An Intra-patient Dose Escalation Study of Propranolol in Patients With Lymphedema
Phase: PHASE2
Conditions: Primary Lymphedema
Sponsor: Columbia University

 
 
 
 
 
Page 1 
79 
Activated: 
 
Version Date: 
03/22/18 
Closed: 
 
Version #: 
1 
 
  NCT02595996 
 
 
 
 
 
Evaluation of lymphedema severity and treatment response to propranolol using novel imaging 
technologies  
(Abbrievated title: Evaluation of lymphedema severity and treatment response) 
 
Participation Limited to Columbia University  
 
 
 
 
 
 
 
Center: 
 
 
 
 
 
 
Columbia University Medical Center 
 
 
 
Principle Investigator: 
June K. Wu, MD 
 
Division of Plastic Surgery 
 
161 Fort Washington Ave Suite 511 
 
Phone: 212-342-3704 
 
Fax: 212-305-9626 
 
Email: jw92@cumc.columbia.edu 
 
 
 
 
 

 
 
 
 
 
Page 2 
TABLE OF CONTENTS 
SECTION 
PAGE 
 
STUDY COMMITTEE 
4 
ABSTRACT 
5 
EXPERIMENTAL DESIGN SCHEMA 
6 
1.0 
GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
6 
1.1 
Primary Aims 
6 
1.2 
Secondary Aims 
6 
2.0 
BACKGROUND 
6 
2.1 
Introduction/Rationale for Development 
7 
2.2 
Preclinical Studies 
8 
2.3 
Pediatric Studies 
9 
2.4 
Overview of Proposed Pediatric Study 
10 
3.0 
SCREENING AND STUDY ENROLLMENT PROCEDURES 
12 
3.1 
General Guidelines 
12 
3.2 
Patient Registration 
13 
4.0 
PATIENT ELIGIBILITY 
13 
4.1 
Inclusion Criteria 
13 
4.2 
Exclusion Criteria 
14 
5.0 
TREATMENT PROGRAM 
15 
5.1 
Overview of Treatment Plan 
15 
5.2 
Dose Escalation Schema 
15 
5.3 
Grading of Adverse Events 
16 
6.0 
DOSE MODIFICATIONS FOR ADVERSE EVENTS 
16 
6.1  
Dose Modifications for Potential Propranolol Specific Side Effects 
16 
7.0 
SUPPORTIVE CARE AND OTHER CONCOMITANT THERAPY 
18 
7.1 
Concurrent Anti Lymphatic Malformation Therapy 
18 
7.2 
Investigational Agents 
18 
7.3 
Supportive Care 
18 
7.4 
Concomitant Medications 
18 
8.0 
EVALUATIONS/MATERIAL AND DATA TO BE ACCESSIONED 
19 
8.1 
Required Clinical, Laboratory and Disease Evaluation 
19 
8.2 
Correlative Studies 
20 
8.3 
Central Radiology Review 
20 
9.0 
AGENT INFORMATION 
20 
9.1 
Drug Name 
20 
10.0 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY 
CRITERIA 
21 
10.1 
Criteria for Removal from Protocol Therapy 
21 
10.2 
Off Study Criteria 
22 
11.0 
STATISTICAL AND ETHICAL CONSIDERATIONS 
22 
11.1 
Sample Size and Study Duration 
22 
11.2 
Study Design/ Endpoints 
22 

 
 
 
 
 
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11.3  
Analysis of Secondary Endpoints 
23 
11.4 
Ethical Considerations 
25 
11.5 
Reporting and Exclusions 
25 
11.6 
Inclusion of Children, Women and Minorities 
25 
12.0  
EVALUATION CRITERIA 
25 
12.1 
Adverse Events 
25 
12.2  
Disease Parameters 
25 
12.3 
Methods for Evaluation of Measurable Disease 
25 
12.4 
Response 
26 
13.0 
ADVERSE EVENT REPORTING REQUIREMENTS 
26 
13.1 
Steps to Determine If an Adverse Event Is To Be Reported In an Expedited 
Manner Error! Bookmark not defined. 
14.0 
RECORDS, REPORTING, AND DATA AND SAFETY MONITORING PLAN 
27 
14.1 
Data Reporting 
27 
14.4 
Data and Safety Monitoring Plan 
27 
REFERENCES 
31 
 

 
 
 
 
 
Page 4 
STUDY COMMITTEE 
CO-INVESTIGATOR  
 
Dympna Gallagher, PhD 
Obesity Research Center 
21 Audubon Ave 
New York, NY 10032 
Phone: 212-523-4196 
Fax: 
 
e-mail: dg108@cumc.columbia.edu 
 
 
CO-INVESTIGATOR 
RESEARCH NURSE, TBA 
Jacques Merab, MD 
, RN or NP 
Cardiology 
Discipline 
161 Fort Washington Ave, 6th Fl 
Address 
New York, NY 10032 
Address 
Phone: 212-305-7934 
Phone: 
Fax: 
 
Fax: 
 
e-mail: jpm6@cumc.columbia.edu 
e-mail:  
 
 
CO-INVESTIGATOR 
STUDY COORDINATOR/DATA MANAGER 
Thomas Starc, MD 
TBA 
Pediatric Cardiology 
Dept 
3959 Broadway, 2N 
Address 
New York, NY 10032 
Address 
Phone: 212-305-4432 
Phone: 
Fax: 
 
Fax: 
 
e-mail: tjs1@cumc.columbia.edu 
e-mail:  
 
 
CO-INVESTIGATOR 
STUDY STATISTICIAN  
Angela Kadenhe-Chiweshi, MD 
Codruta Chiuzan,Ph.D. 
Pediatric Surgery 
Biostatistics 
3959 Broadway, 2N-215 
Mailman School of Public Health 
New York, NY 10032 
722 W 168th St, 6th Fl 
Phone: 212-342-8586 
Phone:  
Fax: 
 
Fax: 
 
e-mail: avk2102@cumc.columbia.edu 
e-mail: cc3780@cumc.columbia.edu 
 
 
CO-INVESTIGATOR 
 
,MD 
 
Pathology 
 
Address 
 
Address 
 
Phone: 
 
Fax: 
 
 
e-mail:  
 
 
 
Study Exemption from IND Requirements per 21 CFR 312.2(b) is pending 

 
 
 
 
 
 
Page 5 
ABSTRACT 
 
Lymphatic malformations (LMs) arise from abnormal development of lymphatic vasculature. 
Associated morbidity can be severe, including bleeding, sepsis, airway and visual axis obstruction 
(cervicofacial LMs), respiratory compromise (thoracic LMs), ascites and malabsorption (peritoneal/pelvic 
LMs), and limitations on mobility (extremity LMs). Severe symptoms can be life-threatening. Treatment 
options are often palliative and recurrence is common [1, 2]. Recently, results in our laboratory 
demonstrated that propranolol, a pan beta-adrenergic receptor (AR) antagonist, had cytotoxic and anti-
proliferative effects against cells isolated from LM tissues. Preliminary results from treating symptomatic 
LM patients at our institution with propranolol at a dose range from 0.7-1mg/kg/day demonstrated a 70% 
positive response rate, with patients reporting improvement in their symptoms.  
 
Despite severe morbidities and even mortality, there are no effective, objective, repeatable 
diagnostic tools to evaluate lymphedema severity, and there is no FDA-approved medical treatment for this 
devastating condition. Thus, we hypothesize that quantitative magnetic resonance (QMR) can accurately 
and quickly evaluate lymphedema severity, and propranolol will be effective in improving lymphedema, 
using QMR as a treatment response evaluator. 
 
QMR has been validated in obesity research but has never been validated for lymphedema. It has 
the ability to quantify total body water, extracellular and intracellular water. Lymphedema results when 
there is excess, pathological accumulation of fluid in the interstitial spaces (extracellular water). Therefore, 
QMR has the potential to sensitively and accurately quantify the severity of extracellular water 
accumulation, thus severity of lymphedema. 
 
Propranolol has been used for different indications for many years. Most recently, propranolol 
gained FDA approval for use in infants with hemangiomas, a related vascular anomaly (Hemangeol ®)  
(http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails, 
accessed May 23, 2014). FDA-approved dose range for treating hemangiomas in infants (>5 weeks old, 
>2kg) ranged from 1-3mg/kg/day in divided doses. Propranolol has also been used to treat pediatric 
supraventricular tachycardia at doses up to 4mg/kg/day[3, 4]. However,AR antagonists are not without 
potential adverse effects, including hypotension, bradycardia, hypoglycemia, bronchospasms, and sleep 
disturbances[5]. 
 
The dose range of 0.7-1mg/kg/day was chosen for our LM patients as it was the low end of dose 
range for infants treated with propranolol for problematic hemangiomas. At this dose, no significant 
hemodynamic adverse effects were noted in our LM patients. However, when patients stopped propranolol 
or their dose fell below 0.7mg/kg/day, they suffered rebound worsening of their symptoms.  Moreover, 
inflammatory events such as infections temporarily overcame the effects of 0.7-1mg/kg/day of propranolol. 
Thus, it is unknown whether we have achieved maximum propranolol efficacy at our current dose range. 
We propose to escalate propranolol dosages up to 3mg/kg/day in this study, still well below the dose ranges 
currently used in clinical settings.  
 
In this clinical trial, we will examine whether QMR can quickly and accurately quantify 
lymphedema severity, as well as evaluating whether we have optimized propranolol usage for treatment of 
LM patients. The primary endpoints for this study are to: 1) validate QMR as a tool for evaluation of 
lymphedema, and 2) ascertain whether LM patients can tolerate higher doses of propranolol, as measured 
by known propranolol adverse effects and patient-reported symptoms. A secondary endpoint will address 
whether patient-reported LM symptoms and quality of life are improved with higher doses of propranolol; 
objective findings such as LM size on physical examination and imaging studies will be analyzed as well. 
In addition, LM tissue biopsies will acquired from patients before and after propranolol treatment for further 
analyses of disease progression. 
 

