Methods and compositions for treating hemangiomas

Abstract

The present invention relates to methods and compositions for treating hemangiomas, and in particular, but not exclusively, methods and compositions for treating infantile hemangiomas. In certain aspects, the methods comprise topically administering an ACE inhibitor or an ATIIR2 antagonist to a subject. In other aspects, the methods comprise systemically administering two or more of an ACE inhibitor, a beta-blocker, and an ATIIR2 antagonist. The present invention also relates to compositions suitable for topical administration and comprising: an ACEi and a beta-blocker; an ACEi and an ATIIR2 antagonist; a beta-blocker and an ATIIR2 antagonist; or an ACEi, a beta-blocker, and an ATIIR2 antagonist.

Description

Technical Field

[0001] The present invention relates to methods and compositions for treating hemangiomas, and particularly, but not limited to, methods and compositions for treating infantile hemangiomas. Background Technology

[0002] Hemangiomas are complex growths that develop due to the proliferation of endothelial cells surrounding a blood-filled lumen. They can occur anywhere on the body, but are most common on the face, scalp, chest, or back. Hemangiomas usually regress slowly over time and most do not require treatment. However, they can disfigure, cause psychological distress, and may lead to functional impairments depending on the location of the lesion; for example, blindness if it occurs in the tissue around the eye. In these cases, treatment is necessary to avoid permanent complications.

[0003] Infantile hemangioma (IH), affecting up to 10% of children, is the most common type of hemangioma. IH is characterized by an initial rapid proliferative phase followed by slow spontaneous regression over 5 to 10 years, which usually results in fibrous fatty remnants (Itinteanget al., Plast. Reconstr. Surg. 2011; 128, 499-507).

[0004] The current standard of care for treating proliferative infarction (IH) involves oral administration of low-dose beta-blockers, such as propranolol. This approach is relatively successful, with approximately 88% of treated patients showing improvement within 5 weeks and a total success rate of approximately 60% (Léauté-Labrèze et al. N. Engl. J. Med., 2015; 372, 735-746). However, due to the potentially intolerable side effects that may occur during beta-blocker therapy (Ji et al. Sci. Rep. 2018; 8, 4264), the management of IH is largely conservative, and it is typically treated only in 10-15% of patients who require intervention during infancy due to life-threatening or functionally debilitating lesions, or tissue deformities or destruction leading to physical defects. In addition, rebound or regrowth of hemangioma lesions, defined as an increase in size, a change in color, or both, may occur after discontinuation of oral propranolol treatment, especially when treatment is stopped before 1 year of age (Price et al., 2011, Arch. Dermatol., 147, 1371-1376; Menezes et al., 2011, Ann. Otol. Rhinol. Laryngol., 120, 686-695).

[0005] Several clinical studies have been conducted to investigate the effects of oral captopril, an ACE (angiotensin-converting enzyme) inhibitor (ACEi), on proliferating infarcted hemorrhage (IH). In one study of eight patients, captopril was administered at a dose of 1.5 mg / kg daily, demonstrating a positive effect in all patients (Tan et al. Br. J. Dermatol. 2012; 167, 619-624). Responses varied among patients and were rated as giant (n=3), moderate (n=2), and slow (n=3), and no rebound growth was observed after treatment was discontinued at 14 months. However, randomized controlled trials comparing the efficacy of oral propranolol to captopril in 30 patients with IH and 35 healthy controls demonstrated significantly better and faster clinical improvement in patients treated with propranolol (Zaher et al. 2016, J. Am. Acad. Dermatol., 74, 499-505).

[0006] Topical treatment options for controlling the growth of proliferating inflammatory hemangiomas (IH) have been investigated, but are currently unavailable for clinical use and have several undesirable side effects. Topical application of super-potent corticosteroids, such as 0.05% clobetasol propionate, has been used to treat flat or minimally convex IH lesions in 27 infants for periods ranging from 4 to 21 weeks, with various clinical improvements observed (35% good response, 38% partial response, 27% no response) (Garzon et al. 2005, J. Am. Acad. Dermatol., 52, 281-286). However, adverse reactions may include localized atrophy, hypopigmentation, hirsutism, and infection. Imiquimod, an immunomodulator with anti-angiogenic and pro-apoptotic properties, has been used as a topical treatment for superficial IH. Typically, all cases of superficial IH improve within 4 months of treatment with 5% imiquimod cream (Ho et al. 2007, J. Am. Acad. Dermatol., 56, 63-68). However, side effects may include severe local inflammatory reactions leading to disfiguring scarring (Qiu et al. 2013, Pediatr. Dermatol., 30, 342-347).

[0007] Topical beta-blockers have also been tested in the management of proliferative intraocular hemorrhages (IHs). Timolol, a non-selective beta-blocker used to treat increased intraocular pressure, has been shown to produce a clinically beneficial response when applied topically as a 0.5% solution or gel. Topical timolol has been used primarily for localized, non-ulcerated superficial IHs with a mean diameter less than 11.3 mm or a volume of approximately 100 mm. 3Timolol does not penetrate deep into the hemangioma volume and is therefore ineffective in managing larger hemangiomas (Guo et al., 2010, Arch. Opthamol., 128, 255-256; Chan et al., 2013, 131, e1739-1747). Topical propranolol 1% ointment has also been tested in small clinical studies of proliferative hemangiomas, with good to moderate response rates of approximately 75-90% (57-59% good response, 26-33% moderate response, 10-15% no response) (Kunzi-Rapp. 2012, Pediatr. Dermatol. 29, 154-159; Xu et al., 2012, J. Am. Acad. Dermatol., 67, 1210-1213). However, in a randomized, double-blind, placebo-controlled, multicenter study evaluating the efficacy of propranolol 1% gel in 81 patients, only 6 patients (14.6%) showed a significant clinical response compared to 1 patient (2.6%) in the placebo group (Clinical Study Report V00400 GL 2 01 1A). This contrasts with the approximately 60% response rate observed with oral propranolol.

[0008] Purpose

[0009] The object of this invention is to provide an improved method and / or composition for treating hemangiomas, or at least to provide the public with a useful alternative. Summary of the Invention

[0010] In a first aspect, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the step of locally administering ACEi to the hemangioma.

[0011] In a second aspect, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the step of locally administering ACEi and a β-blocker to the hemangioma.

[0012] In one embodiment, the β-blocker is administered in a lower amount relative to the amount of ACEi administered. In one embodiment, the ratio of administered ACEi to β-blocker is approximately 1:1 to approximately 10:1. In other embodiments, the ratio of administered ACEi to β-blocker is approximately 2:1 to approximately 10:1, approximately 3:1 to approximately 9:1, approximately 4:1 to approximately 8:1, or approximately 5:1 to approximately 7:1. In other embodiments, the ratio is approximately 1:1, approximately 2:1, approximately 3:1, approximately 4:1, approximately 5:1, approximately 6:1, approximately 7:1, approximately 8:1, approximately 9:1, or approximately 10:1.

[0013] In one embodiment, ACE inhibitors and β-blockers are administered simultaneously. In another embodiment, ACE inhibitors and β-blockers are administered sequentially in any order.

[0014] In a third embodiment, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the step of locally administering an ACEi and an ATIIR2 antagonist to the hemangioma.

[0015] In one embodiment, ACEi and ATIIR2 antagonists are administered simultaneously. In another embodiment, ACEi and ATIIR2 antagonists are administered sequentially in any order.

[0016] In a fourth embodiment, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the steps of locally administering a β-blocker and an ATIIR2 antagonist to the hemangioma.

[0017] In one embodiment, the β-blocker and the ATIIR2 antagonist are administered simultaneously. In another embodiment, the β-blocker and the ATIIR2 antagonist are administered sequentially in any order.

[0018] In a fifth embodiment, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the steps of locally administering ACEi, a β-blocker, and an ATIIR2 antagonist to the hemangioma.

[0019] In one embodiment, ACEi, a β-blocker, and an ATIIR2 antagonist are administered simultaneously. In another embodiment, ACEi, a β-blocker, and an ATIIR2 antagonist are administered sequentially in any order.

[0020] In one embodiment of the first to fifth aspects, two or more ACE inhibitors are administered. In another embodiment, two or more β-blockers are administered. In yet another embodiment, two or more ATIIR2 antagonists are administered. Two or more ACE inhibitors, β-blockers, and ATIIR2 antagonists may be administered simultaneously or sequentially in any order.

[0021] In one embodiment of the first to fifth aspects, ACEi, β-blockers, and / or ATIIR2 antagonists are administered topically. In another embodiment of the first to fifth aspects, ACEi, β-blockers, and / or ATIIR2 antagonists are administered to the hemangioma via local injection.

[0022] In one embodiment of the first to fifth aspects, ACEi is a prodrug. In a preferred embodiment, ACEi is selected from the group consisting of: enalapril, ramipril, trandolapril, ciliapril, benazepril, perindopril, imidapril, fosinopril, zofenopril, and quinapril. In another embodiment, ACEi is selected from captopril and lisinopril.

[0023] In one embodiment of the first to fifth aspects, the β-blocker is a non-selective β-blocker.

[0024] In one embodiment of the first to fifth aspects, the method further includes systemically administering to the subject at least one ACEi, at least one β-blocker, and / or at least one ATIIR2 antagonist. In one embodiment, at least one ACEi, β-blocker, and / or ATIIR2 antagonist is administered orally. In a specific embodiment, at least one β-blocker or at least one ACEi is administered.

[0025] In one specific embodiment of the first aspect, the method includes topical administration of an ACEi and systemic administration of a β-blocker. In another embodiment, the method includes topical administration of an ACEi and systemic administration of an ACEi. In yet another embodiment, the method includes topical administration of an ACEi and systemic administration of an ATIIR2 antagonist. In one embodiment, one or more agents are administered topically and one or more are administered orally and systemically.

[0026] In one embodiment of the first aspect, the method includes topically administering an ACE inhibitor and a β-blocker, and systemically administering a β-blocker. In another embodiment, the method includes topically administering an ACE inhibitor and a β-blocker, and systemically administering an ACE inhibitor. In yet another embodiment, the method includes topically administering an ACE inhibitor and a β-blocker, and systemically administering an ATIIR2 antagonist. In one embodiment, one or more agents are administered topically and one or more are administered orally or systemically.

[0027] In one embodiment of the fourth aspect, the method includes topically administering an ATIIR2 antagonist and a β-blocker, and systemically administering a β-blocker. In another embodiment, the method includes topically administering an ATIIR2 antagonist and a β-blocker, and systemically administering an ACEi. In yet another embodiment, the method includes topically administering an ATIIR2 antagonist and a β-blocker, and systemically administering an ATIIR2. In one embodiment, one or more agents are administered topically and one or more are administered orally or systemically.

[0028] In one embodiment of the third aspect, the method includes topically administering an ACEi and an ATIIR2 antagonist, and systemically administering a β-blocker. In another embodiment, the method includes topically administering an ACEi and an ATIIR2 antagonist, and systemically administering an ACEi. In yet another embodiment, the method includes topically administering an ACEi and an ATIIR2 antagonist, and systemically administering an ATIIR2. In one embodiment, one or more agents are administered topically and one or more are administered orally and systemically.

[0029] In one embodiment of the first to fifth aspects, the method includes topically administering an ACEi, a β-blocker, and an ATIIR2 antagonist, and systemically administering an ACEi, an ATIIR2 antagonist, or a β-blocker. In one embodiment, one or more agents are administered topically or orally or systemically.

[0030] In embodiments of the second to fifth aspects, these methods include local administration: a non-selective β-blocker and an ACEi in prodrug form; a non-selective β-blocker and an ATIIR2 antagonist; or an ATIIR2 antagonist and an ACEi in prodrug form.

[0031] In embodiments of the second to fifth aspects, the method includes local administration:

[0032] R-Propranolol and Cilabapril; S-Propranolol and Cilabapril; RS-Propranolol and Cilabapril; R-Propranolol and Ramipril; S-Propranolol and Ramipril; RS-Propranolol and Ramipril; R-Propranolol and Qundopril; S-Propranolol and Qundopril; RS-Propranolol and Qundopril; R-Propranolol and Enalapril; S-Propranolol and Enalapril; RS-Propranolol and Enalapril; R-Propranolol and Quinapril; S-Propranolol and Quinapril; RS-Propranolol and Quinapril; R-Propranolol and Benazepril; S-Propranolol and Benazepril RS-Propranolol and Benazepril; R-Propranolol and Captopril; S-Propranolol and Captopril; RS-Propranolol and Captopril; R-Timolol and Cilapril; S-Timolol and Cilapril; RS-Timolol and Cilapril; R-Timolol and Ramipril; S-Timolol and Ramipril; RS-Timolol and Ramipril; R-Timolol and Qundopril; S-Timolol and Qundopril; RS-Timolol and Qundopril; R-Timolol and Enalapril; S-Timolol and Enalapril; RS-Timolol and Enalapril; R-Timolol and Quinapril Li; S-Timolol and Quinapril; RS-Timolol and Quinapril; R-Timolol and Benazepril; S-Timolol and Benazepril; RS-Timolol and Benazepril; R-Timolol and Captopril; S-Timolol and Captopril; RS-Timolol and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Timolol and EMA401; S-Timolol and EMA401; RS-Timolol and EMA401; R-Propranolol and SMM02; S-Propranolol and SM M02; RS-propranolol and SMM02; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril.

