Oral Beta Blocker Reduces Periocular Infantile Hemangiomas in Most Cases

Kathleen Louden

October 28, 2010

October 28, 2010 (Chicago, Illinois) — Propranolol, an old drug being used off label, is an effective way to reduce vision-threatening periocular infantile hemangiomas, according to a study presented here at the American Academy of Ophthalmology and Middle East Africa Council of Ophthalmology 2010 Joint Meeting.

"[Oral] propranolol is not a common treatment used by ophthalmologists, but it may be now," said David Plager, MD, who presented the findings. "It gives impressive results." Dr. Plager is professor of ophthalmology and director of the Section of Pediatric Ophthalmology at Indiana University in Indianapolis.

Propranolol, an oral beta blocker, "looks to be a very promising addition to our treatment armamentarium," Dr. Plager told Medscape Medical News.

In 2008, French physicians serendipitously discovered that propranolol improves infantile hemangiomas when they gave the drug to 2 children to correct a heart condition that resulted from their large hemangiomas, and the beta blocker shrunk the hemangiomas, Dr. Plager told the audience.

Infantile hemangiomas are the most common benign tumors in infants. When these vascular tumors affect the eye, they can cause exposure of the cornea and threaten vision.

Dr. Plager presented the results of a small study that he and his colleagues conducted. In this retrospective observational case series, 17 infants with vision-threatening periocular infantile hemangiomas received daily oral propranolol, according to the abstract. Over the course of 1 to 2 weeks, the researchers gradually increased the daily dosage to 2 mg/kg, after starting at 25% of the full dose, he said.

Of the 17 patients, 10 had excellent results — their hemangioma shrunk by more than 50% — and 6 had good results — shrinkage of less than 50%, Dr. Plager reported. One patient had no decrease but had no further growth, which was considered a fair result. No patient had poor results, defined as the continued growth of the hemangioma or intolerable adverse effects.

The results of the study were published in the June issue of the Journal of AAPOS.

Other investigators recommend inpatient treatment with propranolol for infants younger than 3 months. However, Dr. Plager said their protocol is for outpatient treatment if the child does not have PHACES syndrome (posterior fossa anomalies, hemangiomas, and arterial, cardiac, eye, and sternum anomalies).

"Not for Everyone"

The world medical literature has no documented cases of serious adverse events or death in any of the propranolol-treated children with hemangiomas, according to Dr. Plager. Still, he said, "this is not a miracle drug. It is not for everyone."

"There are other viable options, depending on the specific case," Dr. Plager told Medscape Medical News. "I think that some patients will be better treated with injection of steroid or surgical resection, depending on the location, size, and characteristics of the tumor."

A pediatric ophthalmologist who did not participate in the study, John Roarty, MD, assistant professor of ophthalmology at Wayne State University, and chief of ophthalmology at Children's Hospital of Michigan in Detroit, said that propranolol is his first choice for larger infiltrative periocular hemangiomas, particularly if they involve the orbit. Less clear, he told Medscape Medical News, is the treatment of smaller periocular hemangiomas. Some pediatric dermatologists consider propranolol first-line therapy even in that situation, said Dr. Roarty.

"What do we do with the lesions that are localized to the lid? No matter what the dermatologists say, I'm not convinced that a systemic medication is the answer when you have a good local therapy," Dr. Roarty said.

Periocular steroid injections into the hemangioma are effective for these smaller lesions and minimize the systemic adverse effects of oral steroids, he said.

Adverse Effects

Dr. Roarty said that he and his colleagues, who have used propranolol to treat periocular infantile hemangiomas for about 2 years, have had very few adverse effects with the beta blocker. "We monitor the patient's heart rate and blood pressure," he said. "Propranolol does appear to be relatively safe."

Potential complications of propranolol treatment, according to Dr. Plager, include hypoglycemia (although they did not see this adverse effect in their patients) and lethargy. Therefore, he said, children need a baseline evaluation of vital signs, glucose monitoring, and an echocardiogram. He added that "as long as the child has adequate oral intake, the risk for hypoglycemia is pretty low."

Researchers do not yet understand the mechanism of action of propranolol in the treatment of hemangiomas. "We also don't know the ideal time to start treatment," Dr. Plager told conference attendees.

Dr. Plager and Dr. Roarty have disclosed no relevant financial relationships.

J AAPOS. 2010;14:251-256. Abstract

American Academy of Ophthalmology (AAO) and Middle East Africa Council of Ophthalmology (MEACO) 2010 Joint Meeting: Late Breakers Symposium 33. Presented October 19, 2010.

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