 
 
 
 
 
 
Page 6 
EXPERIMENTAL DESIGN SCHEMA 
The dose escalation for each patient will be as follows (Table 1): 
 
 
*Weight will be rounded to the nearest 10-kg increment 
aDose escalation in the absence of clinical contraindications. 
bIn the presence of clinical contra-indications, the patients will 
remain on their current level of dosage, or decreased to the 
previous level, or have their medications held. 
A maximum of 8-weeks of therapy may be administered.  
 
 
 
1.0 
GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
 
1.1 
Primary Aims 
1.1.1 
To assess whether QMR can accurately and quantitatively assess lymphedema 
severity. QMR results will be compared to validated, gold standard quantitation of 
total body, extracellular and intracellular water distribution using deuterium 
(“heavy water”) and sodium bromide (NaBr) and whole body MRI. 
1.1.2 
To assess tolerability, and define and describe the toxicities of propranolol, 
administered two times daily in patients with lymphedema both by  
1.1.2a subjective patient-reported symptoms (energy levels, fatigue, dizziness, 
respiratory issues/wheezing, activities of daily living) by validated questionnaires 
 
(SF-36, LYMPH—ICF, LYMPH—ICF--LL) 
1.1.2b objective measures (heart rate, blood pressure) by physical exam 
 
 
1.2 
Secondary Aims 
 
 
1.2.1 
to assess disease-specific lymphedema patients’ response to propranolol  
 
 
1.2.1a to assess subjective patient-reported lymphedema-related symptoms 
 
 
 
i) 
Validated questionnaires:  LYMPH—ICF, LYMPH—ICF--LL 
 
 
 
 
 
1.2.1b to assess objective measures 
 
 
 
i) 
Physical examination: Weight, BMI, limb girth discrepancy 
 
 
 
ii) 
Imaging evaluation: MRI 
 
 
 
iii) 
Blood and tissue analysis: circulating and tissue biomarkers 
iv) 
Genetic analysis: correlation of somatic mutations to propranolol response 
 
 
 
Table 2. Primary and secondary endpoints 
 
 
 
2.0 
BACKGROUND 
 
Propranolol
Dose Schedule*
Subjective
Objective
Other 
Week 1 
(initiation)
0.5 mg/kg/day, divided bid
Enterance 
Interview Quality 
of Life 
Questionnaire
Physical 
Exam, 
Imaging
Blood	Draw,	
Tissue	Biopsy	
Week 2
1 mg/kg/day, divided bida,b
Quality of Life 
Questionnaire
Physical 
Exam
Week 4
2 mg/kg/day, divided bida,b
Quality of Life 
Questionnaire
Physical 
Exam
Blood	Draw
Week 6 
3 mg/kg/day, divided bida,b
Quality of Life 
Questionnaire
Physical 
Exam
Week 8 
3 mg/kg/day, divided bida,b
Exit Interview, 
Quality of Life 
Questionnaire
Physical 
Exam, 
Imaging
Blood	Draw,	
Tissue	Biopsy	
Assessments
Table 1. Propranolol intra-patient dose escalation schedule and assessments
Primary Endpoint (Aim 1)
Secondary Endpoint (Aim 2)
Subjective Assessment
Questionnaires QOL
Questionnaires
Short Form 36
Lymph-ICF
Lymph-ICF-LL
Symptoms (Drainage, pain)
Activity levels
Clothing size change
Objective Assessment
Clinical and radiological Exam
Clinical and radiological Exam
Blood pressure
Heart rate
Blood sugar
Whole Body MRI
QMR
Deuterium and NaBr
Weight, BMI
Limb girth discrepancy
CTCAE Grading for Lymphedema
Imaging: QMR, whole body MRI
Blood and Tissues
Circulation biomarkers
IHC lymphatic vessel phenotype
PiK3CA mutational analysis
Next Gen sequencing analysis

 
 
 
 
 
 
Page 7 
2.1 
Introduction/Rationale for Development 
 
Primary lymphedema is a vascular malformation of the lymphatic system, or a 
lymphatic malformation (LM)[6]. In lymphedema, regional edema develops, most 
commonly in the lower extremities, although it can affect any location[7, 8]. Primary 
lymphedema is classified based on the age of onset: congenital, childhood (praecox), and 
adulthood (tarda)[9]. Primary lymphedema with early onset (excluding tarda) is considered 
rare and estimated to affect 1.2/100,000 people under the age of 20[9], while another study 
reported a 1/6000 incidence for primary lymphedema presenting under the age of 36[10]. 
Since adult-onset of primary lymphedema is defined to occur after 35, these data possibly 
underestimate the true incidence.  
 
Lymphatics function to maintain tissue fluid homeostasis, immune surveillance 
and lipid uptake from the intestines. Defective lymphatic development can cause both mass 
effects and physiologic derangements.  Over time, the abnormal lymphatic drainage leads 
to chronic, progressive swelling of tissues, increased adipose deposition and fibrosis[8], 
interfering with ambulation and use of the affected extremity. Such abnormal lymphatic 
tissue also harbors pools of lymph, which do not drain or circulate normally, and are 
consequently static and prone to severe infections. Cutaneous involvement can lead to 
weeping of lymph or blood-tinged lymph from skin lesions. Psychological trauma can be 
experienced by these patients, who may struggle with the social isolation consequent to 
physical differences and repeated illness[7-9]. Collectively, co-morbidities of lymphedema 
include pain, swelling, lymph leakage, hyperkeratosis, interference with function, cellulitis 
and sepsis and produce a severe lifelong burden of disease associated with significant 
morbidities.  
 
Because LM pathobiology is poorly understood, existing treatments are largely 
empirical, and often ineffective. Fuerthermore, there are no objective diagnostic toolds. 
Treatment options are limited and ranges from lymphatic massage, compression garments, 
diuretics[11, 12], to surgery[13], only with partial success. Residual tissue after incomplete 
resection is prone to recur when infectious or inflammatory stimuli occur, and recurrence 
is frequent. Without effective diagnostic tools, any response to treatment can not be 
documented or quantified. Patients with primary lymphedema are frequently therapeutic 
orphans and new approaches to treatment are desperately needed. Interest in identifying 
medical treatments has been great, although limited by the lack of knowledge of the basic 
pathophysiology of these lesions. 
 
Recently our laboratory has identified two cell types in LMs: lymphatic 
malformation progenitor cells (LMPCs) and lymphatic malformation endothelial cells 
(LMECs) that are potential therapeutic targets as they can both recapitulate the LM 
phenotype in our LM mouse model[14]. In a screen of different drugs using LMPCs, we 
identified propranolol, a non-selective pan-beta adrenergic receptor (βAR) inhibitor, as a 
candidate for lymphedema/LM treatment. We find low levels of β2AR expression in 
normal lymphatic endothelium, and high levels of β1AR/β2AR expression in LMPC/ECs 
of LM tissues. In vitro, propranolol suppresses LMPC/EC proliferation, and in our LM 
mouse model, propranolol decreases the abnormal lymphatic vessel dilation that is 
associated with lymphatic vessel dysfunction. These data suggest that propranolol 
normalizes LM vessel phenotype, possibly by decreasing LM cell proliferation. 
 
In addition to our laboratory studies, there are prior anecdotal reports of 
propranolol efficacy in children with lymphatic anomalies[15-18]. More recently, it has 
become the therapy of choice for infants and children with complicated hemangiomas[19], 
and FDA approval for Hemangeol (March 2014) as a treatment for infantile hemangiomas 
heralded the first time any medications has obtained FDA approval in treatment of a 
vascular anomaly.  Based on our pre-clinical data, published anecdotal reports of efficacy 

 
 
 
 
 
 
Page 8 
against lymphatic anomalies, FDA approval for treatment of a vascular anomaly, and the 
lack of effective treatments led us to offer propranolol to families of severely affected 
patients.  
 
In a retrospective study, we have found that propranolol was effective in 5 out of 
6 lymphatic malformations patients (2 out of 2 patients with lymphedema) with a dose of 
0.75mg/kg/day-1mg/kg/day (Wu, et al, unpublished). LM patient symptoms improvement 
included reduced edema, infections, and need for transfusions without any obvious adverse 
events (unpublished data). However, we are at the lower end of propranolol dosing, when 
compared to other vascular anomalies[19, 20]. In fact, in one lymphedema patient, 
symptoms reappeared when the daily propranolol dose was reduced in half. In the other 
lymphedema patient, the girth of his lower extremities increased and lymphedema recurred 
to pre-treatment levels after propranolol discontinuation. Thus, we find that propranolol in 
the dose window of 0.75mg/kg/day-1mg/kg/day improves lymphedema symptoms, but is 
not curative. It is possible that increasing the propranolol dose will further improve the 
lymphedema and minimize morbidities associated with this condition. In pediatric patients, 
4mg/kg/day of propranolol can be safely used for the treatment of arrhythmias such as 
supraventricular tachycardia[3, 4]. Our goal of the trail is to optimized propranolol dosing 
to treat our lymphedema patients. 
 
The initial positive experience with this therapy, and its lack of apparent toxicity, 
suggest that systematic evaluation of the effect of propranolol in patients with lymphedema 
may provide a useful addition to the therapeutic armamentarium. 
 
