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A new treatment pathway for propranolol use in infantile haemangiomas
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 67, e91ee92
CORRESPONDENCE AND COMMUNICATION A new treatment pathway for propranolol use in infantile haemangiomas Dear Sir, Propranolol is now the first-line treatment for rapidly proliferating haemangiomas. It has been shown to cause rapid halt of proliferation and promote regression of problematic haemangiomas, with minimal side effects.1e3 We have previously described a treatment protocol, which was used for 31 consecutive patients seen at a tertiary referral centre with problematic haemangiomas.4 Prior to treatment, all patients underwent a thorough cardiovascular assessment. This was developed in conjunction with the paediatric cardiologists, and involved baseline observations, electrocardiogram, and echocardiogram. Initiation of propranolol treatment involved the monitoring of heart rate and blood pressure every 15 min for 2 h following a starting dose of 0.5 mg/kg orally. If tolerated, a second dose of 1 mg/kg orally was given at 4 h, followed by the same post-dose monitoring. If observations remained stable, the patient received a further 2 doses and was discharged at the target dose of 3 mg/kg/day. No patients had any side effects. In view of our results, and the well-documented safety profile of propranolol,1e4 we developed a new protocol that allowed treatment to be initiated on an outpatient basis. We then conducted a further study to examine the efficacy and safety of the new treatment regime. Consecutive patients who met the inclusion criteria were enrolled into the study and commenced on propranolol treatment (Table 1). Propranolol was prescribed at a dose of 0.5 mg/kg three times a day for 24 h, then increased to 1 mg/kg, initiated by parents at home. Parents were given a full instruction leaflet with information on spotting potential treatment side effects such as hypotension, hypoglycaemia, and exacerbation of asthma. The hospital contact number was also given.
Follow up phone calls were made to the parents at home 24 h after commencement of treatment. The patients were seen at 4 weekly intervals, for monitoring of treatment efficacy and potential side effects. At each clinic visit, no blood pressures were taken, since only asymptomatic hypotension was noted on induction of propranolol in our previous study. In addition, very young children are often agitated when their blood pressures are taken in clinic, so the readings are not a true reflection of their resting pressure. 41 patients were recruited into the study. The average age at start of treatment was 14 weeks (range 3e25). Average treatment response time was 3.4 weeks (range 1e9). There were no side effects of treatment observed and no treatment had to be discontinued. All parents reported the ease of starting treatment, and were comfortable with the therapeutic regime. We have demonstrated in this study that, with the good safety profile of propranolol, extensive cardiovascular screening prior to starting the drug for treatment of infantile haemangioma is unnecessary. In addition, close monitoring with regular blood pressure measurements, which can be cumbersome in small infants, is not required. Participating parents in our study were comfortable with the treatment regime. A streamlined and safe treatment regime, which can be initiated at home, and does not necessitate a 24-h hospital admission, is also important in the current financial climate.
Table 1 List of inclusion and exclusion criteria for enrolment in study. Any rapidly growing lesion defined as doubling in size over 2 weeks Any functional or significant cosmetic deformity Any lesion that is likely to compromise normal physiological function Any lesion likely to cause significant cosmetic deformity in the future No previous treatment for haemangiomas Heart rate above 80 beats per minute Exclusion criteria Known cardiovascular disorder Significant asthma Inclusion criteria
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.008
e92
Conflict of interest None.
Funding None.
References 1. Baetz J, Eigelshoven S, Marquard J, et al. Infantile hemangioma. Successful treatment with propranolol. Hautarzt 2010;61: 290e2.
Correspondence and communication 2. Zimmerman AP, Wiegand S, Werner JA, et al. Propranolol therapy for infantile haemangiomas: review of the literature. Int J Pediatr Otorhinoloaryngol 2010;74(4):338e42. 3. Le ´aute ´-Labre `ze C, Dumas de la Roque E, Hubiche T, et al. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358(24):2649e51. 4. Holmes WJM, Mishra A, Gorst C, Liew SH. Propranolol as firstline treatment for rapidly proliferating infantile haemangiomas. J Plast Reconstr Aesthet Surg 2011;64(4):445e51.
