Oral Propranolol for Hemangiomas of Infancy

Marcia L. Buck, Pharm.D., FCCP, FPPAG


Pediatr Pharm. 2010;16(8) 

In This Article

Additional Clinical Experience

Shortly after the initial case series appeared, several other case reports and small case series were published describing the successful use of propranolol.[4–11] Bonifazi reported another 5 infants treated with propranolol at a dose of 2 mg/kg/day (divided and given orally 3 or 4 times daily).[4] In 2009, Maturo and Harnick gave propranolol to two infants with hemangiomas involving the airway.[5] The patients, a 3-month-old with an isolated paraglottic hemangioma and a 5-month-old subglottic hemangioma, were treated with propranolol as their sole therapy. The infants were initially started on a dose of 0.5 mg/kg and titrated over the next 24 hours to 2 mg/kg/day (divided and given orally twice daily). Both patients were asymptomatic at follow-up, with a plan to continue treatment for one year.

Earlier this year, Truong and colleagues treated another infant with a subglottic and mediastinal hemangioma using a combination of oral propranolol (2 mg/kg/day) and prednisolone (3 mg/kg/day).[6] Despite having failed previous attempts at surgical resection, the patient's stridor resolved within two days of starting drug treatment. An MRI performed a week later revealed a 50% reduction in the size of the mass. Prednisolone was tapered off at that time, while the propranolol was continued for 5 months. It was tapered off with no recurrence of symptoms.

In a letter published in the British Journal of Dermatology, Manunza and colleagues briefly described their experience with propranolol in 30 infants with hemangiomas between July 2008 and April 2009.[7] The average patient age at the start of therapy was 5.8 months (range 1.2–13.5 months). Ten patients had facial hemangiomas, nine had periocular lesions, six had nasal lesions, and three had subglottic lesions. Nine of the patients were treated after failure to respond to corticosteroids. Two were treated with both prednisolone and propranolol, while the rest received only propranolol. Oral propranolol solution was initiated at a dose of 1 mg/kg/day (divided into three daily doses). Heart rate, blood pressure, and blood glucose were monitored in all patients. If tolerated, the dose was increased to 2 mg/kg/day after 1 week. Doses were adjusted for weight increases every month on follow-up. Treatment continued for 1 year unless complete resolution occurred earlier, and therapy was tapered off over the last month. At publication, 19 infants had successfully completed treatment and the remaining patients had demonstrated significant improvement. The majority of patients responded within a week of initiating propranolol. No significant adverse effects were reported.

After reporting on their initial experience with propranolol in 2009,[8] Buckmiller and colleagues published a retrospective study of 32 infants treated at the Arkansas Children's Hospital in the April 2010 issue of Laryngoscope.[9] Fifteen of the patients had experienced a complication related to their hemangioma, including ulceration, bleeding, and visual or airway obstruction. Patients were treated with propranolol 2 mg/kg/day (divided and given orally three times daily), after a thorough history, physical examination, and baseline electrocardiogram (ECG). Doses were adjusted for growth at monthly follow-up. Treatment was continued for one year, tapered at completion by reducing the dose by 50% for 1–2 weeks. Ninety-seven percent of the patients had a positive response to treatment (50% were considered excellent responders, 47% partial responders, and 3% non-responders). Adjunct therapy for partial and non-responders consisted of laser treatment, intralesional corticosteroid injection, or surgical resection. Minor adverse effects included somnolence in 27% of patients, gastroesophageal reflux in 9%, respiratory syncytial virus exacerbation or rash in 4.5%. Additional case series have reported similar success with propranolol for isolated orbital and hepatic hemangiomas.[10,11]

In addition to these reports, the authors of the original case series subsequently published data from a larger group of patients.[12] A total of 32 infants received propranolol at oral doses of 2–3 mg/kg/day after ECG, echocardiography, and baseline heart rate and blood pressure were assessed. Ultrasound evidence was used to supplement clinical observation in determining regression. As in their earlier paper, the authors noted improvement in hemangioma color and growth in all patients. The patients were treated for a mean duration of 6.1 months. Propranolol was well tolerated, with one patient requiring discontinuation of therapy for wheezing.


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