In the United States, most lymphedema patients are monitored for response to 
therapy with clinical examinations. Therefore, establishment of standardized, validated 
tools to stage severity of lymphedema, as well as treatment response, is urgently needed as 
well to test the efficacy of any proposed treatment method. In addition to the currently used 
weight, BMI, and clinical examinations, we have proposed to collaborate with Dr. Dympna 
Gallagher, as expert is using MRIs to quantify adiposity and edema in patients[21-23] to 
monitor treatment response in our study patients (details on assessment below). Therefore, 
as an endpoint in the second aim of our study, we will use imaging with MRIs to evaluate 
treatment response. In addition to imaging studies, we also propose to study circulating 
biomarkers and genetic profiling of lymphedema tissues and correlate with treatment 
response. 
 
2.2 
Preclinical Studies 
 
2.2.1 
Anti Lymphatic Malformation Activity 
 
Our laboratory has used a cytotoxicity assay to screen for candidate molecules for 
use against LMPCs and LMECs. Our results demonstrated that propranolol was cytotoxic 
against both LMPCs and LMECs with an LD50 300-500m. At lower concentrations (50-
100m), propranolol had anti-proliferative effects on both LMPCs and LMECs, and in 
LMPCs upregulated transcript expression of lymphatic endothelial differentiation genes 
(Prox1, podoplanin, VEGFR-2, VEGFR-3, and LYVE1) in a dose-dependent manner 
(range 10-100m).  When LMPCs were injected into nude mice, the development of 
dilated lymphatic channels was disrupted in mice that were treated with propranolol 
(6mg/kg/day) when compared to control mice. In mice the improved lymphatic vessel 
phenotype correlated with reduced infiltration of inflammatory macrophages.  Thus, both 
in vitro and in vivo pre-clinical data demonstrated propranolol was efficacious against LM 
formation and LM physiology. 
 
2.2.2 
Animal Toxicology (if applicable) 
Preliminary results in our laboratory treating immunosuppressed mice in our 

 
 
 
 
 
 
Page 9 
murine LM model demonstrated that these mice tolerated up to 40mg/kg/day of 
propranolol by echocardiography. Based on general clinical observations, these mice 
continued to behave normally, without signs of weight loss, lethargy, or mortalities. 
Propranolol has been used in other murine studies with no reported toxicities or intolerance 
reported[24, 25]. We have found that 6mg/kg/day, a dose far below the 40mg/kg/day, in a 
mouse model was sufficient to improve LM vessel abnormalities. Using equivalent surface 
area dosage conversion factors, 6mg/kg/day in a mouse correlated to 3.3-4.8mg/kg/day, 
higher than the 0.7-1mg/kg/day we used to treat our patients 
(https://ncifrederick.cancer.gov/lasp/acuc/frederick/Media/Documents/ACUC42.pdf, 
accessed Nov 7, 2015)[26, 27].  
 
2.2.3 
Preclinical Pharmacokinetic Studies 
Preliminary in vitro studies performed in our laboratory has shown that propranolol 
had anti-proliferative effects in “low-dose” range (in the nanomolar range: 10-9 to 10-7M). 
However, as propranolol dosage is increased, it exhibits cytotoxic effects on cells (in the 
micromolar range: 10-6 to 10-4M). The anti-proliferative effects were also accompanied by 
a does-dependent decrease in cAMP activity. The cytoxic dose range coincided with 
increased MAPK activation (ERK 1/2). Our results are consistent with other reports that 
propranolol had partial agonist effects with MAPK activation [Azzi, Baker, Galandrin].  
The dose range of propranolol used to treat infantile hemangiomas ranged from 1-
3mg/kg/day. This correlates to plasma concentration of 21-448ng/mL (private 
communication, Dr. Christine Cazeau) corresponding to 10-6 to 10-5M dose range. In adults 
given 0.5-1mg/kg/day, an average of 50ng/mL was achieved[28, 29]. This correlates to 
approximately 10-6M range. We propose to study patient responses at 2- to 3-mg/kg/day, 
corresponding to 10-6 to 10-5M, within the 10-6 to 10-4 anti-proliferative dose range. 
 
2.3 
Pediatric Studies 
 
2.3.1 
Prior Experience in Children  
Recent reviews of the activity of propranolol in children with vascular anomalies 
report apparent efficacy in infantile hemangioma[19, 20, 30], and anecdotal 
experience with lymphatic malformations of the tongue and other anatomic 
locations[15-18]. The biologic basis for these effects is not known, but is 
hypothesized to relate to role of beta-adrenergic receptors in regulation of 
angiogenic factor expression[31-35]. Our pilot biologic studies of cells derived 
from lymphatic malformations suggest that beta-adrenergic signaling functions as 
survival pathway in both lymphatic progenitor and lymphatic endothelial cells. 
 
2.3.2  Risk Assessment 
 
2.3.2.1  Hypotension and Bradycardia: 
Studies have shown that the peak effect of oral propranolol on blood pressure and 
heart rate occurs 1 to 3 hours after it is taken[28, 29]. As such, current recommendations 
are that patients should have HR and BP done at baseline and also hourly for the first 2 
hours after a dose increase, and at least once after the target dose is achieved. As dose 
response is generally most significant after the first dose, once normal vitals are obtained 
with the first dose there is no recommendation that vitals should be re-checked at the same 
dose level, unless the patient is very young, has cardiovascular issues or co-morbidities, or 
if clinical complaints arise. 
 
Pediatric patients must have vitals within the normal range for their age group, and 
adults with normal established vitals, prior to starting a dose. Dose escalations will take 

 
 
 
 
 
 
Page 10 
place as given in the table above. Patient must have no evidence of clinical 
contraindications with acceptable HR and BP parameters prior to dose escalation 
occurring. If individuals are found to have a fall in their blood pressure or heart rate outside 
of normal range, they will have dose de-escalation to the prior tolerated dose level. If they 
are able to tolerate this lower dose level with normal parameters and no clinical 
symptomatology they will have a re-challenge of the dose escalation after 2 weeks.  If on 
re-escalation they once again have fall in HR and blood pressure, they will again undergo 
dose de-escalation to the prior tolerated dose level for 2 weeks and re-evaluated again until 
the end of the 8-week study. If the patients are already at the lowest doses, they will be 
given a 2-week rest and re-evaluated after 2 weeks. If HR and BP then fall within normal 
parameters they will be reintroduced to the study at the lowest study dose of propranolol. 
If patient is once again found to have fall in HR/BP below normal parameters for age upon 
an attempt to re-start propranolol, they will be removed from the study. That is, all patients 
who do not tolerate a dose increase for the 2nd time will be held at the last tolerated dose 
until the end of the study. If a patient cannot tolerate the lowest doses twice, they will be 
removed from the study. 
 
2.3.2.3  Hypoglycemia: 
 
Propranolol has been reported to cause hypoglycemia in infants treated with 
propranolol. While these data is not established in old patients, all study patients will be 
encouraged to keep a regular food schedule and snack if they feel fatigue or dizzy. 
 
If patients become ill for other reasons during the study period (eg URIs, 
gastroenteritis) during the study period, they are encouraged to contact us. Their 
propranolol dose will be held until they are able to tolerate POs. 
 
2.3.2.4 Bronchospasm: 
 
Patients will be monitored for respiratory symptoms such as coughing, wheezing, 
or shortness of breath. 
 
2.3.2 
Pharmacology/Pharmacokinetics/Correlative Biological Studies 
 
Propranolol is well absorbed after oral administration. It is lipophilic and subject 
to significant first-pass hepatic metabolism so that only approximately 25% of propranolol 
reaches the systemic circulation. Peak blood levels occur at about 1-4 hours after an oral 
dose. Multiple metabolic pathways are involved in propranolol elimination (including 
those in the cytochrome P450 system). 
 
2.4 
Overview of Proposed Lymphedema Study 
 
After patients have been registered, screened, and consented (Eligibility Screening 
Worksheet, Registration Form Consent form, HIPAA authorization form, Appendix 1), 
they will be entered into the study. Propranolol as a single agent will be administered orally, 
equally divided, two times a day (BID). Patients may receive up to 8-weeks of therapy in 
the absence of progressive disease or unacceptable toxicity. Treatment response will be 
assessed by patient self-reported symptoms and questionnaires (Appendix 2), physical 
exam, and radiograpically by MRI.  
 
The starting dose of propranolol will be 0.5 mg/kg/day, which is the current 
institutional dose for initial treatment for cardiovascular and hemangioma indications in 
children. Patients will be weighed and their weight will be rounded to the closest 10kg (eg 
50-54kg = 50kg, 55-59 = 60kg).  
Table 1 

 
 
 
 
 
 
Page 11 
*Weight rounded to the nearest 10-kg increment 
aDose escalation in the absence of clinical 
contraindications. 
bIn the presence of clinical contra-indications, the 
patients will remain on their current level of dosage, 
or decreased to the previous level, or have their 
medications held.  
 A maximum of 8-weeks of therapy may be 
administered 
 
 
Studies have shown that the peak effect 
of oral propranolol on blood pressure and heart 
rate occurs 1 to 3 hours after it is taken. As such, current recommendations are that patients 
should have HR and BP done at baseline and also hourly for the first 2 hours after a dose 
increase, and at least once after the target dose is achieved. As dose response is generally 
most significant after the first dose, once normal vitals are obtained with the first dose there 
is no recommendation that vitals should be re-checked at the same dose level, unless the 
patient is very young, has cardiovascular issues or co-morbidities, or if clinical complaints 
arise. 
 