[0033] In some embodiments of aspects two through five, these methods include topical administration of: R-timolol and cilazapril; S-timolol and cilazapril; R / S-timolol and cilazapril; R-propranolol and cilazapril; S-propranolol and cilazapril; R / S-propranolol and cilazapril; SMM02 and cilazapril; R-propranolol and SMM02; S-propranolol and SMM02; R / S-propranolol and SMM02; SMM02 and S-timolol; SMM02 and R-timolol; EMA401 and S-timolol; EMA401 and R-timolol; EMA401 and cilazapril; EMA401 and R-propranolol; EMA401 and S-propranolol; or EMA401 and R / S-propranolol.

[0034] In a sixth aspect, the present invention provides the use of ACEi or ACEi for treating a subject’s hemangioma, wherein ACEi is formulated for local administration to the hemangioma.

[0035] In a seventh aspect, the present invention provides the use of an ACEi and a β-blocker, or an ACEi and a β-blocker, for treating a hemangioma in a subject, wherein the ACEi and the β-blocker are formulated for local administration to the hemangioma. In one embodiment of the seventh aspect, the present invention provides an ACEi in combination with a β-blocker for treating a hemangioma in a subject, wherein the ACEi and the β-blocker are formulated for local administration to the hemangioma. In one embodiment of the seventh aspect, the present invention provides a β-blocker in combination with an ACEi for treating a hemangioma in a subject, wherein the ACEi and the β-blocker are formulated for local administration to the hemangioma.

[0036] In one embodiment, the β-blocker is used in a lower amount relative to ACEi. In one embodiment, the ratio of ACEi to β-blocker used is approximately to approximately 10:1. In other embodiments, the ratio of ACEi to β-blocker used is approximately 2:1 to approximately 10:1, approximately 3:1 to approximately 9:1, approximately 4:1 to approximately 8:1, or approximately 5:1 to approximately 7:1. In other embodiments, the ratio is approximately 1:1, approximately 2:1, approximately 3:1, approximately 4:1, approximately 5:1, approximately 6:1, approximately 7:1, approximately 8:1, approximately 9:1, or approximately 10:1.

[0037] In one implementation, ACEi and a β-blocker are used simultaneously. In another implementation, they are used sequentially in any order.

[0038] In an eighth aspect, the present invention provides the use of an ACEi and ATIIR2 antagonist, or an ACEi and ATIIR2 antagonist, for treating a hemangioma in a subject, wherein the ACEi and ATIIR2 are formulated for local administration to the hemangioma. In one embodiment of the eighth aspect, the present invention provides an ACEi in combination with an ATIIR2 antagonist for treating a hemangioma in a subject, wherein the ACEi and ATIIR2 antagonist are formulated for local administration to the hemangioma. In one embodiment of the eighth aspect, the present invention provides an ATIIR2 antagonist in combination with an ACEi for treating a hemangioma in a subject, wherein the ACEi and ATIIR2 antagonist are formulated for local administration to the hemangioma.

[0039] In one implementation, ACEi and ATIIR2 are used simultaneously. In another implementation, they are used sequentially in any order.

[0040] In a ninth aspect, the present invention provides the use of a β-blocker and an ATIIR2 antagonist, or a β-blocker and an ATIIR2 antagonist, for treating a hemangioma in a subject, wherein the β-blocker and ATIIR2 are formulated for local administration to the hemangioma. In one embodiment of the ninth aspect, the present invention provides an ATIIR2 antagonist in combination with a β-blocker for treating a hemangioma in a subject, wherein the β-blocker and ATIIR2 antagonist are formulated for local administration to the hemangioma. In one embodiment of the ninth aspect, the present invention provides a β-blocker in combination with an ATIIR2 antagonist for treating a hemangioma in a subject, wherein the β-blocker and ATIIR2 antagonist are formulated for local administration to the hemangioma.

[0041] In one implementation, β-blockers and ATIIR2 are used simultaneously. In another implementation, they are used sequentially in any order.

[0042] In a tenth aspect, the present invention provides the use of an ACEi, a β-blocker, and an ATIIR2 antagonist, or an ACEi, β-blocker, and ATIIR2 antagonist, for treating a hemangioma in a subject, wherein the ACEi, β-blocker, and ATIIR2 antagonist are formulated for local administration to the hemangioma. In one embodiment of the tenth aspect, the present invention provides an ACEi in combination with a β-blocker and an ATIIR2 antagonist for treating a hemangioma in a subject, wherein the ACEi, β-blocker, and ATIIR2 antagonist are formulated for local administration to the hemangioma. In one embodiment of the tenth aspect, the present invention provides an ATIIR2 antagonist in combination with a β-blocker and an ACEi for treating a hemangioma in a subject, wherein the β-blocker, ACEi, and ATIIR2 antagonist are formulated for local administration to the hemangioma. In one embodiment of the tenth aspect, the present invention provides a β-blocker for use in combination with an ATIIR2 antagonist and an ACEi for treating a subject’s hemangioma, wherein the β-blocker, ACEi, and ATIIR2 antagonist are formulated for local administration to the hemangioma.

[0043] In one implementation, ACEi, a β-blocker, and an ATIIR2 antagonist are used simultaneously. In another implementation, they are used sequentially in any order.

[0044] In one embodiment of aspects six through ten, two or more ACEi are used. In another embodiment, two or more β-blockers are used. In yet another embodiment, two or more ATIIR2 antagonists are used. Two or more ACEi, β-blockers, and ATIIR2 antagonists may be used simultaneously or sequentially in any order.

[0045] In one embodiment of the sixth to tenth aspects, the ACEi, β-blocker, and / or ATIIR2 antagonist are formulated for topical administration. In another embodiment of the sixth to tenth aspects, the ACEi, β-blocker, and / or ATIIR2 antagonist are formulated for local injection.

[0046] In one embodiment of aspects six through ten, ACEi is a prodrug. In a preferred embodiment, ACEi is selected from the group consisting of: enalapril, ramipril, quindopril, cilazapril, benazepril, perindopril, imidapril, fosinopril, zolfenpril, and quinapril. In another embodiment, ACEi is selected from captopril and lisinopril.

[0047] In one embodiment of the sixth to tenth aspects, the β-blocker is a non-selective β-blocker.

[0048] In one embodiment of aspects six through ten, the treatment further comprises systemically administering to the subject at least one ACEi, at least one β-blocker, and / or at least one ATIIR2 antagonist. In one embodiment, at least one ACEi, β-blocker, and / or ATIIR2 antagonist is administered orally. In a specific embodiment, at least one β-blocker or at least one ACEi is administered.

[0049] In one embodiment of the sixth aspect, the present invention provides the use of i) ACEi and ii) ACEi, β-blocker and / or ATIIR2 antagonist, or i) ACEi and ii) ACEi, β-blocker and / or ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject (i) ACEi in combination with ii) ACEi, β-blocker and / or ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the hemangioma).

[0050] In one specific embodiment of the sixth aspect, the present invention provides the use of i) ACEi and ii) a β-blocker, or i) ACEi and ii) a β-blocker, for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject. In another embodiment, the present invention provides the use of i) an ACEi formulated for local administration to the hemangioma and ii) an ACEi formulated for systemic administration to the subject. In yet another embodiment, the present invention provides the use of i) an ACEi formulated for local administration to the hemangioma and ii) an ATIIR2 formulated for systemic administration to the subject. In a preferred embodiment, i) is formulated for topical administration and ii) is formulated for oral administration.

[0051] In one embodiment of the seventh aspect, the present invention provides the use of i) an ACEi and β-blocker and ii) an ACEi, β-blocker and / or an ATIIR2 antagonist, or i) an ACEi and β-blocker and ii) an ACEi, β-blocker and / or an ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject (i) an ACEi and β-blocker in combination with ii) an ACEi, β-blocker and / or an ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject). In one embodiment, the present invention provides the use of i) ACEi and β-blockers and ii) ACEi or β-blockers or ATIIR2, or i) ACEi and β-blockers and ii) ACEi or β-blockers or ATIIR2, for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject. In a preferred embodiment, i) is formulated for topical administration and ii) is formulated for oral administration.

[0052] In one embodiment of the eighth aspect, the present invention provides the use of i) an ACEi and ATIIR2 antagonist and ii) an ACEi, β-blocker and / or ATIIR2 antagonist, or i) an ACEi and ATIIR2 and ii) an ACEi, β-blocker and / or ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject (i) an ACEi and ATIIR2 antagonist in combination with ii) an ACEi, β-blocker and / or ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject). In one embodiment, the present invention provides the use of i) ACEi and ATIIR2 and ii) ACEi or a β-blocker or ATIIR2, or i) ACEi and ATIIR2 and ii) ACEi or a β-blocker or ATIIR2, for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject. In a preferred embodiment, i) is formulated for topical administration and ii) is formulated for oral administration.

[0053] In one embodiment of the ninth aspect, the present invention provides the use of i) a β-blocker and an ATIIR2 antagonist and ii) an ACEi, β-blocker and / or an ATIIR2 antagonist, or i) a β-blocker and an ATIIR2 and ii) an ACEi, β-blocker and / or an ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject (i.e., i) combined with ii) an ACEi, β-blocker and / or an ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject). In one embodiment, the present invention provides the use of i) a β-blocker and ATIIR2 and ii) ACEi or a β-blocker or ATIIR2, or i) a β-blocker and ATIIR2 and ii) ACEi or a β-blocker or ATIIR2 for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject. In a preferred embodiment, i) is formulated for topical administration and ii) is formulated for oral administration.

[0054] In one embodiment of the tenth aspect, the present invention provides the use of i) an ACEi, β-blocker and ATIIR2 antagonist and ii) an ACEi, β-blocker and / or ATIIR2 antagonist, or i) an ACEi, β-blocker and ATIIR2 antagonist and ii) an ACEi, β-blocker and / or ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject (i) in combination with ii) an ACEi, β-blocker and ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject).

[0055] In one embodiment of the tenth aspect, the present invention provides the use of i) an ACEi, a β-blocker, and an ATIIR2 antagonist, and ii) an ACEi or a β-blocker or an ATIIR2 antagonist, or i) an ACEi, a β-blocker, and an ATIIR2 antagonist, and ii) an ACEi or a β-blocker or an ATIIR2 antagonist for treating a subject's hemangioma, wherein i) is formulated for local administration to the hemangioma and ii) is formulated for systemic administration to the subject. In a preferred embodiment, i) is formulated for topical administration and ii) is formulated for oral administration.

[0056] In embodiments of the seventh to ninth aspects, the following are provided: a non-selective β-blocker and an ACEi in prodrug form; a non-selective β-blocker and an ATIIR2 antagonist; an ATIIR2 antagonist and an ACEi in prodrug form, or the combination thereof, for use in treating hemangiomas by local administration.

[0057] In embodiments of aspects seven through nine, the following are provided: R-propranolol and cilazapril; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and tritonol; S-propranolol and tritonol; RS-propranolol and tritonol; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and benazepril; S-propranolol Propranolol and benazepril; RS-propranolol and benazepril; R-propranolol and captopril; S-propranolol and captopril; RS-propranolol and captopril; R-timolol and cilazapril; S-timolol and cilazapril; RS-timolol and cilazapril; R-timolol and ramipril; S-timolol and ramipril; RS-timolol and ramipril; R-timolol and quinapril; S-timolol and quinapril; RS-timolol and quinapril; R-timolol and enalapril; S-timolol and enalapril; RS-timolol and enalapril; R-timolol and quinapril; S- Timolol and quinapril; RS-timolol and quinapril; R-timolol and benazepril; S-timolol and benazepril; RS-timolol and benazepril; R-timolol and captopril; S-timolol and captopril; RS-timolol and captopril; R-propranolol and EMA401; S-propranolol and EMA401; RS-propranolol and EMA401; R-timolol and EMA401; S-timolol and EMA401; RS-timolol and EMA401; R-propranolol and SMM02; S-propranolol and SMM02; RS-propranolol and SMM02 02; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril, or any of the combinations thereof, for the purpose of treating hemangiomas by topical administration.

