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    Taking a closer look at oral propranolol as first-line treatment in infantile hemangioma

    Oral propranolol is prescribed for the most serious cases. In this Lancet review, experts highlight some considerations for treatment.

    Most cases of infantile hemangiomas do not require therapy due to their tendency to regress spontaneously, but for the few infants with complicated cases, oral propranolol has become the first-line treatment, researchers wrote in a review on infantile hemangioma published in The Lancet.

    Led by Christine Léauté-Labrèze, M.D., of Pellegrin Children’s Hospital in Bordeaux, France, researchers reviewed studies published between 2008 and 2015 finding that 2-3 mg/kg of propranolol daily for six months, resulted in a response rate of 96-98% of 1,264 cases. Sixty percent of cases experienced a complete or nearly complete regression.

    “Propranolol has been shown to be effective for obstructive, life-threatening airway infantile hemangioma and for ulcerated infantile hemangioma. Its exact mechanisms of action are incompletely understood so far, but propranolol could regulate hemangioma cell proliferation via catecholamines or the VEGF pathway,” the authors wrote in the review, which was published in January.

    There has been “tremendous progress” in infantile hemangioma research in the last 10 years. Risk factors have been identified, more is known about its pathophysiology, more clinical presentations have been documented and propranolol has been well-vetted in the scientific literature.

    Propranolol has been shown to be effective for the most serious cases. The chief indications for treatment are life-threatening infantile hemangiomas that cause heart failure or respiratory distress; tumors posing functional risks such as visual obstruction, amblyopia or feeding challenges; ulceration; and severe anatomic distortion, especially on the face.

    The literature search revealed that the beta-blocker propranolol should be administered as early as possible to avoid potential complications.

    Between 20-25% of patients experience the most common side effects of treatment: sleep disorders, somnolence and irritability. Fortunately, side effects are reversible and mostly benign. Less common side effects (>1%) include bronchospasm or bronchiolitis and asymptomatic hypotension. Even more rare are more serious side-effects of bradycardia, complications of undiagnosed atrioventricular blocks, and hypoglycaemia are possible. In most cases, discontinuing the treatment will successfully resolve side effects, but in 10-15% of cases, recurrence after discontinuation occurs — primarily in segmental and deep infantile hemangioma. Temporary discontinuation is recommended in cases of poor oral feeding, diarrhea and obstructive bronchitis.

    “Because propranolol is a highly lipophilic β blocker and thus capable of crossing the blood–brain barrier, there are theoretical concerns regarding potentially relevant neurodevelopmental or cognitive side-effects of propranolol,” researchers wrote.

    NEXT:  Referring patients

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