Patients must have vitals within the normal range for their age group prior to 
starting in the study. After the first dose (0.5mg/kg/day), they will be re-evaluated. If their 
heart rate (HR) and blood pressure (BP) are within normal limits (WNL), they will continue 
on this dose for the next week until the next evaluation. If there is a fall below normal range 
(>15%) of HR and BP, they will rest off medications for 2 weeks and re-challenged. If they 
tolerate the dose, they will continue on the study. If they cannot tolerate the lowest dose 
for the 2nd time, they will be removed from the study, as they cannot tolerate the lowest 
dose. 
 
At the 2nd-week re-evaluation, they will be escalated to the new dose (1mg/kg/day) 
if the baselines HR and BP are WNL. Patients will have HR and BP noted after first new 
dose (1mg/kg/day) of propranolol to ensure that the propranolol is tolerated. If the HR and 
BP are WNL, they will continue on this new dose and re-evaluated in 2 weeks for the 4th-
week evaluation. If they have a drop in HR and BP to below normal range, they will be de-
escalated and remain on the prior dose (0.5mg/kg/day) until the next visit (week 4).  
 
At the 4th and 6th-week evaluation, their baseline vitals will be evaluated and their 
propranolol escalated to the next dose (if vitals are WNL) and have their HR and BP 
assessed after first new dose. Propranolol will stay increased or held at old dose depending 
on HR and BP after the first new dose as described above. If on re-evaluation in 2 weeks a 
patient continues to have below normal HR and blood pressure on re-challenge of the 
escalated dose, they will not be escalated and remain at the last tolerated dose for the 
remainder of the 8 week period with no further re-challenges. For patients with below 
normal HR and BP and needed their doses held, they will be reported as AEs. 
 
At each study visit, patients will be asked to complete validated questionnaire to 
assess for tolerance to propranolol treatment, subjective changes in lymphedema 
symptoms, and self-reported function and activities of daily living (SF-36, LYMPH—ICF, 
and LYMPH—ICF—LL) (See attached documents, Appendix 2). Physical examination 
will include weight and BMI, vitals (HR, BP), and measurement of girth of normal and 
affected extremity. 
 
MRIs and blood tests will be performed at study entry and study endpoint to assess 
for changes in lymphedema tissue composition[21-23] in response to propranolol.  
 
Blood draws will be performed at study entry, at the midpoint, and study endpoint 
to assess for changes in circulating biomarkers in response to propranolol treatment. 
Propranolol
Dose Schedule*
Subjective
Objective
Other 
Week 1 
(initiation)
0.5 mg/kg/day, divided bid
Enterance 
Interview Quality 
of Life 
Questionnaire
Physical 
Exam, 
Imaging
Blood	Draw,	
Tissue	Biopsy	
Week 2
1 mg/kg/day, divided bida,b Quality of Life 
Questionnaire
Physical 
Exam
Week 4
2 mg/kg/day, divided bida,b Quality of Life 
Questionnaire
Physical 
Exam
Blood	Draw
Week 6 
3 mg/kg/day, divided bida,b Quality of Life 
Questionnaire
Physical 
Exam
Week 8 
3 mg/kg/day, divided bida,b Exit Interview, 
Quality of Life 
Questionnaire
Physical 
Exam, 
Imaging
Blood	Draw,	
Tissue	Biopsy	
Assessments
Table 1. Propranolol intra-patient dose escalation schedule and assessments

 
 
 
 
 
 
Page 12 
Correlative biomarkers assessed will include markers of progenitor, endothelial, lymphatic, 
macrophage, and adipocyte cells, and expression of beta-adrenergic receptors (Table 3). 
 
Patients will also receive punch biopsies at study entry and at study endpoint to 
assess for expression of biomarkers. Genetic studies will be performed from tissues 
obtained at study entry to evaluate for presence of PIK3CA mutation[36, 37] and correlated 
to response to propranolol. Genomic data generated will be deposited into an NIH database 
per NIH regulations (de-identified). 
 
In the context of this study, we will perform immunohistochemical analyses on 
biopsied tissues to assess alterations in lymphatic vessel/channel formation, and changes 
in inflammation (Table 3).  We have selected markers that we have previously shown to 
be altered by propranolol either in isolated LMPCs in culture or in the mouse model. 
Expression of the beta-adrenergic receptors will be assessed, as propranolol is a pan-beta-
adrenergic receptor antagonist. To date, no tissue nor circulating molecular markers have 
been identified to correlate with LM patient improvement.  Identification of such markers 
could provide an important benefit to affected patients. Morphological changes in the 
lymphatic vasculature will also be quantified using ImageJ software. Student’s T-test will 
be employed to determine significance, with p < 0.05 considered significant. 
 
 
Table 3. Markers to be probed and assessed in blood and tissues 
Progenitor cell markers 
CD133, CD45, podoplanin, CD90, NG2  
Lymphatic endothelial cell 
markers 
VEGFR-2, VEGFR-3, podoplanin, Prox1, 
LYVE1  
Beta-adrenergic receptors  
Beta-1, beta-2, beta-3 adrenergic receptors  
Macrophage markers  
CD68, iNOS, F4/80  
 
 
These analyses have been optimized and validated using discarded de-identified 
involved and uninvolved LM specimens. Fixed frozen tissue will be prepared and 5-micron 
sections generated. Standard immunohistochemistry will be performed with commercially 
available antibodies and H&E staining performed. Results will be captured by microscopy 
and digital camera. Results will be quantified using ImageJ software and Student’s t-test to 
determine significance, with a p < 0.05 considered significant. We have already isolated 
similar specimens from > 10 patients and have obtained consistent results using these 
methodologies. 
 
Analysis of circulating biomarkers will also be done. Identification of pertinent 
circulating biomarkers of a positive response will aid in future studies and minimize the 
need for more invasive procedures.  We will use FACS to determine if LMPCs double 
positive for podoplanin and CD90 are in circulation.  Expression of circulating VEGFR-2 
and VEGFR-3 will also be assessed as it has been reported that propranolol reduced 
circulating VEGFR-3 levels in a patient with a generalized lymphatic anomaly[18]. 
 
 
3.0 
SCREENING AND STUDY ENROLLMENT PROCEDURES 
 
3.1 
General Guidelines 
 
Eligible patients will be registered on-study at Columbia University by the Study 
Coordinator. The required forms (Eligibility Screening Worksheet and Study Registration 
Form) can be found in Appendix 1. 
 
Following registration, patients should have baseline evaluations (physical 
examination, EKG, MRI, blood draw and tissue biopsy—see Table 8) before 
beginning protocol treatment within 14 days.  Issues that would cause treatment delays 
should be discussed with the Principal Investigator. If a patient does not receive protocol 

 
 
 
 
 
 
Page 13 
therapy following registration, the patient’s registration on the study may be canceled. The 
Study Coordinator should be notified of cancellations as soon as possible. 
 
3.2 
Patient Registration 
To register a patient, the following documents should be completed by the research nurse, 
PI, or co-Investigator and faxed [212-305-9626] or e-mailed [jw92@cumc.columbia.edu] 
to the Study Coordinator/Data Manager: 
 
Copy of required laboratory and radiology tests 
 
Signed patient consent form 
 
HIPAA authorization form 
 
Other appropriate forms (e.g., Eligibility Screening Worksheet, Registration 
Form)  
 
To complete the registration process, the Study Coordinator will: 
 
Assign a patient study number. 
 
Register the patient on the study. 
 
 
 
4.0 
PATIENT ELIGIBILITY  
Baseline evaluations are to be conducted within 2 weeks (14 days) prior to start of protocol therapy.  
In the event that the patient’s condition is deteriorating, laboratory evaluations should be repeated 
within 48 hours prior to initiation of the next dose escalation of propranolol. 
 
Important note: The eligibility criteria listed below are interpreted literally and cannot be 
waived. All clinical and laboratory data required for determining eligibility of a patient 
enrolled on this trial must be available in the patient’s medical or research record which will 
serve as the source document for verification at the time of audit. 
 
4.1 
Inclusion Criteria 
 
4.1.1 
Age:  Patients must be ≥ 12 years of age at the time of study enrollment. 
 
4.12a 
Diagnosis: Patients must have a clinically, pathologically, and/or radiographically 
diagnosed (lymphscintogram or MRI) lymphedema affecting an extremity without 
prior surgical intervention or major trauma at that extremity.  
 
4.1.3 
Disease Status: Patients must have either measurable or evaluable disease (see 
Sections 12.2 and 12.3 for definitions). 
 
4.1.4 
Therapeutic Options: Patient’s current disease state must be one for which there is 
no known curative therapy or therapy proven to prolong survival with an 
acceptable quality of life. 
  
4.1.5 
Performance Level:  Karnofsky  50% for patients > 16 years of age and Lansky 
 50 for patients ≥ 12 to  16 years of age. Patients who are unable to walk because 
of paralysis, but who are up in a wheelchair, will be considered ambulatory for the 
purpose of assessing the performance score.  
 
4.1.6 
Prior Therapy 
Prior therapy may have included surgery or interventional radiology procedures, 

 
 
 
 
 
 
Page 14 
but must have occurred > 4 weeks prior to baseline imaging studies and study 
entry.  Prior therapy may have included other investigational drugs (e.g. sirolimus, 
sildenafil), since there are no standard medical therapies for lymphedema, but must 
have concluded > 4 weeks prior to baseline imaging studies. 
 