[0058] In embodiments of aspects seven through nine, the following are provided: R-timolol and cilazapril; S-timolol and cilazapril; RS-timolol and cilazapril; R-timolol and SMM02; S-timolol and SMM02; R / S-timolol and SMM02; R-timolol and EMA401; S-timolol and EMA401; R / S-timolol and EMA401; R-propranolol and cilazapril; S-propranolol The use of R-propranolol and cilazapril; R / S-propranolol and cilazapril; SMM02 and cilazapril; EMA401 and cilazapril; R-propranolol and SMM02; R-propranolol and EMA401; S-propranolol and SMM02; S-propranolol and EMA401; R / S-propranolol and EMA401; or R / S-propranolol and SMM02; or any of the combinations thereof for the treatment of hemangiomas by topical administration.

[0059] In an eleventh aspect, the present invention provides the use of ACEi in the preparation of a medicament for treating a hemangioma in a subject, wherein the medicament is formulated for local administration to the hemangioma.

[0060] In a related aspect, the present invention provides the use of ACEi in the preparation of a medicament for treating hemangiomas in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with a β-blocker. In a preferred embodiment, the β-blocker is formulated for local administration.

[0061] In a related aspect, the present invention provides the use of ACEi in the preparation of a medicament for treating hemangiomas in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with an ATIIR2 antagonist, either simultaneously or in any order. In a preferred embodiment, the ATIIR2 antagonist is formulated for topical administration.

[0062] In a related aspect, the present invention provides the use of ACEi in the preparation of a medicament for treating hemangiomas in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with an ATIIR2 antagonist and a β-blocker, either in any order. In a preferred embodiment, the ATIIR2 antagonist and β-blocker are formulated for local administration.

[0063] In a twelfth aspect, the present invention provides the use of ACEi and β-blockers in the preparation of a medicament for treating a hemangioma in a subject, wherein the medicament is formulated for local administration to the hemangioma.

[0064] In one embodiment, the amount of β-blocker in the medicament is lower than that of the ACEi inhibitor. In one embodiment, the ratio of ACEi to β-blocker in the medicament is about 1:1 to about 10:1. In other embodiments, the ratio of ACEi to β-blocker in the medicament is about 2:1 to about 10:1, about 3:1 to about 9:1, about 4:1 to about 8:1, or about 5:1 to about 7:1. In other embodiments, the ratio is about 1:1, about 2:1, about 3:1, about 4:1, about 5:1, about 6:1, about 7:1, about 8:1, about 9:1, or about 10:1.

[0065] In a related aspect, the present invention provides the use of a β-blocker in the preparation of a medicament for treating a hemangioma in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with an ACEi, either simultaneously or in any order. In a preferred embodiment, the ACEi is formulated for local administration.

[0066] In a thirteenth aspect, the present invention provides the use of ACEi and ATIIR2 antagonists in the preparation of a medicament for treating a subject’s hemangioma, wherein the medicament is formulated for local administration to the hemangioma.

[0067] In a related aspect, the present invention provides the use of ATIIR2 in the preparation of a medicament for treating hemangiomas in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with ACEi. In a preferred embodiment, ACEi is formulated for local administration.

[0068] In a fourteenth aspect, the present invention provides the use of a β-blocker and an ATIIR2 antagonist in the preparation of a medicament for treating a subject’s hemangioma, wherein the medicament is formulated for local administration to the hemangioma.

[0069] In a related aspect, the present invention provides the use of a β-blocker in the preparation of a medicament for treating a hemangioma in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with an ATIIR2 antagonist, either simultaneously or in any order. The ATIIR2 antagonist may be formulated for local or systemic administration, preferably local administration.

[0070] In a related aspect, the present invention provides the use of an ATIIR2 antagonist in the preparation of a medicament for treating hemangiomas in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with a β-blocker, either locally or in any order. The β-blocker may be formulated for local or systemic administration. In a preferred embodiment, the β-blocker is formulated for local administration.

[0071] In a fifteenth aspect, the present invention provides the use of ACEi, β-blockers and ATIIR2 antagonists in the preparation of a medicament for treating a subject’s hemangioma, wherein the medicament is formulated for local administration to the hemangioma.

[0072] In a related aspect, the present invention provides the use of a β-blocker in the preparation of a medicament for treating a hemangioma in a subject, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with an ACEi and an ATIIR2 antagonist, either simultaneously or in any order. In a preferred embodiment, the ACEi is formulated for local administration. In a preferred embodiment, the ATIIR2 is formulated for local administration.

[0073] In a related aspect, the present invention provides the use of ATIIR2 in the preparation of a medicament for treating hemangiomas in subjects, wherein the medicament is formulated for simultaneous or sequential administration to the hemangioma in combination with ACEi and a β-blocker, either locally or in any order. In a preferred embodiment, the ACEi is formulated for local administration. In a preferred embodiment, the β-blocker is formulated for local administration.

[0074] In one embodiment of embodiments eleven through fifteen and related aspects, the drug comprises a combination of two or more ACEi. In another embodiment, the drug comprises a combination of two or more β-blockers. In yet another embodiment, the drug comprises a combination of two or more ATIIR2 antagonists.

[0075] In one embodiment of aspects eleven through fifteen and related thereto, the drug is formulated for external administration. In another embodiment of aspects eleven through fifteen, the drug is formulated for local injection.

[0076] In one embodiment of eleven through fifteen and related aspects, the ACEi is a prodrug. In a preferred embodiment, the ACEi is selected from the group consisting of: enalapril, ramipril, quindopril, cilazapril, benazepril, perindopril, imidapril, fosinopril, zolfenpril, and quinapril. In another embodiment, the ACEi is selected from captopril and lisinopril.

[0077] In one embodiment of the eleventh to fifteenth and related aspects thereto, the β-blocker is a non-selective β-blocker.

[0078] In one embodiment of the eleventh to fifteenth aspects and related aspects, the drug is formulated for local administration simultaneously or sequentially in combination with systemically administered ACEi, β-blockers and / or ATIIR2 antagonists.

[0079] In one embodiment of the eleventh to fifteenth aspects and related embodiments, the drug is formulated for simultaneous or sequential application to a systemically administered ACEi for local administration, either concurrently or in any order. In another embodiment, the drug is formulated for simultaneous or sequential application to a systemically administered β-blocker for local administration, either concurrently or in any order. In yet another embodiment, the drug is formulated for simultaneous or sequential application to a systemically administered ATIIR2 antagonist for local administration, either concurrently or in any order.

[0080] In certain embodiments of the eleventh to fifteenth aspects and related aspects, the combination of agents refers to: the β-blocker being a non-selective β-blocker and ACEi being a prodrug; the β-blocker being a non-selective β-blocker and ATIIR2 being an antagonist; or ACEi being a prodrug and ATIIR2 being an antagonist.

[0081] In certain embodiments of the eleventh to fifteenth aspects and related aspects, the combination of agents used refers to: β-blocker R-propranolol and ACEi cilazapril; β-blocker S-propranolol and ACEi cilazapril; β-blocker RS-propranolol and ACEi cilazapril; β-blocker R-propranolol and ACEi ramipril; β-blocker S-propranolol and ACEi ramipril; β-blocker RS-propranolol and ACEi ramipril; β-blocker R-propranolol and ACEi quindulpril; β-blocker S-propranolol and ACEi quindulpril; β-blocker RS-propranolol and A CEi is quinapril; β-blockers are R-propranolol and ACEi is enalapril; β-blockers are S-propranolol and ACEi is enalapril; β-blockers are RS-propranolol and ACEi is enalapril; β-blockers are R-propranolol and ACEi is quinapril; β-blockers are S-propranolol and ACEi is quinapril; β-blockers are RS-propranolol and ACEi is quinapril; β-blockers are R-propranolol and ACEi is benazepril; β-blockers are S-propranolol and ACEi is benazepril; β-blockers are RS-propranolol and ACEi is benazepril; β-blockers are R-propranolol and ACEi... It is captopril; the β-blocker is S-propranolol and ACEi is captopril; the β-blocker is RS-propranolol and ACEi is captopril; the β-blocker is R-timolol and ACEi is cilazapril; the β-blocker is S-timolol and ACEi is cilazapril; the β-blocker is RS-timolol and ACEi is cilazapril; the β-blocker is R-timolol and ACEi is ramipril; the β-blocker is S-timolol and ACEi is ramipril; the β-blocker is RS-timolol and ACEi is ramipril; the β-blocker is R-timolol and ACEi is quinduprel; the β-blocker is S-timolol and ACEi is quinduprel. ACE inhibitors include: β-blockers such as RS-timolol and ACE inhibitors such as quinapril; β-blockers such as R-timolol and ACE inhibitors such as enalapril; β-blockers such as S-timolol and ACE inhibitors such as enalapril; β-blockers such as RS-timolol and ACE inhibitors such as enalapril; β-blockers such as R-timolol and ACE inhibitors such as quinapril; β-blockers such as S-timolol and ACE inhibitors such as quinapril; β-blockers such as RS-timolol and ACE inhibitors such as benazepril; β-blockers such as S-timolol and ACE inhibitors such as benazepril; β-blockers such as RS-timolol and ACE inhibitors such as benazepril.The β-blocker is R-timolol and the ACEi is captopril; the β-blocker is S-timolol and the ACEi is captopril; the β-blocker is RS-timolol and the ACEi is captopril; the β-blocker is R-propranolol and the ATIIR2 antagonist is EMA401; the β-blocker is S-propranolol and the ATIIR2 antagonist is EMA401; the β-blocker is RS-propranolol and the ATIIR2 antagonist is EMA401; the β-blocker is R-timolol and the ATIIR2 antagonist is EMA401; the β-blocker is R-timolol and the ATIIR2 antagonist is EMA401; β- The β-blocker is S-timolol and the ATIIR2 antagonist is EMA401; the β-blocker is RS-timolol and the ATIIR2 antagonist is EMA401; the β-blocker is R-propranolol and the ATIIR2 antagonist is SMM02; the β-blocker is S-propranolol and the ATIIR2 antagonist is SMM02; the β-blocker is RS-propranolol and the ATIIR2 antagonist is SMM02; the β-blocker is R-timolol and the ATIIR2 antagonist is SMM02; the β-blocker is S-timolol and the ATIIR2 antagonist is SMM02; the β-blocker is S-timolol and the ATIIR2 antagonist is SMM02. The 2-antagonist is SMM02; the β-blocker is RS-timolol; and the ATIIR2 antagonist is SMM02; the ATIIR2 antagonist is EMA401; and the ACEi is cilazapril; the ATIIR2 antagonist is EMA401; and the ACEi is ramipril; the ATIIR2 antagonist is EMA401; and the ACEi is quinapril; the ATIIR2 antagonist is EMA401; and the ACEi is quinapril. ACEi is benazepril; ATIIR2 antagonist is EMA401 and ACEi is captopril; ATIIR2 antagonist is SMM02 and ACEi is cilazapril; ATIIR2 antagonist is SMM02 and ACEi is ramipril; ATIIR2 antagonist is SMM02 and ACEi is quinapril; ATIIR2 antagonist is SMM02 and ACEi is benazepril; or ATIIR2 antagonist is SMM02 and ACEi is captopril.

[0082] In certain embodiments of the eleventh to fifteenth aspects and related aspects, the combination of agents used refers to: β-blocker R-timolol and ACEi cilazapril; β-blocker S-timolol and ACEi cilazapril; β-blocker RS-timolol and ACEi cilazapril; β-blocker R-timolol and ATIIR2 antagonist SMM02; β-blocker S-timolol and... The ATIIR2 antagonist is SMM02; the β-blocker is RS-timolol; the ATIIR2 antagonist is SMM02; the β-blocker is R-timolol; the ATIIR2 antagonist is EMA401; the β-blocker is S-timolol; the ATIIR2 antagonist is EMA401; the β-blocker is RS-timolol; the ATIIR2 antagonist is EMA401; the β-blocker is R-propranolol. And ACEi is cilazapril; β-blocker is S-propranolol and ACEi is cilazapril; β-blocker is R / S-propranolol and ACEi is cilazapril; ATIIR2 antagonist is SMM02 and ACEi is cilazapril; ATIIR2 antagonist is EMA401 and ACEi is cilazapril; β-blocker is R-propranolol and ATIIR2 antagonist is SMM02; β-blocker The β-blocker is R-propranolol and the ATIIR2 antagonist is EMA401; the β-blocker is S-propranolol and the ATIIR2 antagonist is SMM02; the β-blocker is S-propranolol and the ATIIR2 antagonist is EMA401; the β-blocker is R / S-propranolol and the ATIIR2 antagonist is SMM02; or the β-blocker is R / S-propranolol and the ATIIR2 antagonist is EMA401.

[0083] In a sixteenth aspect, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the step of systemically administering two or more of ACEi, a β-blocker, and an ATIIR2 antagonist to the subject.

[0084] In one embodiment of the sixteenth aspect, the method includes at least the step of systemically administering ACEi and β-blocker. In other embodiments, the method includes at least the step of systemically administering: ACEi and ATIIR2 antagonist; β-blocker and ATIIR2 antagonist; or ACEi, β-blocker and ATIIR2 antagonist.

