PROPRANOLOL FOR HEMANGIOMAS
- Blocks Beta 1 and Beta 2 adrenergic receptors.
- Works quickly, 2-4 weeks.
- Low heart rate or arrhythmia, e.g., 3rd degree heart block. Any family history of congenital heart defects or arrhythmia. Any bradycardia?
- Recent studies suggest EKG is not necessary. Can get EKG to rule out low heart rate, e.g., sick sinus syndrome or sinus bradycardia, but studies show the yield of this is low.
- Start 1 mg/kg/day
- Target dose is 2 mg/kg/day BID or TID. Despite large prospective studies, most only go to 3 mg/kg/day if not responding.
- Hospitalize for very small babies, e.g., < age adjusted 5 weeks of age.
- Initiate therapy on an outpatient basis with 2-3 hours of monitoring heart rate and blood pressure.
In a study of infants < 8 weeks with a corrected gestational age of range -11 weeks to 8 weeks, a slight increased risk of side effects was found. Five percent had serious side effects.
Side Effects to Worry About Most
- Hypoglycemia, rare. Only occurs if baby is not eating. (If less than 4 months, wake up every 6 hours to feed, and if > 4 months, after 8 hours to feed.)
This prospective, randomized trial of 460 infants showed that propranolol was effective at a dose of 3 mg per kilogram per day for 6 months in the treatment of infantile hemangioma [N Engl J Med. 2015 Feb 19;372(8):735-46.]. But note, most experts go to 2 mg/kg/day.
The frequency of successful treatment was higher with this regimen than with placebo (60% vs. 4%, P<0.001). A total of 88% of patients who received the selected propranolol regimen showed improvement by week 5, versus 5% of patients who received placebo. A total of 10% of patients, in whom treatment with propranolol was successful, required systemic retreatment during followup. Known adverse events associated with propranolol (hypoglycemia, hypotension, bradycardia, and bronchospasm) occurred infrequently, with no significant difference in frequency between the placebo group and the groups receiving propranolol.
Treatment with propranolol was not associated with developmental risk or growth impairment at 4 years of age [JAAD 2016;75;59].
Predictors of Rebound Growth
- Stopping at 9 months or less (so try to go to 12-14 months).
- Discontinuing without tapering (so tapering recommended)
- Female gender.
- The presence of a large, deep component of the hemangioma.
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