4.1.7 
Organ Function Requirements 
These are required for enrolled patients with LMs. 
 
4.1.7.1 Adequate Bone Marrow and Renal Function Defined as: 
 
Table 4. Organ Function Criteria 
Hemoglobin 
≥ 8 mg/dl 
Creatinine 
Within normal limits (<1.2) 
 
OR 
Creatinine Clearance 
≥ 60 mL/min/1.73 m2 for patients with 
creatinine levels above institutional 
normal 
 
 
 
 
 
4.1.7.4 Adequate Cardiac Function Defined as: 
- 
Baseline heart rate and blood pressure on physical exam within age-
defined normal ranges* 
- 
Normal cardiac rhythm by electrocardiogram 
- 
Normal intracardiac anatomy, pericardial space, and function by 
echocardiogram (if indicated by screening cardiologist) 
 
 
 
*See Appendix 7. 
 
 
 
 
4.1.7.5 Adequate Pulmonary Function Defined as: 
- 
No evidence of dyspnea at rest, no exercise intolerance, and a pulse 
oximetry > 94% if there is clinical indication for determination. 
 
4.1.8  Pregnancy: A negative pregnancy test must be obtained in girls who are post-
menarchal. Males or females of reproductive potential may not participate unless 
they have agreed to use an effective contraceptive method. 
 
 
4.1.9 
Informed Consent: All patients and/or their parents or legal guardians must sign a 
written informed consent. Assent, when appropriate, will be obtained according to 
institutional guidelines.  
 
4.2 
Exclusion Criteria 
 
4.2.1 
Patients with secondary lymphedema. 
4.2.2 
Patients who have had surgery or interventional radiology treatment within 4 
weeks prior to baseline imaging studies and/or study entry, or those who have not 
recovered from these interventions. 
 
4.2.3 
Patients who are receiving any other investigational agents. 
 
4.2.4 
Patients with known contraindications to propranolol therapy, or a history of 
allergic, hypersensitive, or adverse reaction to propranolol. 

 
 
 
 
 
 
Page 15 
 
4.2.5 
History of allergic reactions attributed to compounds of similar chemical or 
biologic composition to propranolol. 
 
4.2.6 
Patients requiring treatment with drugs known to interact with propranolol 
including those with other cardiovascular drugs (e.g. antiarrhythmics, calcium 
channel blockers); migraine drugs; theophylline; neuroleptic, anti-ulcer, and lipid-
lowering drugs; and warfarin.  
 
4.2.7  Patients must be able to swallow capsules or liquid. 
 
4.2.8 
Patients who in the opinion of the investigator may not be able to comply with the 
safety monitoring requirements of the study are not eligible. 
 
4.2.9  Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection; asthma, reactive airway disease, or bronchospasm requiring medication; 
ulcers or nonhealing wounds of the lymphatic malformation; symptomatic 
congestive heart failure, pericardial effusion, cardiac arrhythmia; or psychiatric 
illness/social situations that would limit compliance with study requirements. 
 
4.2.10 Other contraindications including pheochromocytoma, bradycardia, first degree 
heart block, decompensated heart failure. 
 
 
5.0 
TREATMENT PROGRAM 
 
5.1 
Overview of Treatment Plan 
Patients will be provided with propranolol prescriptions. Dosing is weight-based (corrected 
to the closest 10kg increment) and will be prescribed by the PI after medical evaluation by 
the study cardiologist.  
 
The starting dose of propranolol will be 0.5 mg/kg/day, which is the current institutional 
dose for initial treatment for cardiovascular and hemangioma indications in children.  Dose 
escalation to 1 mg/kg/day will take place at the 2-week evaluation in the absence of clinical 
contraindications. If patient tolerates 1 mg/kg/day dose, they will be escalated to 2 
mg/kg/day at the 4-week evaluation. In the absence of clinical contraindications, dose 
escalation will be increased to 3mg/kg/day at week 6 and continued for the duration of the 
study. A maximum of 8-weeks of therapy may be administered.   
 
 
5.2 
Dose Escalation Schema 
 
5.2.1 
Inter-Patient Escalation 
There is no inter-patient escalation allowed on this study.  
 
5.2.2 
Intra-Patient Escalation 
The starting dose will be 1 mg/kg/day (BID) with dose escalation up to 3 
mg/kg/day (BID) in the absence of clinical contra-indications. There will be no 
escalations beyond 3 mg/kg/day (Table 1). 
 

 
 
 
 
 
 
Page 16 
At the return visit, patients must have no evidence of clinical contraindications 
with normal HR and BP parameters prior to dose escalation occurring. They will 
be re-evaluated 2 hours after the first escalated dose. If individuals have normal 
heart rate and blood pressure and report no clinical symptoms (dizziness, increased 
fatigue), they will be given the new escalated dose and re-evaluated 2 hours after 
the new dose. If their HR and BP are within normal limits (WNL), they will be 
sent home on this new escalated dose and will return in another 2 weeks for 
evaluation. If individuals are found to have a fall in their blood pressure or heart 
rate below the normal value at 2 hours after the new dose, they will not be escalated 
and will be sent home at the current dose. They will return in 2 weeks for 
evaluation for dose escalation. 
 
If individuals are found to have a fall in their blood pressure or heart rate below 
the normal value at the return visit and clinically asymptomatic, they will held at 
the current tolerated dose level (no escalation). If they are able to tolerate this lower 
dose level with normal parameters and no clinical symptomatology they will return 
for evaluation of dose escalation at the next visit. If their parameters are WNL, 
they will be escalated and evaluated. If they do not tolerate dose escalation, they 
will be held at the current tolerated dose of propranolol until the end of the study 
without further attempts to escalate. Patients who are not able have their dose 
escalation at 2 consecutive visits will have no more dose escalation challenges and 
stay for the remainder of the study at the current tolerated dose.   
 
Individuals found to have a fall in HR and BP below normal parameters at 
initiation (0.5mg/kg/day, week 1) will be removed from the study for 1 week. At 
week 2 they will be re-evaluated. If HR and BP are within normal parameters they 
will be reintroduced to the study. If patient is once again found to have fall in 
HR/BP below normal parameters upon an attempt to re-initiate (failed the lowest 
intiation dose of 0.5mg/kg/day twice), they will be removed from the study.  
 
 
5.3 
Grading of Adverse Events 
Adverse events (toxicities) will be graded according to the NIH’s Common Terminology 
Criteria for Adverse Events v4.0 (CTCAE): 
Grade 1 Mild AE 
Grade 2 Moderate AE 
Grade 3 Severe AE 
Grade 4 Life-threatening or disabling AE 
Grade 5 Death related to AE 
Any life-threatening toxicity (Grades 4 and 5) should be reported immediately (within 24 
hours) to the PI and to the Data Safety Monitoring Board. 
 
 
6.0 
DOSE MODIFICATIONS FOR ADVERSE EVENTS 
 
The Study Chair must be notified of any dosage modification. 
 
6.1  
Dose Modifications for Potential Propranolol Specific Side Effects 
 
 
6.1.1 
Hypotension and Bradycardia 

 
 
 
 
 
 
Page 17 
Baseline blood pressure (BP) is defined as the blood pressure obtained at the 
examination used for study enrollment. This baseline BP should be obtained as 
follows: 1) Obtain 3 serial blood pressures from the same extremity with the patient 
in the same position that are separated by at least 5 minutes. Avoid using the lower 
extremity if possible. BP will not be obtained from the affected limb. 2) Average 
the systolic blood pressure from the 2nd and 3rd measurements. 3) Average the 
diastolic blood pressure from the 2nd and 3rd measurements. 4) The baseline BP is 
the average of the systolic over the average of the diastolic measurements.  
 
Heart rate will be measured by palpation of the radial pulse serially from the same 
extremity for 15 secs, separated by at least 5 minutes. In the case of extremity LMs, 
pulse rate will not be obtained from the affected limb. 2) Average the pulse rate 
from 2nd and 3rd measurements. 
 
6.1.1.1 Patient must have no evidence of clinical contraindications with normal 
HR and BP parameters prior to dose escalation occurring. If individuals are found 
to have a fall in their blood pressure or heart rate to below normal limits, but 
asymptomatic: 
 
a. patient will be not have dose escalation 
b. patient will be evaluated for dose escalation at the next 2-week cycle. 
c. if HR and BP fall below normal ranges and patient is symptomatic, 
propranolol will be held for 2 weeks, and re-introduced at the next visit at 
the lowest tolerated dose. 
d. if patient is at the lowest dose already (0.5mg/kg/day), they will be 
pulled from the study and re-evaluated at the next visit. 
c. Patients receiving 0.5mg/kg/day who experience HR or BP decrease 
below the normal range at 4 weeks must be taken off protocol therapy. 
 
 
 
Table 5. Side effects and propranolol dosing guidelines 
Hypotension and Bradycardia 
Propanolol Dosing Guidelines 
Within normative range 
No change in dose 
Below normal range, asymptomatic  
Cardiology 
evaluation, 
EKG, 
echocardiogram; 
if 
cardiac 
status 
is 
acceptable, patient will not have dose 
escalation and remain at current dose level 
with subsequent re-evaluation at 2 weeks 
Below normal range, symptomatic 
Discontinue 
propranolol 
(off 
protocol 
therapy. Re-evaluate after 2 weeks. If HR 
and BP then fall within normal parameters 
they will be reintroduced to the study with 
dose de-escalation to the prior tolerated dose 
of propanolol. If HR/BP below normative 
range at 0.5mg/kgday, patient will be 
removed from study 
 
 
Hypoglycemia 
Management/Next Dose for propranolol 
Blood glucose >80 mg/dl 
No change in dose 
Blood glucose <80, >60, asymptomatic 
Clinical 
evaluation, 
review 
feeding 
schedule, 
repeat 
test 
after 
more 

 
 
 
 
 
 
Page 18 
Hypoglycemia 
Management/Next Dose for propranolol 
frequent/supplemental feeds 
Blood glucose <80, symptomatic  
Discontinue 
propranolol 
(off 
protocol 
therapy) 
 
 
Bronchospasm 
Management/Next Dose for propranolol 
Transient/self-limited episode 
Clinical evaluation, may continue at same 
dose 
Associated with URI 
Hold propranolol till URI resolves; if >7 
days, off protocol 
Not associated with URI, persistent or requiring new 
medical treatment 
Discontinue 
propranolol 
(off 
protocol 
therapy)  
 
 
7.0 
SUPPORTIVE CARE AND OTHER CONCOMITANT THERAPY 
 
7.1 
Concurrent Anti Lymphatic Malformation Therapy 
Concurrent lymphatic malformation therapy, including surgery, immunotherapy, or 
biologic therapy may NOT be administered to patients receiving study drug >4 weeks prior 
to study initiation and during the study period. If these treatments are administered the 
patient will be removed from protocol therapy. 
 