[0085] In one embodiment of the sixteenth aspect, ACEi, a β-blocker, and an ATIIR2 antagonist are administered simultaneously. In another embodiment, ACEi, a β-blocker, and an ATIIR2 antagonist are administered sequentially in any order.

[0086] In one embodiment of the sixteenth aspect, the ACEi, β-blocker and / or ATIIR2 antagonist are administered orally.

[0087] In one embodiment of the sixteenth aspect, ACEi is in the form of a prodrug.

[0088] In one embodiment of the sixteenth aspect, the β-blocker is a non-selective β-blocker.

[0089] In some embodiments of the sixteenth aspect, these methods include at least the steps of systemically administering to the subject: a non-selective β-blocker and an ACEi in prodrug form; a non-selective β-blocker and an ATIIR2 antagonist; or an ATIIR2 antagonist and an ACEi in prodrug form.

[0090] In some embodiments of the sixteenth aspect, these methods include at least the step of systemically administering the following to a subject: R-propranolol and cilazapril; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; Napharil; R-Propranolol and Benazepril; S-Propranolol and Benazepril; RS-Propranolol and Benazepril; R-Propranolol and Captopril; S-Propranolol and Captopril; RS-Propranolol and Captopril; R-Timolol and Cilabapril; S-Timolol and Cilabapril; RS-Timolol and Cilabapril; R-Timolol and Ramipril; S-Timolol and Ramipril; RS-Timolol and Ramipril; R-Timolol and Grundopril; S-Timolol and Grundopril; RS-Timolol and Grundopril; R-Timolol and Enalapril; S-Timolol and Enalapril; RS-Timolol and Enalapril; Timolol and Enalapril; R-Timolol and Quinapril; S-Timolol and Quinapril; RS-Timolol and Quinapril; R-Timolol and Benapril; S-Timolol and Benapril; RS-Timolol and Benapril; R-Timolol and Captopril; S-Timolol and Captopril; RS-Timolol and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Timolol and EMA401; S-Timolol and EMA401; RS-Timolol and EMA401; R-Propranolol and SMM02; S-Propranolol and SMM02; RS-Propranolol and SMM02; R-Timolol and SMM02; S-Timolol and SMM02; RS-Timolol and SMM02; EMA401 and Cilapril; EMA401 and Ramipril; EMA401 and Qundopril; EMA401 and Enalapril; EMA401 and Quinapril; EMA401 and Benazepril; EMA401 and Captopril; SMM02 and Cilapril; SMM02 and Ramipril; SMM02 and Qundopril; SMM02 and Quinapril; SMM02 and Benazepril; or SMM02 and Captopril.

[0091] In some embodiments of the sixteenth aspect, these methods include at least the step of systemically administering the following to a subject: R-timolol and cilazapril; S-timolol and cilazapril; RS-timolol and cilazapril; R-propranolol and cilazapril; S-propranolol and cilazapril; R / S-propranolol and cilazapril; SMM02 and cilazapril; EMA401 and cilazapril; R-propranolol and SMM02; S-propranolol and SMM02; R / S-propranolol and SMM02; R-propranolol and EMA401; S-propranolol and EMA401; RS-propranolol and EMA401; EMA401 and R-timolol; EMA401 and S-timolol; or EMA401 and RS-timolol.

[0092] In one embodiment of the sixteenth aspect, these methods include administering two or more ACEi, two or more β-blockers, and / or two or more ATIIR2 antagonists.

[0093] In a seventeenth aspect, the present invention provides the use of two or more of ACEi, β-blockers and ATIIR2 antagonists, or two or more of ACEi, β-blockers and ATIIR2 antagonists, for treating a subject with a hemangioma, wherein the ACEi, β-blockers and ATIIR2 antagonists are formulated for systemic administration.

[0094] In one embodiment, the present invention provides an ACEi for treating a hemangioma in a subject in combination with at least one of a β-blocker and an ATIIR2 antagonist, wherein the ACEi, β-blocker, and ATIIR2 antagonist are formulated for systemic administration. In another embodiment, the present invention provides an ATIIR2 antagonist for treating a hemangioma in a subject in combination with at least one of a β-blocker and an ACEi, wherein the ACEi, β-blocker, and ATIIR2 antagonist are formulated for systemic administration. In yet another embodiment, the present invention provides a β-blocker for treating a hemangioma in a subject in combination with at least one of an ACEi and an ATIIR2 antagonist, wherein the ACEi, β-blocker, and ATIIR2 antagonist are formulated for systemic administration.

[0095] In one embodiment of the seventeenth aspect, ACEi is in the form of a prodrug.

[0096] In one embodiment of the seventeenth aspect, the β-blocker is a non-selective β-blocker.

[0097] In an embodiment of the seventeenth aspect, the following are provided: a non-selective β-blocker and an ACEi in prodrug form; a non-selective β-blocker and an ATIIR2 antagonist; an ACEi and an ATIIR2 antagonist in prodrug form, or the combination thereof, for use in treating hemangiomas by systemic administration.

[0098] In the seventeenth aspect of the embodiments, the following are provided: R-propranolol and cilazapril; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and benazepril; S-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and benazepril; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and quinapril; R-propranolol and benazepril; S-propranolol and enalapril; RS-propranolol and enalapril; R ... Propranolol and benazepril; RS-propranolol and benazepril; R-propranolol and captopril; S-propranolol and captopril; RS-propranolol and captopril; R-timolol and cilazapril; S-timolol and cilazapril; RS-timolol and cilazapril; R-timolol and ramipril; S-timolol and ramipril; RS-timolol and ramipril; R-timolol and quinapril; S-timolol and quinapril; RS-timolol and quinapril; R-timolol and enalapril; S-timolol and enalapril; RS-timolol and enalapril; R-timolol and quinapril; S-timolol and enalapril; Tamarol and Quinapril; RS-Timolol and Quinapril; R-Timolol and Benazepril; S-Timolol and Benazepril; RS-Timolol and Benazepril; R-Timolol and Captopril; S-Timolol and Captopril; RS-Timolol and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Timolol and EMA401; S-Timolol and EMA401; RS-Timolol and EMA401; R-Propranolol and SMM02; S-Propranolol and SMM02; RS-Propranolol and SMM02 2; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril; or any of the combinations thereof for the treatment of hemangiomas by systemic administration.

[0099] In the seventeenth aspect of the embodiments, the following are provided: R-timolol and cilazapril; S-timolol and cilazapril; R / S-timolol and cilazapril; R-propranolol and cilazapril; S-propranolol and cilazapril; R / S-propranolol and cilazapril; SMM02 and cilazapril; R-propranolol and SMM02; R-propranolol and EMA401; S-propranolol and SMM02; S-propranolol and EMA401. 1; R / S-propranolol and SMM02; R / S-propranolol and EMA401; R-timolol and SMM02; S-timolol and SMM02; R / S-timolol and SMM02; R-timolol and EMA401; S-timolol and EMA401; R / S-timolol and EMA401; Cilapril and EMA401; or any of the combinations thereof for the treatment of hemangiomas by systemic administration.

[0100] In an eighteenth aspect, the present invention provides the use of two or more of ACEi, β-blockers and ATIIR2 antagonists in the preparation of a medicament for treating a subject’s hemangioma, wherein the medicament is formulated for systemic administration.

[0101] In one embodiment of the seventeenth or eighteenth aspect, a combination of ACEi and a β-blocker is used. In other embodiments, the following combinations are used: ACEi and an ATIIR2 antagonist; a β-blocker and an ATIIR2 antagonist; or ACEi, a β-blocker, and an ATIIR2 antagonist.

[0102] In one embodiment of the eighteenth aspect, ACEi is in the form of a prodrug.

[0103] In one embodiment of the eighteenth aspect, the β-blocker is a non-selective β-blocker.

[0104] In one embodiment of the seventeenth or eighteenth aspect, the ACEi, β-blocker, and ATIIR2 antagonist are formulated for simultaneous administration. In another embodiment, the ACEi, β-blocker, and ATIIR2 antagonist are formulated for sequential administration in any order.

[0105] In one embodiment of the seventeenth or eighteenth aspect, the ACEi, β-blocker, and ATIIR2 antagonist are formulated for oral administration.

[0106] In some embodiments of the eighteenth aspect, the present invention provides: a non-selective β-blocker and an ACEi in prodrug form; a non-selective β-blocker and an ATIIR2 antagonist; or an ATIIR2 antagonist and an ACEi in prodrug form in the preparation of a medicament for treating a subject’s hemangioma, wherein the medicament is formulated for systemic administration.

[0107] In certain embodiments of the eighteenth aspect, the present invention provides the use of the following in the preparation of a medicament for treating a subject's hemangioma, wherein the medicament is formulated for systemic administration: R-propranolol and cilazapril; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and quina ... enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and enalapril; S-propranolol and Napharol and quinapril; RS-propranolol and quinapril; R-propranolol and benazepril; S-propranolol and benazepril; RS-propranolol and benazepril; R-propranolol and captopril; S-propranolol and captopril; RS-propranolol and captopril; R-timolol and cilazapril; S-timolol and cilazapril; RS-timolol and cilazapril; R-timolol and ramipril; S-timolol and ramipril; RS-timolol and ramipril; R-timolol and quinapril; S-timolol and quinapril; RS-timolol and quinapril; R-timolol and enalapril; S-timolol Tadalafil and Enalapril; RS-Tadalafil and Enalapril; R-Tadalafil and Quinapril; S-Tadalafil and Quinapril; RS-Tadalafil and Quinapril; R-Tadalafil and Benapril; S-Tadalafil and Benapril; RS-Tadalafil and Benapril; R-Tadalafil and Captopril; S-Tadalafil and Captopril; RS-Tadalafil and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Tadalafil and EMA401; S-Tadalafil and EMA401; RS-Tadalafil and EMA401; R-Propranolol and SMM02; S-propranolol and SMM02; RS-propranolol and SMM02; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril.

[0108] In certain embodiments of the eighteenth aspect, the invention provides the following use in the preparation of a medicament for treating a subject's hemangioma, wherein the medicament is formulated for systemic administration: R-timolol and cilazapril; S-timolol and cilazapril; R / S-timolol and cilazapril; R-timolol and SMM02; S-timolol and SMM02; R / S-timolol and SMM02; R-timolol and EMA401; S-timolol and EMA401. 1; R / S-Timolol and EMA401; R-Propranolol and Ciladrexate; S-Propranolol and Ciladrexate; R / S-Propranolol and Ciladrexate; SMM02 and Ciladrexate; EMA401 and Ciladrexate; R-Propranolol and SMM02; S-Propranolol and SMM02; R / S-Propranolol and SMM02; R-Propranolol and EMA401; S-Propranolol and EMA401; or R / S-Propranolol and EMA401.

[0109] In one embodiment of the seventeenth or eighteenth aspect, two or more ACEi, two or more β-blockers and / or two or more ATIIR2 antagonists are used.

[0110] In a nineteenth aspect, the present invention provides a composition comprising a combination of ACE inhibitors and a β-blocker, wherein the composition is suitable for topical administration to a hemangioma. In one embodiment, the composition is suitable for external administration. In one embodiment, the composition comprises a lower amount of a β-blocker relative to the amount of ACE inhibitor.

[0111] In one embodiment, the ratio of ACEi to β-blocker in the composition is from about 1:1 to about 10:1. In other embodiments, the ratio of ACEi to β-blocker in the composition is from about 2:1 to about 10:1, from about 3:1 to about 9:1, from about 4:1 to about 8:1, or from about 5:1 to about 7:1. In other embodiments, the ratio is from about 1:1, about 2:1, about 3:1, about 4:1, about 5:1, about 6:1, about 7:1, about 8:1, about 9:1, or about 10:1.

[0112] In one embodiment, the composition comprises an ACEi in prodrug form. In one embodiment, the ACEi is selected from the group consisting of: enalapril, ramipril, quindopril, cilazapril, benazepril, quinapril, perindopril, imidapril, fosinopril, and zolfenpril. In another embodiment, the ACEi is selected from the group consisting of: captopril and lisinopril.

[0113] In one embodiment, the composition includes a non-selective β-blocker.

[0114] In a twentieth aspect, the present invention provides a composition comprising an ACEi and an ATIIR2 antagonist, wherein the composition is suitable for local administration to a hemangioma. In one embodiment, the composition is suitable for topical administration.

[0115] In a twenty-first aspect, the present invention provides a composition comprising a β-blocker and an ATIIR2 antagonist, wherein the composition is suitable for local administration to a hemangioma. In one embodiment, the composition is suitable for topical administration.

[0116] In a twenty-second aspect, the present invention provides a composition comprising an ACEi, a β-blocker, and an ATIIR2 antagonist, wherein the composition is suitable for local administration to a hemangioma. In one embodiment, the composition is suitable for topical administration.

