Is prolonged monitoring necessary? An updated approach to infantile hemangioma treatment with oral propranolol

Abstract

Infantile hemangiomas (IH) are the most common soft-tissue tumors in childhood, occurring in up to 10% of infants. 1,2 The majority of these benign vascular tumors require no treatment; however, in at least 12% of patients, they can become problematic, and depending on their anatomic location and extent of growth, require clinical evaluation and treatment. 1,3,4 In these cases, oral propranolol has emerged as a first-line treatment. 5 While the efficacy of propranolol as a treatment has been well supported through many studies, substantial variability in administration protocols remains. 2 Current FDA prescribing information for Hemangeol™ and provisional consensus guidelines recommend monitoring heart rate (HR) and blood pressure (BP) after the first and second hours following propranolol initiation and after each dose increase. 1,6,7 However, actual initiation and titration practices differ among providers and

Monitoring oral propranolol for infantile hemangiomata

“…Taking the initiation protocol one step further, in the effort to facilitate the treatment of IHs, thus promoting its use and decreasing costs, the question of the real necessity of prolonged monitoring is brought up in several studies. 5,12 As noted in our study and in all other cited studies, decrease in BP and HR have been recorded. The existence of such adverse effect, despite being asymptomatic in almost all cases, still suggests the possibility of clinically relevant adverse events.…”

“…2 In light of the reported adverse events following propranolol administration, including bradycardia, hypotension, hypoglycemia, bronchospasm and sleep disturbance, 6 meticulous guidelines for close monitoring during initiation and dose augmentation were recommended. 3 However, during the last several years controversy emerged regarding the need for such monitoring, 5,[7][8][9][10]12,13 and according to a survey conducted by Kumar et al most pediatric dermatologists nowadays do not rigorously adhere to these recommendations. 19 The aim of this retrospective cohort study comprising 131 cases of IHs was to ascertain the necessity for long monitoring at the beginning and dose escalation of oral propranolol treatment, by adhering to a strict administration protocol with almost no protocol deviations, thus making our conclusion more robust.…”

“…with a diversity of monitoring protocols ranging from hospitalization of up to 48 h to virtual telemedicine. [3][4][5][6][7][8][9][10][11] Furthermore, the primary debatable question in the literature lately is the necessity of repeated vital sign monitoring, with conservative methods suggesting monitoring on an outpatient basis, and more liberal approaches questioning the actual need of such monitoring. 5,12,13 In this study, we aim to describe our experience adhering to a strict protocol of oral Propranolol administration including pretreatment evaluation and monitoring during initiation and dose augmentation, and verify the need for such monitoring.…”

Case report: Deterioration of infantile hemangioma related to oral or nebulized administration of β2-AR agonist: Three cases reports

“…OPT is currently the first-line treatment for IH because of its high response rate and safety (16)(17)(18)(19)(20). It usually lasts for 6-12 months or longer to overcome the rapid growth during the proliferative phase (21). In most cases, a rapid effect can be observed on color and texture after several days of OPT at a dose of 2-3 mg/kg per day.…”

Propranolol in the Treatment of Infantile Hemangiomas

“…57 The duration of propranolol usage is recommended for at least six months, usually lasting 12 months or longer. [66][67][68] Some researchers recommend the treatment is continued till the involution of IHs, and an average of 14 months is suggested. 69 After reviewing all the materials, we recommend the target propranolol dosage is 2 to 3 mg/kg/d and the medication should start from 0.7-1.0 to 2.0-2.5 mg/kg/d in three divided doses at an interval of at least 3 days.…”