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Original Investigation
April 15, 2021

Efficacy and Safety of Propranolol vs Atenolol in Infants With Problematic Infantile Hemangiomas: A Randomized Clinical Trial

Author Affiliations
  • 1Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
  • 2Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
  • 3Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China
  • 4Department of Dermatology, West China Hospital of Sichuan University, Chengdu, China
  • 5Department of Pediatrics, West China Second University Hospital, Sichuan University Chengdu, China
  • 6Department of Pediatric Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, China
  • 7Department of Pediatric Surgery, Sichuan Women and Children’s Hospital, Chengdu, China
  • 8Department of Pediatric Surgery, Chengdu Women and Children’s Central Hospital, Chengdu, China
JAMA Otolaryngol Head Neck Surg. 2021;147(7):599-607. doi:10.1001/jamaoto.2021.0454
Key Points

Question  In light of the positive efficacy and safety of atenolol, can it be used as a promising therapy for infantile hemangiomas?

Findings  In this randomized clinical trial of 377 patients with infantile hemangiomas, the response rate and hemangioma activity score after 6 months of treatment were similar in the propranolol and atenolol groups. Adverse events were more common in the propranolol group than the atenolol group.

Meaning  Atenolol can be considered a first-line treatment for infantile hemangiomas.


Importance  Propranolol has become the first-line therapy for problematic infantile hemangiomas (IHs) that require systemic therapy. However, different adverse events have been reported during propranolol treatment. The positive efficacy and safety of atenolol raise the question of whether it could be used as a promising therapy for IH.

Objective  To compare the efficacy and safety of propranolol vs atenolol in infants (between age 5 and 20 weeks) with problematic IHs who required systemic therapy.

Design, Setting, and Participants  This was a prospective, multicenter, randomized, controlled, open-label clinical trial conducted in collaboration among 6 separate investigation sites in China from February 1, 2015, to December 31, 2018. A total of 377 patients met the criteria for inclusion and were randomized to the propranolol (190 [50.4%]) and atenolol (187 [49.6%]) groups. Data were analyzed in June 2020.

Interventions  Participants were randomized to receive either propranolol or atenolol for at least 6 months. They completed efficacy assessments at 2 years after the initial treatment.

Main Outcomes and Measures  The primary outcome was any response or nonresponse at 6 months. The key secondary outcome was changes in the hemangioma activity score.

Results  Of 377 participants, 287 (76.1%) were female, and the mean (SD) age was 10.2 (4.0) weeks in the propranolol group and 9.8 (4.1) weeks in the atenolol group. After 6 months of treatment, in the propranolol and atenolol groups, the overall response rates were 93.7% and 92.5%, respectively (difference, 1.2%; 95% CI, −4.1% to 6.6%). At 1 and 4 weeks after treatment, and thereafter, the hemangioma activity score in the atenolol group aligned with the propranolol group (odds ratio, 1.034; 95% CI, 0.886-1.206). No differences between the propranolol group and atenolol group were observed in successful initial responses, quality of life scores, complete ulceration healing times, or the rebound rate. Both groups presented a similar percentage of complete/nearly complete responses at 2 years (82.1% vs 79.7%; difference, 2.4%; 95% CI, −5.9% to 10.7%). Adverse events were more common in the propranolol group (70.0% vs 44.4%; difference, 25.6%; 95% CI, 15.7%-34.8%), but the frequency of severe adverse events did not differ meaningfully between the groups.

Conclusions and Relevance  In this randomized clinical trial, when compared with propranolol, atenolol had similar efficacy and fewer adverse events in the treatment of infants with problematic IHs. The results suggest that oral atenolol can be used as an alternative treatment option for patients with IH who require systemic therapy.

Trial Registration  ClinicalTrial.gov Identifier: NCT02342275

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