[0117] In some embodiments of aspects nineteen to twenty-two, the composition comprises: a non-selective β-blocker and an ACEi in prodrug form; a non-selective β-blocker and an ATIIR2 antagonist; or an ATIIR2 antagonist and an ACEi in prodrug form.

[0118] In certain embodiments of aspects nineteen to twenty-two, the composition comprises: R-propranolol and cilazapril; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and enalapril; Propranolol and benazepril; S-propranolol and benazepril; RS-propranolol and benazepril; R-propranolol and captopril; S-propranolol and captopril; RS-propranolol and captopril; R-timolol and cilazapril; S-timolol and cilazapril; RS-timolol and cilazapril; R-timolol and ramipril; S-timolol and ramipril; RS-timolol and ramipril; R-timolol and quindolin; S-timolol and quindolin; RS-timolol and quindolin; R-timolol and enalapril; S-timolol and enalapril; RS-timolol and enalapril Propranolol; R-Timolol and Quinapril; S-Timolol and Quinapril; RS-Timolol and Quinapril; R-Timolol and Benazepril; S-Timolol and Benazepril; RS-Timolol and Benazepril; R-Timolol and Captopril; S-Timolol and Captopril; RS-Timolol and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Timolol and EMA401; S-Timolol and EMA401; RS-Timolol and EMA401; R-Propranolol and SMM02; S- Propranolol and SMM02; RS-propranolol and SMM02; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril.

[0119] In some embodiments of aspects nineteen to twenty-two, the composition comprises: R-timolol and cilazapril; S-timolol and cilazapril; R / S-timolol and cilazapril; R-timolol and SMM02; S-timolol and SMM02; R / S-timolol and cilazapril; R-timolol and EMA401; S-timolol and EMA401; R / S-timolol and EMA401 R-Propranolol and Cilabesil; S-Propranolol and Cilabesil; R / S-Propranolol and Cilabesil; SMM02 and Cilabesil; EMA401 and Cilabesil; R-Propranolol and SMM02; S-Propranolol and SMM02; R / S-Propranolol and SMM02; R-Propranolol and EMA401; S-Propranolol and EMA401; or R / S-Propranolol and EMA401.

[0120] In a twenty-third aspect, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the step of topically administering an ATIIR2 antagonist to the hemangioma. In one embodiment, the ATIIR2 antagonist is administered topically.

[0121] In one embodiment of the twenty-third aspect, the method further includes administering a β-blocker and / or ACEi.

[0122] In one embodiment of the twenty-third aspect, a β-blocker and / or ACEi are administered topically to the hemangioma. In another embodiment, a β-blocker and / or ACEi are administered systemically. In one embodiment, an ATIIR2 antagonist and a β-blocker and / or ACEi are administered simultaneously. In another embodiment, an ATIIR2 antagonist and a β-blocker and / or ACEi are administered sequentially in any order.

[0123] In one embodiment of the twenty-third aspect, two or more ATIIR2 antagonists are administered. In another embodiment, two or more β-blockers are administered. In yet another embodiment, two or more ACEi are administered. Two or more ACEi, β-blockers, and ATIIR2 antagonists may be administered simultaneously or sequentially in any order.

[0124] In a twenty-fourth aspect, the present invention provides the use of an ATIIR2 antagonist, or an ATIIR2 antagonist, for treating a hemangioma in a subject, wherein the ATIIR2 antagonist is formulated for local administration to the hemangioma. In one embodiment, the ATIIR2 antagonist is formulated for topical administration.

[0125] In one embodiment of the twenty-fourth aspect, the ATIIR2 antagonist is used in combination with a β-blocker and / or an ACE inhibitor to treat a subject's hemangioma. In one embodiment, the β-blocker and / or ACE inhibitor are administered topically to the hemangioma. In another embodiment, the β-blocker and / or ACE inhibitor are administered systemically. In one embodiment, the ATIIR2 antagonist and the β-blocker and / or ACE inhibitor are administered simultaneously. In another embodiment, the ATIIR2 antagonist and the β-blocker and / or ACE inhibitor are administered sequentially in any order.

[0126] In one embodiment of aspect twenty-four, two or more ATIIR2 antagonists are used. In another embodiment, two or more β-blockers are used. In yet another embodiment, two or more ACEi are used. Two or more ACEi, β-blockers, and ATIIR2 antagonists may be administered simultaneously or sequentially in any order.

[0127] In a twenty-fifth aspect, the present invention provides the use of an ATIIR2 antagonist in the preparation of a medicament for treating a hemangioma in a subject, wherein the medicament is formulated for local administration to the hemangioma. In one embodiment, the medicament is formulated for topical administration.

[0128] In one embodiment of the twenty-fifth aspect, the drug is formulated for simultaneous or sequential administration to the hemangioma in combination with an ACE inhibitor and / or a β-blocker, either locally or in any order. In a preferred embodiment, the ACE inhibitor and / or the β-blocker is formulated for local administration. In another embodiment, the ACE inhibitor and / or the β-blocker is formulated for systemic administration.

[0129] In one embodiment of the twenty-fifth aspect, the drug comprises two or more ATIIR2 antagonists.

[0130] In one embodiment of the twenty-fifth aspect, the drug comprises one or more ACE inhibitors and / or one or more β-blockers.

[0131] In one embodiment of the twenty-fifth aspect, the drug is formulated in combination with two or more ACE inhibitors and / or two or more β-blockers for local administration.

[0132] In one embodiment of aspects 23 to 25, ACEi is in the form of a prodrug.

[0133] In one embodiment of aspects 23 to 25, the β-blocker is a non-selective β-blocker.

[0134] In one embodiment of aspects 1 to 19 and 23 to 25 and related aspects, the hemangioma is an infantile hemangioma. In another embodiment, the hemangioma is a proliferative hemangioma.

[0135] In one embodiment, the β-blocker is selected from the group consisting of: propranolol, timolol, pindolol, sotalol, and atenolol. In one embodiment of aspects one through nineteen, the β-blocker is a combination of enantiomers. In one embodiment, the β-blocker is a combination of enantiomers comprising a higher proportion of (R)-enantiomers. In one embodiment, the β-blocker is substantially in the form of an S-enantiomer. In one embodiment, the β-blocker is substantially in the form of an R-enantiomer. In a preferred embodiment, the β-blocker is selected from the group consisting of: R-timolol, S-timolol, R / S-timolol, R-propranolol, S-propranolol, and R / S-propranolol.

[0136] In one embodiment of the first to twenty-fifth aspects, the ATIIR2 antagonist is selected from the group consisting of: EMA401, SMM02 (L-159,686); PD-123,319, PD-121,981, PD-126,055, L-161,638 (sodium salt), and L-163,579. In one embodiment of the first to twenty-fifth aspects, the ATIIR2 antagonist is selected from the group consisting of: EMA401 and SMM02.

[0137] The invention may also be broadly included in any and all combinations of two or more of the parts, elements and features mentioned or indicated in this application specification, individually or collectively, and wherein specific integers mentioned herein have known equivalents in the field to which the invention relates, such known equivalents are considered to be incorporated herein as if listed separately. Attached Figure Description

[0138] These and other aspects of the invention, which should be considered in all their novel aspects, will become apparent from the following description, which is given by way of example only, with reference to the accompanying drawings:

[0139] Figure 1 Effects of ACE inhibitors (cilapril) and beta-blockers (timolol) on the inhibition of in vitro hemangioma cell proliferation after a single 100 μM dose.

[0140] Figure 2The effect of ACE inhibitors (cilapril) and beta-blockers (timolol) in different ratios on the inhibition of in vitro hemangioma cell proliferation. Legend: Left bar: 24 hours; Middle bar: 48 hours; Right bar: 72 hours.

[0141] Figure 3 The effect of a β-blocker (timolol) on the inhibition of proliferative infantile hemangioma cells derived in vitro from multiple patients (n=5).

[0142] Figure 4 The effect of the ACE inhibitor (cilapril) on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0143] Figure 5 The effect of AT2 receptor inhibitor (EMA401) on inhibiting proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0144] Figure 6 Effects of AT2 receptor inhibitor (EMA401) on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (raw absorbance data) (n=5).

[0145] Figure 7 The effect of AT2 receptor inhibitor (SMM02) on inhibiting proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0146] Figure 8 Effects of AT2 receptor inhibitor (SMM02) on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (raw absorbance data) (n=5).

[0147] Figure 9 The effect of AT1 receptor inhibitor (losartan) on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0148] Figure 10 : Effects of experimental adjuvants (solvents) on cell proliferation of hemangioma cells in vitro (control experiment) (n=5).

[0149] Figure 11 The effects of ACE inhibitors (cilapril) and beta-blockers (timolol) in different ratios on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0150] Figure 12 The effects of different ratios of beta-blockers (timolol) and AT2 receptor inhibitors (EMA401) on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0151] Figure 13 The effects of different ratios of beta-blockers (timolol) and AT2 receptor inhibitors (SMM02) on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0152] Figure 14 The effects of ACE inhibitors (cilapril) and AT2 receptor inhibitors (EMA401) in different ratios on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0153] Figure 15 The effects of ACE inhibitors (cilapril) and AT2 receptor inhibitors (SMM02) in different ratios on the inhibition of proliferative infantile hemangioma cells derived from multiple patients in vitro (n=5).

[0154] Figure 16 The effects of β-blockers (timolol and propranolol) and ACE inhibitors (cilapril) as single agents on the inhibition of proliferative hemangioma cells in vitro were investigated. Timolol (25A, B) and propranolol (25C, D) were studied as single enantiomers (S-timolol, R-timolol, S-propranolol, and R-propranolol) and as a racemic mixture of enantiomers (R / S-propranolol) (25E).

[0155] Figure 17 The effect of a single enantiomer of timolol (a beta-blocker) combined with cilazapril (an ACE inhibitor) on the inhibition of proliferative hemangioma cells in vitro.

[0156] Figure 18 The effect of a single enantiomer of propranolol (a beta-blocker) or a racemic mixture thereof in combination with cilazapril (an ACE inhibitor) on the inhibition of proliferative hemangioma cells in vitro.

[0157] Figure 19 : 72 hours after administration, the dose response of a renin-angiotensin system inhibitor as a single agent to multiple proliferative hemangioma cell lines (n=9) derived from biopsies of different patients.

[0158] Figure 20 The combined effect of an AT2 receptor inhibitor (SMM02) and an ACE inhibitor (cilapril) on the inhibition of multiple proliferative hemangioma cell lines (n=9) 72 hours after administration.

[0159] Figure 21 The effect of the combination of ACE inhibitor (cilapril) and β-blocker (R-propranolol) on the inhibition of multiple proliferative hemangioma cell lines (n=9) 72 hours after administration.

[0160] Figure 22 The combination of cilazapril and R-propranolol showed mean inhibition of multiple proliferative hemangioma cell lines after 72 hours (n=9; error represents the standard error of the mean).

[0161] Figure 23 The combination of an ACE inhibitor (cilapril) and a β-blocker (S-propranolol) inhibited the growth of multiple proliferative hemangioma cell lines (n=9) 72 hours after administration.

[0162] Figure 24 The combination of cilazapril and S-propranolol showed mean inhibition of multiple proliferative hemangioma cell lines after 72 hours (n=9; error represents the standard error of the mean).

[0163] Figure 25 The combined effect of AT2 receptor antagonist (SMM02) and β-blocker (R-propranolol) on the inhibition of multiple proliferative hemangioma cell lines (n=9) 72 hours after administration.

[0164] Figure 26 The combined effect of AT2 receptor antagonist (SMM02) and β-blocker (S-propranolol) on the inhibition of multiple proliferative hemangioma cell lines (n=9) 72 hours after administration.

[0165] Figure 27 The distribution of combined index (CI) values ​​in primary hemangioma cell lines (n=9) generated by the combination of AT2 receptor antagonist (SMM02) and ACE inhibitor (cilapril) 72 hours after administration showed an average synergistic effect (CI<1).

[0166] Figure 28 The distribution of combined index (CI) values ​​in primary hemangioma cell lines (n=9) generated by the combination of the ACE inhibitor (cilapril) and the β-blocker (R-propranolol) 72 hours after administration showed an average synergistic effect (CI<1).

[0167] Figure 29 The distribution of combined index (CI) values ​​in primary hemangioma cell lines (n=9) generated by the combination of the ACE inhibitor (cilapril) and the β-blocker (S-propranolol) 72 hours after administration showed an average synergistic effect (CI<1).

[0168] Figure 30 The distribution of combined index (CI) values ​​in primary hemangioma cell lines (n=9) generated by the combination of AT2 receptor antagonist (SMM02) and β-blocker (R-propranolol) 72 hours after administration showed an average synergistic effect (CI<1).

