The Use of Propranolol for Infantile Hemangioma: Consensus Recommendations

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These guidelines will help optimize the safe use of this valuable hemangioma treatment until results of controlled studies become available.

Infantile hemangiomas (IHs) are common benign neoplasms that comprise proliferating endothelial-like cells. As many as 12% require treatment, but the need for FDA-approved therapies remains. In the past, standard treatments such as systemic steroids induced numerous adverse effects and variable responses. Since 1998, the nonselective beta adrenergic receptor blocker propranolol has become the first-line treatment for complicated IH; however, evidence-based recommendations are lacking, and initiation and safety protocols vary. A group of expert clinicians in dermatology, pediatrics, otolaryngology, cardiology, and hematology/oncology gathered to review the existing literature and current practices.

Propranolol therapy has been used safely for 40 years for pediatric arrhythmias, hypertension, congenital heart disease, and hypertrophic cardiomyopathy without a designated pediatric indication. In 2008, it was serendipitously discovered that propranolol therapy shrinks IHs.

Pediatric dermatologists usually recommend pretreatment cardiology evaluation. Infants younger than 8 weeks of gestationally corrected age or with comorbid conditions are typically admitted for monitoring during initiation. Using a 20-mg/5-mL oral solution, the starting dose is 1 mg/kg/day, divided 3 times daily, titrating up to effect to 2 mg/kg/day (less commonly, 3 mg/kg/day). To avoid hypoglycemia, possibly the most common serious complication, the drug should be given with a feeding. Prolonged fasting should be avoided. The peak effect on heart rate and blood pressure occurs 1 to 3 hours after administration, with greatest response occurring after the first dose. Treatment is discontinued during intercurrent illness, especially if poor oral intake or bronchospasm occurs.

Adverse events (hypotension, hypoglycemia, sleep disturbance, and bronchospasm and two reports of hyperkalemia), drug interactions, contraindications, and the risk for stroke in PHACE patients are also reviewed.

Comment: This practical and well-reasoned consensus report is required reading for clinicians who treat infantile hemangioma with propranolol. Despite considerable controversy, these guidelines will help optimize the safe use of this valuable hemangioma treatment until results of controlled studies become available.

— Mary Wu Chang, MD

Published in Journal Watch Dermatology February 22, 2013