroids; however, further randomised control studies are needed to compare adverse events.

Haemangioma: clinical course, complications and management

Despite their high incidence, most infantile haemangiomas (IH) do not require treatment as they regress spontaneously and most do not leave significant sequelae. For the subset of haemangiomas that require treatment, indications for intervention can be divided into three main categories: ulceration, disfigurement and impairment of function or vital structures. In addition, certain IH have a risk of associated structural anomalies. Given the wide heterogeneity of haemangiomas, deciding which haemangiomas need intervention and when to intervene requires a detailed knowledge of natural history and clinical indicators of increased risk.

Propranolol and infantile hemangiomas four years later: a systematic review

To systematically review the literature evaluating efficacy and adverse events of propranolol treatment for infantile hemangiomas, we searched the MEDLINE and Cochrane databases for all studies examining the response of infantile hemangiomas (IHs) to propranolol published between June 12, 2008, and June 15, 2012. Forty-one studies with 1,264 patients were included; 74% of patients were female and approximately 30% had received other treatments before propranolol. Propranolol was initiated at a mean age of 6.6 months at a mean dose of 2.1 mg/kg/day and for a mean treatment duration of 6.4 months. The response rate for patients with IHs treated with propranolol was 98% (range 82%-100%), with response rate defined as any improvement with propranolol. Treatment response rates were comparable for studies evaluating IHs at specific sites, such as periorbital IHs. Studies that followed patients after treatment completion reported IH rebound growth in 17% of patients. There were 371 adverse events reported in 1,189 patients. The most common adverse events were changes in sleep (n = 136) and acrocyanosis (n = 61). Serious adverse events were rare, with reports of symptomatic hypotension in five patients, hypoglycemia in four, and symptomatic bradycardia in one. This systematic review of 1,264 patients treated with propranolol for IHs showed a high rate of efficacy and a low rate of serious adverse events.

Initiation and use of propranolol for infantile hemangioma: report of a consensus conference

Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells. Despite the relative frequency of IH and the potential severity of complications, there are currently no uniform guidelines for treatment. Although propranolol has rapidly been adopted, there is significant uncertainty and divergence of opinion regarding safety monitoring, dose escalation, and its use in PHACE syndrome (PHACE = posterior fossa, hemangioma, arterial lesions, cardiac abnormalities, eye abnormalities; a cutaneous neurovascular syndrome characterized by large, segmental hemangiomas of the head and neck along with congenital anomalies of the brain, heart, eyes and/or chest wall). A consensus conference was held on December 9, 2011. The multidisciplinary team reviewed existing data on the pharmacologic properties of propranolol and all published reports pertaining to the use of propranolol in pediatric patients. Workgroups were assigned specific topics to propose protocols on the following subjects: contraindications, special populations, pretreatment evaluation, dose escalation, and monitoring. Consensus protocols were recorded during the meeting and refined after the meeting. When appropriate, protocol clarifications and revision were made and agreed upon by the group via teleconference. Because of the absence of high-quality clinical research data, evidence-based recommendations are not possible at present. However, the team agreed on a number of recommendations that arose from a review of existing evidence, including when to treat complicated IH; contraindications and pretreatment evaluation protocols; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol in infants; cardiovascular monitoring; ongoing monitoring; and prevention of hypoglycemia. Where there was considerable controversy, the more conservative approach was selected. We acknowledge that the recommendations are conservative in nature and anticipate that they will be revised as more data are made available.