7.2 
Investigational Agents 
No other investigational agents may be given while the patient is on study. 
 
7.3 
Supportive Care 
Patients with lymphedema should continue to receive appropriate supportive care, including 
compression garments, massage, and protective skin care dressings/preparations (emollients 
or barrier agents that protect involved skin). 
 
7.4 
Concomitant Medications 
Patients who require treatment with oral antibiotics for minor soft tissue infections may 
continue to receive these during the study. Antibiotics prescribed to be determined by 
infectious disease specialist, based on the patient’s particular past history of infections and 
potential involved flora. If the patient is determined to need hospital admission for IV 
antibiotics, the patient will be removed from the study. 
 
 

 
 
 
 
 
 
Page 19 
8.0 
EVALUATIONS/MATERIAL AND DATA TO BE ACCESSIONED 
 
8.1 
Required Clinical, Laboratory and Disease Evaluation 
Baseline evaluations are to be conducted within 2 weeks prior to start of protocol therapy.  
Scans and x-rays must be done <4 weeks prior to the start of therapy.  In the event that the 
patient’s condition is deteriorating, laboratory evaluations should be repeated within 48 
hours prior to initiation of the next dose escalation of propranolol. 
 
Table 6. Study schedule and evaluations 
STUDIES TO BE 
OBTAINED 
Pre-
Study Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 
Informed consent 
x 
 
 
 
 
 
 
 
 
Demographics 
x 
 
 
 
 
 
 
 
 
Medical history 
x 
 
 
 
 
 
 
 
 
Questionnaires 
x 
x 
x 
 
x 
 
x 
 
x 
Physical exam 
x 
x 
x 
 
x 
 
x 
 
x 
LM measurements 
x 
x 
x 
 
x 
 
x 
 
x 
Vital signs 
x 
x 
x 
 
x 
 
x 
 
x 
Height 
x 
x 
x 
 
x 
 
x 
 
x 
Weight 
x 
x 
x 
 
x 
 
x 
 
x 
CBC w/diff, platelets x 
 
 
 
x 
 
 
 
x 
Cr 
x 
 
 
 
x 
 
 
 
x 
Blood glucose 
x 
xa 
xa 
 
xa 
 
xa 
 
xa 
EKG 
x 
xa 
xa 
 
xa 
 
xa 
 
xa 
Echocardiograma 
x 
 
 
 
 
 
 
 
 
serum 
β-HCG 
for 
females 
of 
childbearing potential 
x 
 
 
 
 
 
 
 
 
Adverse 
event 
evaluation 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Skin Biopsies 
x 
 
 
 
 
 
 
 
x 
CXRa 
x 
 
 
 
 
 
 
 
 
MRI 
x 
 
 
 
 
 
 
 
x 
QMR 
x 
 
 
 
 
 
 
 
x 
Body water content 
evaluation 
x 
 
 
 
 
 
 
 
x 
aIf clinically indicated after initial evaluation 
 
 

 
 
 
 
 
 
Page 20 
 
 
 
 
8.2 
Correlative Studies 
 
8.2.1 
Description of Studies 
Correlative biology studies will include markers for progenitor, endothelial, 
lymphatic, macrophage, and adipocyte identity, and expression of beta-adrenergic 
receptors. 
 
 
8.2.2 
Sampling Schedule  
In patients with skin lesions on the affected extremity, skin biopsy samples will be 
collected at study entry and at the two-month evaluation point (Week 8). 
 
 
8.2.3 
Sample Labeling 
Each biopsy specimen must be labeled with the patient’s study registration number 
and the date and time the sample was taken.  Data should be recorded on the 
Correlative Study Form (Appendix 1). 
 
8.3 
Radiology Review 
MRIs to be reviewed for comparison and analysis by Dr. Dympna Gallagher. 
 
8.4 
Statistical Analysis 
 
Descriptive statistics will be used to summarize patient characteristics, toxicity 
data, response data and biomarker expression. Toxicity rates at each dose tested will be 
presented with 95% exact confidence intervals. Responses will be evaluated among 
patients treated at the highest tolerable dose. Continuous outcomes will be summarized 
using mean ± standard deviation or median (interquartile range) for non-normal data. 
Comparisons between groups and response changes from baseline will be evaluated using 
two-sided t-tests or the non-parametric equivalent Wilcoxon Rank-Sum test (for non-
normal data). Association between PIK3CA mutational status and patient response will be 
assessed using chi-square/Fisher exact test. All analyses will be performed using a type I 
error of 0.05. Biostatistics will be done using Irving Institute for Clinical and Translational 
Research statistical services at Columbia University Medical Center.  
 
9.0 
AGENT INFORMATION 
 
9.1 
Drug Name  
Propranolol (Inderal, Inderal LA, Innopran XL) 
 
9.1.1 
Structure  
Propranolol 
hydrochloride 
(2-Propanol, 
1-[(1-methylethyl)amino]-3-(1-
naphthalenyloxy)-, hydrochloride is a synthetic, nonselective antagonist of beta-
adrenergic receptors.  It has been used extensively in pediatrics for more than 40 
years, principally for cardiac indications (e.g. supraventricular tachycardias) but 
more recently for other indications. In particular, broad experience with 
propranolol for the treatment of pediatric hemangiomas has recently emerged, after 
the initial serendipitous observation of its efficacy in this condition[30].  

 
 
 
 
 
 
Page 21 
 
9.1.2. Supplied by: Commercially available 
 
9.1.3 
Formulation 
Commercially available. 
 
9.1.4 
Storage 
Patients will obtain propranolol from commercial pharmacy. 
 
9.1.5 
Solution Preparation 
N/A. 
 
9.1.6 
Administration 
Propranolol will be administered orally, either as a tablet or as a suspension, in 
equal divided doses two times a day.   
 
For children (12-18 years of age): Parents will be informed of the signs of 
hypoglycemia, hypotension, and bradycardia.   
 
9.1.7 
Toxicities 
A list of those adverse events encountered in treatment of infantile hemangioma is 
included below with estimates of overall frequency provided in the recent review 
by Drolet et al.[19]. Because infantile hemangiomas are vascular anomalies of 
childhood, like lymphatic malformations, we believe these may best represent 
adverse events that would affect the patients in our study. 
 
  
 
Table 7. Known toxicities of propranolol 
Known Toxicities 
Frequency 
Sleep disturbance 
3.7% 
Asymptomatic hypotension  
2.8% 
Somnolence  
2.2% 
Bronchopulmonary 
symptoms 
(wheezing, breathing disturbance)  
1.9% 
Cool or mottled extremities  
1.7% 
Asymptomatic bradycardia  
0.9% 
Hypoglycemia  
0.9% 
Diarrhea  
0.8% 
Gastroesophageal reflux  
0.7% 
 
Detailed pharmacologic data is available on the FDA website:  
http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/016418s080,016762s
017,017683s008lbl.pdf. 
 
10.0 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY 
CRITERIA  
 
10.1 
Criteria for Removal from Protocol Therapy  
a) 
Intercurrent illness that prevents further administration of treatment.  
b) 
Adverse Events requiring removal from study (See Section 6.0). 
c) 
Refusal of further protocol therapy by patient/parent/guardian 

 
 
 
 
 
 
Page 22 
d) 
Non-compliance that in the opinion of the investigator does not allow for ongoing 
participation. 
e) 
Completion of 2 months of therapy. 
f) 
Physician determines it is not in the patient’s best interest. 
Patients who are off protocol therapy are to be followed until they meet the criteria for Off 
Study (see below). Ongoing adverse events, or adverse events that emerge after the patient 
is removed from protocol therapy, but within 30 days of the last dose of investigational 
agent, must be followed until resolution or stabilization of the adverse event.  Follow-up 
data will be required unless consent is withdrawn. 
 
10.2 
Off Study Criteria 
a) 
Completion of 10 months of follow-up after the last dose of the investigational agent. 
b) 
Death 
c) 
Lost to follow-up 
d) 
Withdrawal of consent for any further data submission 
e) 
Enrollment onto another anti-lymphatic malformation study  
 
 
11.0 
STATISTICAL AND ETHICAL CONSIDERATIONS 
 
11.1 
Sample Size and Study Duration 
Sample Size:  Based on our current clinical volume, we anticipate a total enrollment of 15-
20 (this is just an example to show a range) patients over a period of 24 months. 
Accrual Rate:  We anticipate that 8-10 patients per year will be accrued to the study. 
Accrual Targets:  LMs affect the general population without known differences in genders 
or ethnicities.  Therefore, we expect accrual to reflect the makeup of the population in the 
region(s) surrounding our institution. 
 
11.2 
Study Design/ Endpoints (Table 2) 
 
11.2.1 Study design: Each patient will serve as his/her own control, for comparison of 
study questionnaires (subjective) and with changes in the clinical measurements 
and imaging measurements of the anatomic area affected by lymphatic 
malformation compared before and after treatment (objective).  In our experience, 
children exhibiting responses to propranolol displayed these within 2 weeks of 
beginning propranolol treatment, with estimated reduction in the overall volume 
of the affected area exceeding 20%.   
 