[0169] Figure 31 The distribution of combined index (CI) values ​​in primary hemangioma cell lines (n=9) generated by the combination of AT2 receptor antagonist (SMM02) and β-blocker (S-propranolol) 72 hours after administration showed an average synergistic effect (CI<1).

[0170] Figure 32 Effects of different β-blockers on the inhibition of primary hemangioma cells biopsied during the proliferative phase.

[0171] Figure 33 The effects of different ACE inhibitors on the inhibition of primary hemangioma cells biopsied during the proliferative phase.

[0172] Figure 34 (A) A custom-designed Franz diffusion cell device combined with a Strat-M membrane for in vitro transdermal screening. (B) An example of membrane permeation of a CF solution alone (pH 7.4) (rhombus) and a diluted suspension of CF-containing liposomes (<1 mM) (square). (C) An example of membrane permeation of a 0.5% CF emulgel formulation.

[0173] Figure 35 Preparation and characterization of lisinopril emulsion gels. A) Scalable route for emulsion formulation preparation. B) Photograph of lisinopril emulsion gels. C) Optical microscopy of the emulsion gel formulation. Scale bar = 5 μm. D) Cryofracture transmission electron microscopy of the emulsion gel formulation. Scale bar = 2 μm.

[0174] Figure 36 Scalable production of liposomes. (A) Custom-designed large-volume liposome extruder. (B) Dynamic light scattering data demonstrating liposome size distribution after one, five, and ten extrusions.

[0175] Figure 37 Preparation and characterization of deformable liposome gels. (A) Scalable production route for deformable gel formulations. (B) Photograph of the final deformable liposome gel. (C) Cryofracture transmission electron microscopy revealing deformable liposomes (light arrows) embedded within the hydrogel matrix (dark arrow).

[0176] Figure 38 : Sensitive quantitative fluorescence determination of lisinopril in the Franz diffusion assay. (A) Reaction between lisinopril and fluorescein to form a highly fluorescent conjugate. (B) Reproducible linear relationship between fluorescence intensity and lisinopril concentration.

[0177] Figure 39Permeation experiments. (A) Photograph of a custom-designed Franz diffusion cell containing a liposome gel containing carboxyfluorescein for visual clarity. (B) Permeation of lisinopril from lisinopril emulsion gel formulation (circular) and deformable liposome (SQH) formulation (square).

[0178] Figure 40 (A) Standard curve of propranolol hydrochloride determined by UV-Vis spectroscopy with a maximum absorbance of 288 nm. (B) Permeation of propranolol across the skin model membrane using a 1% propranolol / cyclodextrin emulsion gel formulation. (C) Permeation of propranolol across the skin model membrane using a 1% propranolol cream formulation. (D) Comparison of permeation across the skin model membrane using a 1% emulsion gel formulation between propranolol (round) and lisinopril (square).

[0179] Preferred Implementation

[0180] The following is a description of the present invention, including preferred embodiments thereof, given in general terms. The invention is further clarified by the disclosure given in the heading “Examples” below, which provides experimental data supporting the invention, specific embodiments of various aspects of the invention, and ways of carrying out the invention.

[0181] Following extensive research, the inventors surprisingly discovered that local inhibition of ACE activity within the hemangioma microenvironment via ACE inhibitor administration is an effective treatment modality with a superior long-term safety profile compared to the currently preferred standard of care of oral β-blockers. This contradicts various reports that β-blockers offer superior therapeutic outcomes compared to ACE inhibitors.

[0182] The inventors also discovered that the combination of ACEi and β-blockers applied locally to hemangiomas provides an unexpected synergistic effect, offering an alternative and potentially superior treatment option for hemangiomas. Due to the synergistic nature of the combination, the inventors consider this option particularly useful for treating rebound hemangiomas, more difficult-to-treat hemangiomas that cannot be completely resolved by propranolol alone, or as a dose-saving first-line therapy that reduces the risk of systemic side effects.

[0183] Not wanting to be bound by theory, the inventors considered that the enhanced inhibitory effect of ACE inhibitors combined with local administration and β-blockers may arise from the inhibition of multiple proliferation mechanisms involved in hemangiomas; for example, inhibition of β-1 and β-2 adrenergic receptors associated with hemangioma stem cells, inhibition of SOX18 transcription factor, reduction of angiotensin II production and thus reduction of angiotensin II type 2 receptor stimulation, and regulation of various other currently unknown targets.

[0184] Furthermore, the inventors have confirmed that the use of a combination of a β-blocker and an angiotensin II type 2 receptor (ATIIR2) antagonist, or a combination of ACEi and an ATIIR2 antagonist, applied topically to the hemangioma, provides another alternative treatment option for hemangiomas. Again, the inventors consider that this can provide improved treatment outcomes compared to using a single type of compound alone, as they target multiple proliferative mechanisms involved in hemangiomas.

[0185] The inventors surprisingly found that combination therapy with the agents described herein during the proliferative phase produced more consistent levels of inhibition in primary hemangioma cells derived from individual patient biopsies across patient samples (n=9). In contrast, when treated with a single agent, a greater degree of variation in the responses of these patient-derived cell lines was observed. Based on these results, the inventors considered that at least local treatment of hemangiomas with a combination of inhibitors targeting different aspects of the renin-angiotensin system (e.g., ACEi, ATIIR2 antagonists, and / or β-blockers as described herein) could produce more consistent and clinically superior results than single-agent therapy. Using such a combination also allows administration of lower doses of one or more related agents to the subject (compared to the use of each single agent), with the potential benefit of reducing the risk of any adverse side effects that may be associated with such agents.

[0186] Furthermore, the inventors have discovered that ACEi for the specific use of treating hemangiomas via local administration include those in prodrug form. This is unexpected, as it should be understood in the art that ACEi prodrugs require activation via hepatic biotransformation, suggesting that systemic administration would be the only effective delivery method.

[0187] The inventors also surprisingly discovered a small difference between R-β-blockers and S-β-blockers in their ability to inhibit proliferative hemangioma cells, noting that a single isomer alone is as effective as the racemic mixture currently prescribed for treating proliferative infantile hemangiomas requiring systemic therapy. This is an important finding because R-enantiomers of β-blockers (such as timolol and propranolol) do not exert the same degree of blood pressure effect as their S-enantiomers. Therefore, the inventors propose that using R-enantiomers of β-blockers in hemangioma treatment regimens could allow for effective treatment while reducing or minimizing the risk of negative side effects that may be associated with the use of S-enantiomers and / or racemic mixtures of β-blockers.

[0188] Based on the generated data, the inventors also considered that non-selective β-blockers may be more effective than selective β-blockers in the treatment of hemangiomas.

[0189] The inventors also considered that topical administration of ATIIR2 antagonists could provide an effective treatment option for hemangiomas. Their studies demonstrated that using ATIIR2 as a single agent at lower doses was effective compared to using ACEi or β-blockers. Not wanting to be bound by theory, the inventors considered that ATIIR2 is highly expressed during infancy and may play a role in early growth and development. Clinical development of first-selective ATIIR2 antagonists was recently halted due to systemic toxicity following long-term use, and systemic side effects of topical β-blockers have been previously reported. Therefore, the inventors anticipated that treating patients with low-dose, topical ATIIR2 antagonists would have essentially no side effects (or at least fewer) compared to systemic ATIIR2 antagonists, BB, and ACEi, and would reduce complications commonly associated with these therapies. Furthermore, the inventors unexpectedly found that low-dose ATIIR2 antagonists consistently produced high levels of inhibition when treating proliferative hemangioma cell lines derived from individual patient biopsies in two independent studies (Example 3: n = 5 cell lines, and Example 6: n = 9 cell lines). In contrast, these patient cell lines showed greater variation in response when treated with BB or ACEi as single agents. Based on these results, the inventors considered that local treatment of hemangiomas with an ATIIR2 antagonist might produce more consistent and clinically superior results than treatment with BB or ACEi as single agents.

[0190] The inventors also confirmed the differences in the relevant activities and / or skin diffusion rates of ACEi and β-blockers, and reported novel dosage and treatment regimens for hemangiomas.

[0191] The inventors have considered that this invention provides a first-line medicine / method for the early treatment or intervention of hemangioma development, for example, preventing lesion growth or disfigurement, ulceration, or psychological distress leading to functional impairments such as blindness, and preventing the formation of fibrofatty residues. In areas where the lesion is not severe, the inventors believe that topical (preferably external) application of an ACE inhibitor or ATIIR2 antagonist can be used to effectively manage, control, or prevent lesion growth. In cases where faster regression is required or where there will be other ways to enhance the treatment of the hemangioma, the inventors have considered using combination therapies to treat, manage, or control lesion growth: in one embodiment, an ACE inhibitor is combined with a β-blocker; in another embodiment, an ACE inhibitor is combined with an ATIIR2 antagonist; in yet another embodiment, an ACE inhibitor is combined with both an ATIIR2 antagonist and a β-blocker; and in yet another embodiment, a β-blocker is combined with an ATIIR2 antagonist. In other embodiments, when the lesion is very severe or the treatment response to local administration is less than or slower than expected, the local administration according to the invention may be combined with systemic administration of one or more agents for treating hemangiomas (e.g., ACEi, β-blockers and / or ATIIR2 antagonists).

[0192] Although the inventors’ results indicate that there is benefit in using some forms of local treatment for hemangiomas with ACEi or ATIIR2 antagonists, or a combination of ACEi, β-blockers and / or ATIIR2 antagonists, they consider that such combinations could be equally useful for treating hemangiomas via systemic routes, such as oral administration.

[0193] definition

[0194] The term "treatment" in this document should broadly encompass controlling, inhibiting, stopping, or slowing the growth of hemangiomas, controlling or reducing the size of hemangiomas, improving one or more symptoms associated with hemangiomas, and / or improving the appearance of hemangiomas. It should not be construed as treating the subject until complete recovery (such as complete removal or regression of the hemangioma), although this may be preferred.

[0195] The term "subject" should include references to any animal. In a preferred embodiment, the subject is a mammal, more preferably a human. In other embodiments, the subject is a dog, cat, or horse.

[0196] "Local" administration should be understood to mean direct administration to the hemangioma (including administration to the site of the hemangioma or to tissue proximal to the hemangioma, such as covering the hemangioma) compared to systemic administration. As will be readily understood from the nature of different types of hemangiomas and the context of the invention described herein (including preferred topical delivery methods), "direct" administration to a hemangioma will be understood to include local administration to a tissue in which the hemangioma is located or proximal to the hemangioma. Suitable local administration methods will be readily understood by those skilled in the art. However, by way of example only, they may include (i) local injection into the hemangioma or to tissue proximal to the hemangioma and (ii) application of the drug to the surface of the hemangioma or to the surface of a tissue in which the hemangioma is located or proximal to the hemangioma (i.e., topical administration, such as to the skin). In specific embodiments of the methods of the invention, topical administration is preferred.

[0197] "Systemic" administration should broadly encompass any route of administration that delivers the agent to the subject's circulatory system. Systemic administration includes enteral and parenteral administration. Those skilled in the art will readily understand suitable systemic administration routes. In one specific embodiment of the method of the invention, oral administration is preferred.

[0198] The phrase "pharmaceutically acceptable carriers, diluents, and / or excipients" means any useful carrier, excipient, and diluent that is non-toxic to the cells or animals to which the composition is administered at the dose and concentration used. "Carriers, diluents, and / or excipients" include, but are not limited to, fillers, colorants, preservatives, stabilizers, fillers, agents that help control the release of active agents, agents that enhance delivery, binders, solvents, emulsifiers, suspending agents, lubricants, agents that modify the viscosity of the composition, and humectants.

[0199] In the context of this invention, the “effective amount” of an agent administered to an animal is the amount necessary to at least partially achieve the desired response.

[0200] This document may refer to β-blockers in the form of R-enantiomers. This should not be construed as meaning that the R-β-blocker must be 100% pure, although this may be preferred (within the detection limits). Some tolerances may be permissible for other enantiomer levels. The same applies to references to the S-enantiomer form. In some cases, the β-blocker may comprise a racemic mixture, which in a preferred embodiment has at least the advantage of being an R-enantiomer.

[0201] The term "ATIIR2 antagonist" is defined below.

[0202] The alternative terms AT2 receptor inhibitor and AT2 receptor antagonist may be used interchangeably with ATIIR2 antagonist in this document.

[0203] Unless the context clearly indicates otherwise, references to the singular should include references to the plural. For example, a reference to a administered ACEi should be understood to include a reference to the administration of two or more ACEi. The same applies to references to ATIIR2 antagonists and beta-blockers.

[0204] This document may refer to methods of the invention that include a “combination” of administering two or more compounds (e.g., ramipril and propranolol). Such references should not imply that the compounds must be administered in a single composition or simultaneously (unless the context clearly indicates otherwise). Such references are used only to explain the administration of two or more compounds. Although, in some embodiments, the compounds may be administered in a single composition or simultaneously.

