Loading...
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.
Hengst M et al. Blood pressure monitoring during the induction and maintenance period of propranolol therapy for complicated infantile hemangiomas: A prospective study of 109 infants. Pediatr Dermatol 2015 Nov/Dec; 32:802. (http://dx.doi.org/10.1111/pde.12681)
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.