Beta-blocker explored

Orlando, FL-Propranolol, a nonselective beta-blocker, is an effective treatment for infantile (capillary) hemangiomas that might be used in place of steroids in selected cases. David Plager, MD, talked about the use of propranolol for infantile hemangiomas during Pediatric Subspecialty Day at the annual meeting of the American Academy of Ophthalmology.

Traditionally, infantile hemangiomas have been treated with either an oral steroid or a combination of two steroids, short acting and longer acting, injected throughout the lesions.

"Intralesional injections work very well and have been used for many years," said Dr. Plager, professor of ophthalmology and director of pediatric ophthalmology and strabismus service at Indiana University School of Medicine, Indiana University Medical Center, Indianapolis. The down side are the side effects, which can include loss of vision, although rarely.

The effectiveness of propranolol for capillary hemangiomas was discovered serendipitously by French physicians who noted that children with hemangiomas who were treated with the drug for cardiac issues had resolution of the hemangiomas. Propranolol currently is used in children to treat cardiac arrhythmias, some congenital heart defects, and as migraine prophylaxis.

The side effects of propranolol include hypotension, bradycardia, and hypoglycemia. Others are bronchospasm, sleep disturbance, gastrointestinal disturbance, and rash. Because of concerns about side effects, some physicians (Lawley et al. Pediatric Dermatology. 2009;26:610-614) recommend initiating propranolol therapy as a hospital in-patient for infants under 3 months (or with home nurse assessment if over 3 months) with careful monitoring of baseline vital signs and glucose levels, an echocardiogram, and electrocardiogram.

At the other end of the spectrum, cardiologists in Dr. Plager's institution recommended using propranolol with a less onerous outpatient approach based on their own history of safety with the drug as well as the fact that there had been no reports of death or serious cardiovascular morbidity from beta-blocker exposure in children under 6 years of age in the English language literature (Love JN, Sikka N. J Emerg Med. 2004;26:309–314).

Based on this, Dr. Plager and colleagues developed a treatment algorithm for initiating treatment with propranolol. They recommend a careful physical examination and electrocardiogram; if the results are normal, propranolol is started. If the child has abnormal findings, Dr. Plager orders an echocardiogram; if the echocardiogram is normal, propranolol is administered, and if the echocardiogram is abnormal, the child is referred to a cardiologist. He began using propranolol according to this protocol in 2008.

Dr. Plager and his colleagues reported their results with 17 patients, 16 of whom were treated as outpatients (J AAPOS. 2010;14:251-256).

"The results were quite good," Dr. Plager said. "The side effects were minimal. To say that there has been an explosion of interest in this medication would be an understatement."

Seventeen additional studies have been published in the ophthalmic literature and many others in the plastic surgery and dermatology literature since that initial report in 2008.

The side effects of propranolol are still an issue, a major one being hypoglycemia in children treated with the drug. Dr. Plager noted that virtually all of the children reported to date with symptomatic hypoglycemia had a common denominator, extended reduced oral intake. This was typically due to NPO status prior to surgery, intercurrent illness, or other GI distress.

FYIDavid Plager, MD
E-mail: dplager@iu.edu

Dr. Plager has no financial interest in the subject matter.