[0205] The alternative spellings hemangioma and haemangioma can be used interchangeably in this article.

[0206] This document may refer to the administration of one or more active agents in separate compositions. When this occurs, it should be understood that one or more agents may be provided in the form of a kit.

[0207] method

[0208] As described herein, the present invention provides a method for treating hemangiomas by administering an effective amount of one or more active agents (e.g., ACEi, ATIIR2 antagonists, β-blockers). In some embodiments, the hemangioma is a hemangioma present within, under, or on the surface of the skin or mucous membrane of a subject. In some embodiments, the hemangioma is selected from the group comprising: infantile hemangioma, cutaneous hemangioma, capillary hemangioma, cavernous hemangioma, retinal hemangioma (including, for example, retinal cavernous hemangioma, retinal capillary hemangioma, choroidal hemangioma, orbital cavernous hemangioma) and / or periorbital hemangioma.

[0209] In a preferred embodiment, the method of the present invention relates to the treatment of infantile hemangiomas (in one preferred embodiment, infantile capillary hemangiomas). Infantile hemangiomas exhibit a characteristic evolution consisting of an early rapid proliferative phase followed by a slow, spontaneous, and long-term (e.g., 5 to 10 years) regression phase. Infantile hemangiomas typically become visible on the skin approximately 4 to 6 weeks after birth. In some cases, infantile hemangiomas do not completely regress. Infantile hemangiomas are also characterized by the expression of a homogeneous set of immunohistochemical markers, including GLUT1 (glucose transporter 1), a surface protein expressed by the erythrocytes and endothelial cells of infantile hemangiomas.

[0210] In some preferred embodiments, the method of the present invention relates to the treatment of proliferative hemangiomas; that is, hemangiomas in a growing or proliferative state or stage. Such hemangiomas are typically characterized by rapid spontaneous growth of the hemangioma lesion. As an example, in infantile hemangiomas, the proliferative phase typically occurs within the period from birth to approximately four to six weeks of age. The rapid growth rate is characterized by exceeding the infant's growth rate, thereby distinguishing it from vascular malformations that grow at a rate comparable to that of the infant. By treating the hemangioma during this proliferative phase or state, the method of the present invention can be used to prevent further growth of the hemangioma and any accompanying damage that may result from such growth.

[0211] The method of the present invention can be used to treat hemangiomas of any size and volume. While the inventors consider the method of the present invention useful for treating large or already developed hemangiomas, in a preferred embodiment, the hemangioma is treated when it is relatively small and in its early stages of development to prevent further growth and the risks associated with such growth. In one embodiment, the method of the present invention can be used to treat hemangiomas with a volume of at least about 0.01 cm³. 3 It is useful for treating hemangiomas.

[0212] Topical administration

[0213] In one embodiment, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the step of locally administering an ACEi to the hemangioma. In one embodiment, the method comprises at least the step of locally administering an ACEi and a β-blocker to the hemangioma. In another embodiment, the method comprises at least the step of locally administering an ACEi and an ATIIR2 antagonist to the hemangioma. In yet another embodiment, the method comprises at least the step of locally administering an ACEi, a β-blocker, and an ATIIR2 antagonist to the hemangioma. In yet another embodiment, the method comprises at least the step of locally administering a β-blocker and an ATIIR2 antagonist to the hemangioma.

[0214] Local administration can be performed by any suitable means, including, for example, topical administration and / or local injection. In a preferred embodiment, ACEi, ACEi and β-blockers, ACEi and ATIIR2 antagonists, β-blockers and ATIIR2 antagonists, or ACEi, β-blockers and ATIIR2 antagonists are administered topically at the site of the hemangioma.

[0215] In another embodiment, the present invention provides a method for treating a hemangioma in a subject, the method comprising at least the step of topically administering an ATIIR2 antagonist to the hemangioma. In one embodiment, the ATIIR2 antagonist is administered topically.

[0216] In some implementations, a combination of two or more ACEi is administered, a combination of two or more β-blockers is administered, and / or a combination of two or more ATIIR2 antagonists is administered.

[0217] When two or more agents (e.g., ACEi and β-blockers, ACEi and ATIIR2 antagonists, β-blockers and ATIIR2 antagonists, ACEi, β-blockers and ATIIR2 antagonists, or two or more ACEi, two or more β-blockers or two or more ATIIR2 antagonists, and combinations thereof) are administered topically, they may be administered simultaneously or sequentially in any order. One or more agents may be administered as a single composition or as separate compositions.

[0218] In one embodiment, ACE inhibitors and β-blockers are administered simultaneously. In another embodiment, ACE inhibitors and β-blockers are administered sequentially in any order. In one embodiment, one or more ACE inhibitors are administered followed by one or more β-blockers. In another embodiment, one or more β-blockers are administered followed by one or more ACE inhibitors.

[0219] In one embodiment, ACEi and ATIIR2 antagonists are administered simultaneously. In another embodiment, ACEi and ATIIR2 antagonists are administered sequentially in any order. In one embodiment, one or more ACEi are administered followed by one or more ATIIR2 antagonists. In another embodiment, one or more ATIIR2 antagonists are administered followed by one or more ACEi.

[0220] In one embodiment, a β-blocker and an ATIIR2 antagonist are administered simultaneously. In one embodiment, a β-blocker and an ATIIR2 antagonist are administered sequentially in any order. In one embodiment, one or more ATIIR2 antagonists are administered followed by one or more β-blockers. In another embodiment, one or more β-blockers are administered followed by one or more ATIIR2 antagonists.

[0221] In one embodiment, ACEi, a β-blocker, and an ATIIR2 antagonist are administered simultaneously. In another embodiment, ACEi, a β-blocker, and an ATIIR2 antagonist are administered sequentially in any order.

[0222] In some embodiments, a non-selective β-blocker and an ACEi in prodrug form are administered simultaneously or sequentially in any order; a non-selective β-blocker and an ATIIR2 antagonist; or an ATIIR2 antagonist and an ACEi in prodrug form.

[0223] In some implementations: R-propranolol and cilazapril are administered simultaneously or sequentially in any order; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and quinapril; Benazepril; S-Propranolol and Benazepril; RS-Propranolol and Benazepril; R-Propranolol and Captopril; S-Propranolol and Captopril; RS-Propranolol and Captopril; R-Timolol and Cilabrapril; S-Timolol and Cilabrapril; RS-Timolol and Cilabrapril; R-Timolol and Ramipril; S-Timolol and Ramipril; RS-Timolol and Ramipril; R-Timolol and Gyndopril; S-Timolol and Gyndopril; RS-Timolol and Gyndopril; R-Timolol and Enalapril; S-Timolol and Enalapril; RS-Timolol and Enalapril R-Timolol and Quinapril; S-Timolol and Quinapril; RS-Timolol and Quinapril; R-Timolol and Benazepril; S-Timolol and Benazepril; RS-Timolol and Benazepril; R-Timolol and Captopril; S-Timolol and Captopril; RS-Timolol and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Timolol and EMA401; S-Timolol and EMA401; RS-Timolol and EMA401; R-Propranolol and SMM02; S-Propranolol and EMA402; Naprolol and SMM02; RS-propranolol and SMM02; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril.

[0224] In some embodiments, R-timolol and cilazapril are administered simultaneously or sequentially in any order; S-timolol and cilazapril; R / S-timolol and cilazapril; R-propranolol and cilazapril; S-propranolol and cilazapril; R / S-propranolol and cilazapril; SMM02 and cilazapril; EMA401 and cilazapril; R-timolol and SMM02; S-timolol and SMM02 R / S-Timolol and SMM02; R-Timolol and EMA401; S-Timolol and EMA401; R / S-Timolol and EMA401; R-Propranolol and SMM02; S-Propranolol and SMM02; R / S-Propranolol and SMM02; R-Propranolol and EMA401; S-Propranolol and EMA401; or R / S-Propranolol and EMA401.

[0225] Combination of local and systemic administration

[0226] In one embodiment, the method of the present invention further includes systemic administration of an ACEi, a β-blocker, and / or an ATIIR2 antagonist to the subject (i.e., in addition to local administration). Systemic administration can occur in any suitable manner. However, in a preferred embodiment, at least one ACEi, at least one β-blocker, and / or at least one ATIIR2 antagonist is administered orally. In another embodiment, at least one ACEi, at least one β-blocker, and / or at least one ATIIR2 antagonist is administered by injection; for example, subcutaneously, intramuscularly, or intravenously.

[0227] In one embodiment, the method includes topical administration of an ACEi and systemic administration of a β-blocker. In another embodiment, the method includes topical administration of an ACEi and systemic administration of an ACEi. In yet another embodiment, the method includes topical administration of an ACEi and systemic administration of an ATIIR2 antagonist. In one embodiment, one or more of the agents are administered topically at the site of the hemangioma and one or more of the agents are administered orally or systemically.

[0228] In one embodiment, the method includes topical administration of an ACE inhibitor and a β-blocker, and systemic administration of a β-blocker. In another embodiment, the method includes topical administration of an ACE inhibitor and a β-blocker, and systemic administration of an ACE inhibitor. In yet another embodiment, the method includes topical administration of an ACE inhibitor and a β-blocker, and systemic administration of an ATIIR2 antagonist. In one embodiment, one or more of the agents are administered topically at the site of the hemangioma, and one or more of the agents are administered orally or systemically.

[0229] In one embodiment, the method includes topically administering an ATIIR2 antagonist and a β-blocker, and systemically administering a β-blocker. In another embodiment, the method includes topically administering an ATIIR2 antagonist and a β-blocker, and systemically administering an ACEi. In one embodiment, the method includes topically administering an ATIIR2 antagonist and a β-blocker, and systemically administering an ATIIR2 antagonist. In one embodiment, one or more of the agents are administered topically at the site of the hemangioma, and one or more of the agents are administered orally or systemically.

[0230] In one embodiment, the method includes topical administration of an ACEi and an ATIIR2 antagonist, and systemic administration of a β-blocker. In another embodiment, the method includes topical administration of an ACEi and an ATIIR2 antagonist, and systemic administration of an ACEi. In yet another embodiment, the method includes topical administration of an ACEi and an ATIIR2 antagonist, and systemic administration of an ATIIR2 antagonist. In one embodiment, one or more of the agents are administered topically at the site of the hemangioma, and one or more of the agents are administered orally or systemically.

[0231] In one embodiment, the method includes topical administration of an ACEi, a β-blocker, and an ATIIR2 antagonist, as well as systemic administration of an ACEi, an ATIIR2 antagonist, or a β-blocker. In another embodiment, one or more of the agents are administered topically at the site of the hemangioma, or orally or systemically.

[0232] In another embodiment, the method includes topical administration of an ATIIR2 antagonist and systemic administration of an ACEi, an ATIIR2 antagonist, and / or a β-blocker. In one embodiment, topical administration is external application and systemic administration is oral administration.

[0233] In some embodiments: a non-selective β-blocker and an ACEi in prodrug form are administered simultaneously or sequentially in any order; a non-selective β-blocker and an ATIIR2 antagonist; or an ACEi in prodrug form and an ATIIR2 antagonist. In one embodiment, one agent is administered topically and others are administered systemically.

[0234] In some implementations: R-propranolol and cilazapril are administered simultaneously or sequentially in any order; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and quinapril; Benazepril; S-Propranolol and Benazepril; RS-Propranolol and Benazepril; R-Propranolol and Captopril; S-Propranolol and Captopril; RS-Propranolol and Captopril; R-Timolol and Cilabrapril; S-Timolol and Cilabrapril; RS-Timolol and Cilabrapril; R-Timolol and Ramipril; S-Timolol and Ramipril; RS-Timolol and Ramipril; R-Timolol and Gyndopril; S-Timolol and Gyndopril; RS-Timolol and Gyndopril; R-Timolol and Enalapril; S-Timolol and Enalapril; RS-Timolol and Enalapril R-Timolol and Quinapril; S-Timolol and Quinapril; RS-Timolol and Quinapril; R-Timolol and Benazepril; S-Timolol and Benazepril; RS-Timolol and Benazepril; R-Timolol and Captopril; S-Timolol and Captopril; RS-Timolol and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Timolol and EMA401; S-Timolol and EMA401; RS-Timolol and EMA401; R-Propranolol and SMM02; S-Propranolol and EMA402; Naprolol and SMM02; RS-propranolol and SMM02; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril. In one embodiment, one agent is administered topically and the others are administered systemically.

[0235] In some implementations: R-timolol and cilazapril are administered simultaneously or sequentially in any order; S-timolol and cilazapril; R / S-timolol and cilazapril; R-timolol and SMM02; S-timolol and SMM02; R / S-timolol and SMM02; R-timolol and EMA401; S-timolol and EMA401; R / S-timolol and EMA401; R - Propranolol and cilazapril; S-propranolol and cilazapril; R / S-propranolol and cilazapril; SMM02 and cilazapril; EMA401 and cilazapril; R-propranolol and SMM02; S-propranolol and SMM02; R / S-propranolol and SMM02; R-propranolol and EMA401; S-propranolol and EMA401; or R / S-propranolol and EMA401. In one embodiment, one agent is administered topically and others are administered systemically.