Jolyon E.R. May Se Hwang Liew Alder Hey Hospital, L122AP, United Kingdom E-mail address: [email protected]
9 July 2013
CORRESPONDENCE AND COMMUNICATION A new treatment pathway for propranolol use in infantile haemangiomas Dear Sir, Propranolol is now the first-line treatment for rapidly proliferating haemangiomas. It has been shown to cause rapid halt of proliferation and promote regression of problematic haemangiomas, with minimal side effects.1e3 We have previously described a treatment protocol, which was used for 31 consecutive patients seen at a tertiary referral centre with problematic haemangiomas.4 Prior to treatment, all patients underwent a thorough cardiovascular assessment. This was developed in conjunction with the paediatric cardiologists, and involved baseline observations, electrocardiogram, and echocardiogram. Initiation of propranolol treatment involved the monitoring of heart rate and blood pressure every 15 min for 2 h following a starting dose of 0.5 mg/kg orally. If tolerated, a second dose of 1 mg/kg orally was given at 4 h, followed by the same post-dose monitoring. If observations remained stable, the patient received a further 2 doses and was discharged at the target dose of 3 mg/kg/day. No patients had any side effects. In view of our results, and the well-documented safety profile of propranolol,1e4 we developed a new protocol that allowed treatment to be initiated on an outpatient basis. We then conducted a further study to examine the efficacy and safety of the new treatment regime. Consecutive patients who met the inclusion criteria were enrolled into the study and commenced on propranolol treatment (Table 1). Propranolol was prescribed at a dose of 0.5 mg/kg three times a day for 24 h, then increased to 1 mg/kg, initiated by parents at home. Parents were given a full instruction leaflet with information on spotting potential treatment side effects such as hypotension, hypoglycaemia, and exacerbation of asthma. The hospital contact number was also given.
Follow up phone calls were made to the parents at home 24 h after commencement of treatment. The patients were seen at 4 weekly intervals, for monitoring of treatment efficacy and potential side effects. At each clinic visit, no blood pressures were taken, since only asymptomatic hypotension was noted on induction of propranolol in our previous study. In addition, very young children are often agitated when their blood pressures are taken in clinic, so the readings are not a true reflection of their resting pressure. 41 patients were recruited into the study. The average age at start of treatment was 14 weeks (range 3e25). Average treatment response time was 3.4 weeks (range 1e9). There were no side effects of treatment observed and no treatment had to be discontinued. All parents reported the ease of starting treatment, and were comfortable with the therapeutic regime. We have demonstrated in this study that, with the good safety profile of propranolol, extensive cardiovascular screening prior to starting the drug for treatment of infantile haemangioma is unnecessary. In addition, close monitoring with regular blood pressure measurements, which can be cumbersome in small infants, is not required. Participating parents in our study were comfortable with the treatment regime. A streamlined and safe treatment regime, which can be initiated at home, and does not necessitate a 24-h hospital admission, is also important in the current financial climate.
Table 1 List of inclusion and exclusion criteria for enrolment in study. Any rapidly growing lesion defined as doubling in size over 2 weeks Any functional or significant cosmetic deformity Any lesion that is likely to compromise normal physiological function Any lesion likely to cause significant cosmetic deformity in the future No previous treatment for haemangiomas Heart rate above 80 beats per minute Exclusion criteria Known cardiovascular disorder Significant asthma Inclusion criteria
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.008
e92
Conflict of interest None.
Funding None.
References 1. Baetz J, Eigelshoven S, Marquard J, et al. Infantile hemangioma. Successful treatment with propranolol. Hautarzt 2010;61: 290e2.
Correspondence and communication 2. Zimmerman AP, Wiegand S, Werner JA, et al. Propranolol therapy for infantile haemangiomas: review of the literature. Int J Pediatr Otorhinoloaryngol 2010;74(4):338e42. 3. Le ´aute ´-Labre `ze C, Dumas de la Roque E, Hubiche T, et al. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358(24):2649e51. 4. Holmes WJM, Mishra A, Gorst C, Liew SH. Propranolol as firstline treatment for rapidly proliferating infantile haemangiomas. J Plast Reconstr Aesthet Surg 2011;64(4):445e51.
Jolyon E.R. May Se Hwang Liew Alder Hey Hospital, L122AP, United Kingdom E-mail address: [email protected]
9 July 2013