Objective: There remains variability in initiation protocols for propranolol in patients with infantile hemangiomas including rapid inpatient titrations and slow outpatient protocols. The aim of this study was to determine the utility of a 2-hour outpatient visit to initiate propranolol treatment.
Methods: The outcome measures of utility were complication rates (hypoglycemia, bradycardia, hypotension) and overall cost. 166 patients were included over a 5-year period. All patients were initiated at goal dose of propranolol (2 mg/kg/day divided twice daily). Three prospective cohorts were compared: 48-hr inpatient titration (0.5 mg/kg/dose for 2 doses then 1 mg/kg/dose for 2 doses), 24-hr observation admission (1 mg/kg/dose for 2 doses), and a 2-hour outpatient visit (1 mg/kg/dose for 1 dose). All patients received a screening EKG and hypoglycemia teaching. Patients were excluded for expedited PHACES evaluation, subglottic stenosis, EKG with conduction delay, or if already admitted at time of diagnosis. Gestational age and weight were not determining factors.
Results: There were zero episodes of hypoglycemia, hypotension or bradycardia during initiation or maintenance phase for all cohorts. Cost was dramatically different between the cohorts; controllable expenses were reduced by 1000%. The average cost for the 48-hour cohort was $3,521 versus $350 for the 2-hour outpatient cohort. The total cost savings in the first year of the 2-hour outpatient initiation cohort was over $200,000.
Conclusion: Outpatient initiation of propranolol with a single dose at goal (1 mg/kg/dose twice/day) and a 2-hour observation period is safe and cost effective.