Is Hospitalization Necessary for Propranolol Initiation for Infantile Hemangiomas?

Summary and Comment |
March 18, 2016

Is Hospitalization Necessary for Propranolol Initiation for Infantile Hemangiomas?

  1. Mary Wu Chang, MD

Absent risk factors, propranolol can probably be initiated in the outpatient setting if monitored carefully.

  1. Mary Wu Chang, MD

Although propranolol therapy for infantile hemangiomas (IHs) has been used for 6 years (FDA approved 2 years ago), there is no standardized initiation protocol. Inpatient initiation is often done because accurate blood pressure (BP) monitoring in infants is difficult and time consuming.

To assess BP during initiation, a prospective study was performed in Germany of 109 infants with IH. Mean age at initiation was 2.8 months (range 1–5 months). Exclusion criteria were prematurity, congenital heart defect, coarctation, or having received prior treatment for IH. All had complicated IH (visual obstruction, ulceration, disfiguring centro-facial IH, anogenital obstruction, diffuse hemangiomatosis). Three BP measurements were obtained asleep or at rest 90 minutes after propranolol was given. The initial dose was 0.5 mg/kg/day divided three times a day. Four patients dropped out (2 had sinus bradycardia, 2 had lethargy but normal parameters). The dose was escalated to 2 mg/kg/day by day 3, and infants were discharged on day 5. Follow-up was every 4 weeks, and propranolol was tapered off after 6 months.

During initiation, the mean systolic BP dropped by 5 mm, which was still normal for age. BP was stable during the maintenance phase.

The authors believe that for initiation of therapy, hospital admission is recommended only for infants younger than 8 weeks corrected age, PHACE syndrome, or inadequate social support, or when rapid escalation is required for emergent issues (e.g., IH causing obstruction). In the majority of cases, outpatient gradual dose escalation will obviate the need for BP monitoring. For the maintenance phase, BP monitoring is not required.

Comment

Inpatient initiation of propranolol for IH is done to monitor for hypotension, bradycardia, and hypoglycemia — and in some, bronchospasm or feeding issues. Of these issues, BP is the most difficult to measure in small infants. This rigorous study suggests that in the absence of risk factors, initiation of propranolol can probably be done outpatient carefully using gradual dose escalation.

Editor Disclosures at Time of Publication

  • Disclosures for Mary Wu Chang, MD at time of publication Consultant / Advisory board Pierre Fabre; Valeant Speaker’s bureau Pierre Fabre

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