11.2.2 Primary endpoints: The primary endpoint will be the tolerability of escalating 
dosage of propranolol both by subjective reporting (survey instrument) as well as 
objective measurements of vital signs. Survey instruments include a general 
quality of life (QOL) and function survey (SF-36), as well as validated survey 
instruments for patients with lymphedema (LYMPH—ICF, LYMPH—LCF—
LL)[38, 39].  
 
11.2.3 Secondary endpoints: The secondary endpoints of the study will be both subjective 
and objective evaluation of the lymphedema after propranolol treatment, as 
measured by both survey instrument and objective measurements (clinical exam 
and radiological studies), as well as biological assays from tissues obtained from 
biopsies. 

 
 
 
 
 
 
Page 23 
 
11.2.3.1   We will determine whether higher doses of propranolol are well tolerated 
in this patient population. Secondarily, we will measure determine 
whether higher doses correlate with improvement in lymphedema 
symptoms and signs, and healing or improvement of skin lesions, if 
present (reduced lymphatic leakage, reduced bleeding).  Skin lesions 
will be photographed at clinical visits, and daily lymphatic fluid losses 
estimated by weight measurements.  
Using MRI and body composition analysis, we will determine whether 
propranolol decreases lymphedema, alters edema water content and 
location (intracellular vs. interstitial), or alters adiposity of affected 
extremity. 
We will study the biologic activity of oral propranolol against 
lymphedema, by examining the expression of progenitor cell markers, 
lymphatic endothelial cell markers, beta-adrenergic receptor 
expression, macrophage markers and detection of adipocyte content 
of biopsy specimens (see table below). Results will be compared to 
ultrasound and magnetic imaging data. 
 
11.3  
Analysis of Secondary Endpoints 
 
11.3.1 Biomarkers 
In the context of this study, we plan to perform immunohistochemical studies to 
assess alterations in lymphatic vessel/channel formation, adipocyte differentiation, 
and changes in inflammation.  We have selected markers that we have previously 
shown to be altered by propranolol either in isolated LMPCs in culture or in the 
mouse model (unpublished). Expression of the beta-adrenergic receptors will be 
assessed as propranolol is a pan-beta-adrenergic receptor antagonist. To date, no 
molecular markers have been identified to correlate with LM patient improvement.  
Identification of such markers could provide an important benefit to affected 
patients. Morphological changes in the lymphatic vasculature will also be quantified 
using ImageJ software. Student’s T-test will be employed to determine significance, 
with p < 0.05 considered significant. 
 
 
 
 
 
Table 3. Markers to be probed and assessed in blood and tissues 
Progenitor cell markers 
CD133, CD45, podoplanin, CD90, NG2  
Lymphatic endothelial cell 
markers 
VEGFR-2, VEGFR-3, podoplanin, Prox1, 
LYVE1  
Beta-adrenergic receptors  
Beta-1, beta-2, beta-3 adrenergic receptors  
Macrophage markers  
CD68, iNOS, F4/80  
 
The analyses we plan to perform on the specimens have been validated by our 
laboratory using discarded de-identified specimens[14]. Fixed frozen tissue will be 
prepared and 5-micron sections generated. Standard immunohistochemistry will be 
performed with commercially available antibodies and H&E staining performed. 
Results will be captured by microscopy and digital camera. Results will be 
quantified using ImageJ software and Student’s t-test to determine significance, 
with a p < 0.05 considered significant. We have already isolated similar specimens 
from > 10 patients and have obtained consistent results using these methodologies. 

 
 
 
 
 
 
Page 24 
 
We have comprehensive data on in vitro and in vivo analysis of 12 cells lines from 
patients with LMs. We have demonstrated consistently that LMPCs have unique 
characteristics by FACS analysis and gene expression profile analysis. They express 
mesenchymal stem cell markers CD90 and NG2, and can be differentiated into 
various terminal cell types including adipocytes, mural and endothelial cells. When 
implanted into immunocompromised mice, these LMPCs formed cystic structures 
that phenocopy lymphatic malformations. These features are reproducible between 
LMPC cell lines, and demonstrate consistent changes in gene and protein 
expression after treatment with propranolol. 
 
We are expecting to recruit 20 patients into this study. Our assays are sufficiently 
sensitive to detect 5-10% differences in proliferation rate and gene and protein 
expression changes. 
 
11.3.2 Imaging Studies 
Lymphedema MRI characteristics before and after propranolol therapy will be 
assessed and related to clinical outcome, as applicable. Specifically, whole body 
MRI will be used to evaluate body composition and changes in regional adipose 
tissue depots in the affected limb[21-23].  
 
Furthermore, changes in body composition (water and fat content) in response to 
propranolol treatment will be evaluated in this study. To evaluate water content, the 
standard deuterium dilution technique will be used. Fasting patients will have blood 
draw before drinking stable deuterium isotopes and sodium bromide and after 
isotope equilibration (about 3-4 hours). Total body water, extra-cellular and 
intracellular water content can be calculated[22, 40]. Furthermore, a quantitative 
magnetic resonance (QMR) system will be used to evaluate body (fat and water) 
content in response to propranolol treatment[21]. Quantification and analysis of 
results will be performed by Dr. Gallagher. 
 
11.3.3 Patient-Reported Outcomes; Symptom Assessment etc. 
Patients’ self-reported tolerance to propranolol will be assessed using validated 
quality of life (QOL) health surveys (SF-36, Lymph-ICF, Lymph-ICF-LL) SF-36 
is an accepted general health status survey[38, 39]. Lymph-ICF and Lymph-ICF-
LL are validated, disease-specific survey instruments for patients with lymphedema 
that evaluate physical and mental activity, impairments in function and activity 
limitations related to lymphedema. 
 
11.3.4 Genetic analysis 
Primary lymphedema has been shown to be associated with genetic mutations. 
There is a mutation in flt4 (vegfr3) gene in Milroy’s[8]. More recently, somatic 
mutations have been identified in another subset of patients with lymphatic 
malformations[36, 37]. Patient blood and tissues will also be sequenced using Next-
Gen exome sequencing analyses to probe for de novo genetic mutations and 
screening for mutations in genes known to be associated with lymphedema  (vegfr3, 
pik3ca) and correlated with treatment response to propranolol. Columbia University 
has core facilities available for these analyses. As these tests are performed under 
experimental and not clinical indications, individual results will not be shared with 
study subjects. However, once the studies are published, the published aggregate 
results can be made available to study subjects. 

 
 
 
 
 
 
Page 25 
 
11.4 
Ethical Considerations 
Patients with LMs of the extremities may experience a range of complications, including 
pain, bleeding, infections, and functional limitation.  These can result in a severe lifelong 
burden of disease, exacerbated by the social difficulties imposed by physical differences 
and school absence caused by acute illness.  No validated medical therapies currently exist.  
Surgical and interventional treatments can improve and palliate disease, but are rarely 
curative.  The identification of effective treatments for these patients is therefore urgent.  
 
The recent development in our lab of model LMs in vivo and in vitro has provided a rational 
basis for identifying potential new therapeutic agents[14]. Our in vitro and in vivo studies 
are consistent with recent reports of propranolol efficacy in small groups of patients[15-
18], and with our initial clinical experience.  The systematic study of propranolol, which 
has a favorable risk profile in patients and a biologic basis for efficacy in pediatric patients 
with lymphatic malformations, would thus appear ethically justified. 
 
11.5 
Reporting and Exclusions 
All of the patients who met the eligibility criteria (except those who received no 
propranolol) will be included in the main analysis of the response. All conclusions will be 
based on all eligible patients.   
 
Sub-analyses may then be performed on the basis of a subset of patients, excluding those 
for whom major protocol deviations have been identified.  However, these sub-analyses 
will not serve as the basis for drawing conclusions concerning treatment efficacy, and the 
reasons for excluding patients from the analysis will be clearly reported.   
 
 
11.6 
Inclusion of Children, Women and Minorities 
Children (≥ 12 years) and adults of both gender and of all races and ethnic groups are 
eligible for this trial. 
 
 
12.0  
EVALUATION CRITERIA 
 
12.1 
Adverse Events  
Any patient who receives the study drug will be evaluable for Adverse Effects. This study 
will utilize the NIH Common Terminology Criteria for Adverse Events v4.0 (CTCAE) for 
evaluating adverse events.   
 
12.2  
Disease Parameters 
Measurable disease: Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as > 50 mm by clinical 
exam and MRI.  All measurements must be recorded in millimeters (or decimal fractions 
of centimeters). 
 
12.3 
Methods for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler, measuring 
tape, or calipers.  All baseline evaluations should be performed as closely as possible to 
the beginning of treatment. 
 
The same method of assessment and the same technique should be used to characterize 

 
 
 
 
 
 
Page 26 
each identified and reported lesion at baseline and during follow-up.  
 
Clinical lesions:  The circumference of the affected (vs. unaffected) extremity will be 
documented in the patient’s clinical chart along pre-determined landmarks), as this is a 
standard part of care for patients with extremity LM. Landmarks include: midway point 
between ASIS (anterior superior iliac spine) to the patella for the thigh, and midway point 
between patella to the medial malleolus for lower extremities. The midway point between 
the axillary crease to medial epicondyle (upper arm) and midway point between medial 
epicondyle to hamate bone of the wrist (forearm) for upper extremities. 
 
MRI and QMR have excellent contrast, spatial, and temporal resolution.  The same scanner 
should be used and the image acquisition protocol should be followed as closely as possible 
to prior scans. While CT scans may give even improved spatial resolution, MRI has the 
advantage of no ionizing radiation, gives superior soft tissue resolution, and allows for 
multi-planar imaging.  
 
12.4 
Response  
Patients should be re-evaluated for response by clinical examination every 2 weeks.  
Baseline MRI will be obtained, and an MRI repeated at 8 weeks. Response will be 
evaluated in this study using quality of life survey instruments, physical examination and 
radiologic studies (MRI at baseline and 8 weeks). 
 
12.4.1  Definitions 
 
Subjective Response: 
Patients who complete at least the questionnaires at 
baseline (study entry) and at the last study visit will be included for subjective 
evaluation. 
 
Evaluable for Objective Response: by physical examination and radiological 
studies as outlined above. 
 
 
13.0 
ADVERSE EVENT REPORTING REQUIREMENTS 
 
Adverse events (AEs) will be graded according to the NIH’s Common Terminology Criteria for 
Adverse Events v4.0 (CTCAE) (Section 5.3): 
Grade 1 Mild AE 
Grade 2 Moderate AE 
Grade 3 Severe AE 
Grade 4 Life-threatening or disabling AE 
Grade 5 Death related to AE 
 
 
Any life-threatening (grades 4 and 5) adverse events (AEs) should be reported immediately (within 
24 hours) to the PI and Data Safety Monitoring Board. All other AEs (grades 1-3) will be reported 
to the PI, the IRB, and the Data Safety Monitoring Board as soon as possible, but not later than five 
(5) workdays from first awareness of the problem. Significant AEs include, but are not limited, to: 
 
a. any death, excluding death due to the progression of the disease, and 
b. the combination of the following 3 conditions: 
 
i. Unexpected: any adverse experience that is not identified in nature, severity, or frequency 
in the consent form, and is not due to the progression of a disease process. 
 
ii.  Serious: any event that is fatal or life threatening, is permanently or significantly 

 
 
 
 
 
 
Page 27 
disabling, requires inpatient hospitalization or prolongation of hospitalization, or any 
medical event that requires treatment to prevent one of the medical outcomes listed above. 
 
iii. Related/possibly related: as determined by the research team. 
 
The event will be formally reported on the Significant Adverse Event Report Form (Medwatch 
3500 Form, Appendix 1). All events that do not meet the criteria of significant or trends as listed 
in numbers 1 and 2 above, should be recorded in the summary form. 
 
 
 
 
 
14.0 
RECORDS, REPORTING, AND DATA AND SAFETY MONITORING PLAN 
 
14.1 
Data Safety and Monitoring  
The frequency and severity of all toxicities and/or adverse effects will be tabulated on an 
ongoing basis and summarized for review under the Data Safety and Monitoring Plan for 
this study (DSMP) as per the guidelines for the Data and Safety Monitoring Committee of 
Columbia University. Data for this study will be reviewed and monitored by the PI, as this 
study is deemed minimal or no more than minor increased over minimal risk. All serious 
and/or unexpected events will be communicated to the Study Chair and reviewed within 2 
working days for consideration of notification, amendment, or immediate study 
suspension. 
 
 
14.2 
Data and Safety Monitoring Plan 
 
14.2.1 Monitoring mechanisms 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her 
site.  This safety monitoring will include careful assessment and appropriate reporting of 
adverse events, as well as the construction and implementation of a site data and safety-
monitoring plan. Medical monitoring will include a regular assessment of the number and type 
of serious adverse events. 
 
Data and Safety Monitoring Board 
The PI will oversee the conduct of this trial with an ad hoc Data and Safety Monitoring 
Board. The DSMB will review the progress of the trial following the enrollment of subjects 
and to ensure that patient safety is not being compromised. We have formed an ad hoc DMSB 
comprising of a vascular surgeon (Dr. Alan Bevenisty), a cardiologist (Dr Yi-ming Yang), and 
a pediatric hematologist with expertise in vascular malformations (Dr. Francine Blei). 
 
Reporting of Adverse Events 
All STEAEs should be recorded on a MedWatch 3500 Form and faxed to: 
 
 
 
 
Columbia University/June K. Wu, M.D. 
 
 
 
Fax: (212) 305-9626 
 
 
 
 
 
AND 
 
Columbia University Data and Safety Monitoring Committee of Columbia University 
622 West 168th Street, PH-18 Room 200 
New York, NY 10032 
 
 
 
Telephone: (212) 305-8615 
 
 
 
Fax: (212) 342-3036 
 
 
 
 
 
 

 
 
 
 
 
 
Page 28 
MedWatch 3500 Reporting Guidelines: 
 
In addition to completing appropriate patient demographic and suspect medication 
information, the report should include the following information within the Event 
Description (section 5) of the MedWatch 3500 form: 
 
-Treatment regimen (dosing frequency, combination therapy) 
-Protocol description (and number, if assigned) 
-Description of event, severity, treatment, and outcome, if known 
-Supportive laboratory results and diagnostics 
-Investigator’s assessment of the relationship of the adverse event to each investigational  
product and suspect medication 
 
Follow-up information:   
 
Additional information may be added to a previously submitted report by any of the 
following methods: 
 
-Adding to the original MedWatch 3500 report and submitting it as follow-up 
-Adding supplemental summary information and submitting it as follow-up with the 
original MedWatch 3500 form  
-Summarizing new information and faxing it with a cover letter including subject 
identifiers (i.e. D.O.B. initial, subject number), protocol description and number, if 
assigned, suspect drug, brief adverse event description, and notation that additional or 
follow-up information is being submitted  (The subject identifiers are important so that the 
new information is added to the correct initial report) 
  
 
Assessing Causality: 
 
Investigators are required to assess whether there is a reasonable possibility that 
propranolol caused or contributed to an adverse event.  The following general guidance 
may be used. 
Yes: 
if the temporal relationship of the clinical event to propranolol administration 
makes a causal relationship possible, and other drugs, therapeutic interventions or 
underlying conditions do not provide a sufficient explanation for the observed event. 
 
No: 
if the temporal relationship of the clinical event to propranolol administration 
makes a causal relationship unlikely, or other drugs, therapeutic interventions or underlying 
conditions provide a sufficient explanation for the observed event. 
For Investigator Sponsored IND Exempt Studies, there are some reporting requirements 
for the FDA in accordance with the guidance set forth in 21 CFR 314.80. 
 
Postmarketing 15-Day “Alert Report”: 
The Sponsor-Investigator is required to notify the FDA of any fatal or life-threatening 
adverse event that is unexpected and assessed by the investigator to be possibly related 
to the use of propranolol. An unexpected adverse event is one that is not already described 
in the Investigator Brochure. Such reports are to be submitted to the FDA (2 copies) at the 
following address: Central Document Room, 12229 Wilkins Avenue, Rockville, MD 
20852. 

 
 
 
 
 
 
Page 29 
 
For questions related to safety reporting, contact: 
 
Columbia University/June K. Wu, M.D. 
Fax: (212) 305-9626 
 
 
 
 
 
AND 
 
Columbia University Data and Safety Monitoring Committee of Columbia University 
622 West 168th Street, PH-18 Room 200 
New York, NY 10032 
Telephone: (212) 305-8615 
Fax: (212) 342-3036 
 
 
 
Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the 
period from the initiation of any study procedures to the end of the study treatment follow-
up. However, any serious treatment emergent adverse events must be reported within 24 
hours. 
 
Post-study adverse event 
All unresolved adverse events should be followed by the investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At 
the last scheduled visit, the investigator should instruct each subject to report any 
subsequent event(s) that the subject, or the subject’s personal physician, believes might 
reasonably be related to participation in this study.  The investigator should notify the study 
sponsor of any death or adverse event occurring at any time after a subject has discontinued 
or terminated study participation that may reasonably be related to this study.   
 
14.2.2 Frequency of monitoring 
 
Patients will be monitored and assessed during their study visits (weeks 1, 2, 4, 6, 8). In addition, 
patients will be encouraged to contact the PI and/or study coordination if they have any issues, concerns, 
unexpected symptoms to be assessed. 
 
14.2.3 Stop or change rules 
 
Patients will be removed from study if they cannot tolerate the intiation dose of propranolol. 
Patients who failed 2 challenges to escalate to 1mg/kg/day (lowest study dose) will be pulled from the 
study. Patients who failed 2 challenges to escalate to subsequent doses will be kept at the highest tolerated 
dose without any further attempts to escalate through the study. 
 
14.2.4 Plans for interim analyses and/or futility analyses 
 
This study only lasts 8 weeks and no interim analyses nor futility analyses are planned. 
 
14.2.5 Information to be monitored 
 
a. Information to be monitored include assessment of data quality, timeliness and patient 
recruitment and retention, accrual and retention consistent with plans for diversity and generalizability. 
 
b. A review of outcome and adverse event data to determine whether there is any change to the 
risk/benefit ratio of the study, if a stop rule has been invoked, or a study endpoint has been reached whether 
the study should continue as originally deisgned, be changed, or be stopped. 
 
c. An assessment of external factors or relevant information (eg. developments in the literature, 
reults of related studies, etc) that may have an impact on the safety of pariticipants or on the ethics of the 

 
 
 
 
 
 
Page 30 
research study. 
 
14.2.6 Communication 
 
The PI will be available to the study coordinator, study patients, and the DSMB by person, phone, 
or email (study coordinator and DSMB) for any concerns. Since this is an IND exempt study, the only 
communication with the FDA is for adverse event reporting (Postmarketing 15-day “Alert Report”) 
 

 
 
 
 
 
 
Page 31 
 
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