[0236] In some implementations, depending on the specific circumstances, two or more ACEi, two or more β-blockers, and / or two or more ATIIR2 antagonists may be administered systemically and / or locally.

[0237] Systemic administration

[0238] In other aspects, the present invention provides methods for treating hemangiomas in a subject, methods comprising at least the step of systemically administering two or more of an ACE inhibitor, a β-blocker, and an ATIIR2 antagonist to the subject. In a preferred embodiment, the method comprises at least the step of orally administering an ACE inhibitor and a β-blocker. It should be understood that combinations of two or more of each type of active agent may be used in the methods of this aspect of the invention. Furthermore, the active agents may be administered simultaneously or sequentially in any order.

[0239] Systemic administration can occur by any suitable method. However, in a preferred embodiment, the active agents are formulated for oral administration. In one embodiment, they are formulated as solid oral dosage forms. In an alternative embodiment, they are formulated as liquid oral dosage forms. This form is particularly preferred for pediatric applications.

[0240] In another embodiment, the active agent is formulated for administration by injection; for example, subcutaneous, intramuscular, or intravenous injection. In other embodiments, the active agents are formulated such that they can be delivered via a drug delivery device, such as a transdermal patch. In other embodiments, the active agent is formulated for administration by inhalation.

[0241] In some implementations: a non-selective β-blocker and an ACEi in prodrug form are administered systemically simultaneously or sequentially in any order; a non-selective β-blocker and an ATIIR2 antagonist; or an ACEi in prodrug form and an ATIIR2 antagonist.

[0242] In some implementations: R-propranolol and cilazapril are administered systemically simultaneously or sequentially in any order; S-propranolol and cilazapril; RS-propranolol and cilazapril; R-propranolol and ramipril; S-propranolol and ramipril; RS-propranolol and ramipril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and enalapril; S-propranolol and enalapril; RS-propranolol and enalapril; R-propranolol and quinapril; S-propranolol and quinapril; RS-propranolol and quinapril; R-propranolol and enalapril; Propranolol and benazepril; S-propranolol and benazepril; RS-propranolol and benazepril; R-propranolol and captopril; S-propranolol and captopril; RS-propranolol and captopril; R-timolol and cilazapril; S-timolol and cilazapril; RS-timolol and cilazapril; R-timolol and ramipril; S-timolol and ramipril; RS-timolol and ramipril; R-timolol and quindolin; S-timolol and quindolin; RS-timolol and quindolin; R-timolol and enalapril; S-timolol and enalapril; RS-timolol and enalapril R-Timolol and Quinapril; S-Timolol and Quinapril; RS-Timolol and Quinapril; R-Timolol and Benazepril; S-Timolol and Benazepril; RS-Timolol and Benazepril; R-Timolol and Captopril; S-Timolol and Captopril; RS-Timolol and Captopril; R-Propranolol and EMA401; S-Propranolol and EMA401; RS-Propranolol and EMA401; R-Timolol and EMA401; S-Timolol and EMA401; RS-Timolol and EMA401; R-Propranolol and SMM02; S-Propranolol and EMA402; Naprolol and SMM02; RS-propranolol and SMM02; R-timolol and SMM02; S-timolol and SMM02; RS-timolol and SMM02; EMA401 and cilazapril; EMA401 and ramipril; EMA401 and quinapril; EMA401 and benazepril; EMA401 and captopril; SMM02 and cilazapril; SMM02 and ramipril; SMM02 and quinapril; SMM02 and benazepril; or SMM02 and captopril.

[0243] In some implementations: systemic administration of R-timolol and cilazapril simultaneously or sequentially in any order; S-timolol and cilazapril; R / S-timolol and cilazapril; R-timolol and SMM02; S-timolol and SMM02; R / S-timolol and SMM02; R-timolol and EMA401; S-timolol and EMA401; R / S-timolol and EMA401; R-Propranolol and Cilabesil; S-Propranolol and Cilabesil; R / S-Propranolol and Cilabesil; SMM02 and Cilabesil; EMA401 and Cilabesil; R-Propranolol and EMA401; S-Propranolol and EMA401; R / S-Propranolol and EMA401; R-Propranolol and SMM02; S-Propranolol and SMM02; or R / S-Propranolol and SMM02.

[0244] It should be understood that the method for treating hemangiomas according to this aspect of the invention can be combined with methods for local (e.g., topical) administration according to other aspects of the invention, as described above.

[0245] ACE inhibitors

[0246] In some embodiments of the invention, at least one ACE inhibitor (ACEi) is administered to the subject. ACEi are any agents capable of selectively or non-selectively inhibiting, blocking, or at least reducing the activity of angiotensin-converting enzyme in hemangiomatous lesions and include ACEi prodrugs. Unless the context otherwise requires, references to ACEi herein shall include references to any pharmaceutically acceptable salt thereof. For the avoidance of doubt, references to ACEi herein are intended to include references to their stereoisomers. Mixtures of two or more ACEi may be used in the methods of the invention.

[0247] Examples of ACE inhibitors used in this invention include, but are not limited to, thiol-containing agents such as captopril, zofenoprilat, and zofenoprilat; dicarboxylic acid ester-containing agents such as enalaprilat, enalaprilat, ramiprilat, ramiprilat, quinaprilat, quinaprilat, perindoprilat, perindoprilat, lisinoprilat, benazeprilat, benazeprilat, imidaprilat, trandolaprilat, cilazaprilat; phosphonate-containing agents such as fosinoprilat and fosinoprilat; or any other natural or synthetic agent with inhibitory activity against angiotensin-converting enzyme.

[0248] In a preferred embodiment, the ACEi of the present invention is in prodrug form. In some preferred embodiments, the ACEi is selected from the group consisting of: enalapril, ramipril, trandopril, cilazapril, benazepril, perindopril, imidapril, fosinopril, zolfenpril, and quinapril, or a pharmaceutically acceptable salt thereof. In another preferred embodiment, the ACEi is selected from the group consisting of: ramipril, trandopril, cilazapril, and quinapril, or a pharmaceutically acceptable salt thereof. In another embodiment, the ACEi is selected from captopril and lisinopril, or a pharmaceutically acceptable salt thereof. In yet another embodiment, the ACEi is a long-acting ACEi selected from the group consisting of: cilazapril, ramipril, trandopril, and benazepril, or a pharmaceutically acceptable salt thereof.

[0249] Table 1 provides examples of various ACE inhibitors that can be used in the methods of the present invention, along with information on their physical, chemical and biological properties.

[0250] Table 1: Examples of ACE inhibitors and their chemical, physical, and biological properties.

[0251]

[0252]

[0253]

[0254] β-blockers

[0255] In some embodiments of the invention, a subject is administered at least one β-blocker or a pharmaceutically acceptable salt thereof. A β-blocker is any natural or artificial agent that blocks, inhibits, or at least reduces the binding of an agonist to a β-adrenergic receptor and includes prodrugs. β-adrenergic receptors can be of any type, including β-1, β-2, β-3, or others (including selective or non-selective β-blockers). Unless the context otherwise requires, references to β-blockers herein shall include references to any pharmaceutically acceptable salt thereof. For the avoidance of doubt, references to β-blockers herein are intended to include references to their stereoisomers. Mixtures of two or more β-blockers may be used in the methods of the invention.

[0256] Those skilled in the art will readily understand the β-blockers used in this invention. However, by way of example, those described in Goodman and Gilman's The Pharmacological Basis of Therapeutics, eleventh edition, chapter 10, pp. 271-295, 2006 can be used. As another example, when using β-blockers, they may be selected from, for example, the group including: alprenolol, bucindolol, carteolol, carvedilol, labetalol, levobunolol, medroxalol, mepindolol, metipranolol, nadolol, oxprenolol, penbutolol, pindolol, propafenone (also a sodium channel blocker of β-adrenergic receptor antagonists), propranolol, sotalol, timolol, or pharmaceutically acceptable salts thereof. As another example, in the use of a β-blocker according to the invention, it may be selected from, for example, the group consisting of: acebutolol, atenolol, betaxolol, bisoprolol, celiprolol, esmolol, metoprolol, nebivolol, or pharmaceutically acceptable salts thereof. In some preferred embodiments, the β-blocker used in the invention is a non-selective β-blocker. Those skilled in the art will readily understand non-selective β-blockers, particularly considering the descriptions and examples elsewhere herein. However, by example, non-selective β-blockers include: propranolol, timolol, sotalol, indolol, naldolol, and their isomers.

[0257] In some preferred embodiments, the β-blocker used in this invention is selected from the group consisting of propranolol, timolol, atenolol, betalol, and / or naldolol and / or any pharmaceutically acceptable salt thereof. In specific embodiments, the β-blocker is selected from propranolol, timolol, and / or atenolol and / or any pharmaceutically acceptable salt thereof. In one specific embodiment, the β-blocker is propranolol. As another example, one or more β-blockers may be selected from (RS)-propranolol, (R)-propranolol, (S)-propranolol, (RS)-timolol, (S)-timolol, (R)-timolol, (RS)-atenolol, (S)-atenolol, and (R)-atenolol.

[0258] In one embodiment, the β-blocker is in a racemic form (i.e., a combination of enantiomers). In one embodiment, the β-blocker comprises a combination of enantiomers, preferably comprising a higher proportion of (R)-enantiomers. In one embodiment, the β-blocker is substantially in the form of an R-enantiomer. In another embodiment, the β-blocker is substantially in the form of an S-enantiomer.

[0259] ATIIR2 antagonists

[0260] In some embodiments of the invention, at least one ATIIR2 antagonist is administered to a subject. An ATIIR2 antagonist is any natural or artificial agent that blocks, inhibits, or at least reduces the binding of an agonist to a type II receptor of antagonist II and includes a prodrug form of an ATIIR2 antagonist. Unless the context otherwise requires, references to ATIIR2 antagonists herein shall include references to any pharmaceutically acceptable salt thereof. For the avoidance of doubt, references to ATIIR2 antagonists herein are intended to include references to their stereoisomers. Mixtures of two or more ATIIR2 antagonists may be used in the methods of the invention.

[0261] In some embodiments, the ATIIR2 antagonist may be selected from the group consisting of WO1993023378, WO1995003055, US5173493, WO2006066361, WO2011088504, WO2012010843, WO2013110135, and WO2016142867, as incorporated herein by reference. In one embodiment, the ATIIR2 antagonist is selected from the group consisting of:

[0262] -Olodanrigan (also known as EMA401, PD126055 or (S)-5-(benzyloxy)-2-(2,2-diphenylacetyl)-6-methoxy-1,2,3,4-tetrahydroisoquinoline-3-carboxylic acid);

[0263] -PD123177 (also known as (S)-1-[(4-amino-3-methylphenyl)methyl]-5-(diphenylacetyl)-4,5,6,7-tetrahydro-1H-imidazo[4,5-c]pyridine-6-carboxylic acid trifluoroacetate);

[0264] -SMM02 (also known as L-159686 (or L-159,686) or (S)-1,4-bis(N,N-diphenylcarbamoyl)piperazine-2-carboxylic acid);

[0265] -PD123319 (also known as (S)-1-(4-(dimethylamino)-3-methylbenzyl)-5-(2,2-diphenylacetyl)-4,5,6,7-tetrahydro-1H-imidazo[4,5-c]pyridine-6-carboxylic acid);

[0266] -EXP801 (also known as 2-[(N,N-diphenylamino)carbonyl]-5-[(4-methoxyphenyl)methyl]-1,2,3,4-tetrahydroisoquinoline-3-carboxylic acid); and

[0267] -L161638 (also known as 2-ethyl-6-[N-benzyl-N-(2-thienoyl)amino-3-[2'-(1H-tetrazol-5-yl)-[1,1']-biphenyl-4-yl]methyl]quinazolin-4-(3H)-one).

[0268] In one specific embodiment, one or more ATIIR2 antagonists are selected from the group including ololigan (EMA401) and SMM02. SMM02 is a selective angiotensin II type 2 receptor (ATIIR2) inhibitor and, as mentioned above, may also be referred to as L-159686 or L-159,686, for example. Different names for SMM02 may be used interchangeably herein.

[0269] Combinations of different compounds

[0270] In specific embodiments, the method includes administering a combination of ACEi and a β-blocker. In some embodiments, the ACEi is in prodrug form. In some embodiments, the β-blocker is a non-selective β-blocker. In one embodiment, the method includes administering a combination of ACEi and a β-blocker, wherein the ACEi is in prodrug form and the β-blocker is a non-selective β-blocker. In one embodiment, the ACEi is combined with a β-blocker, wherein the β-blocker is in a racemic form. In another embodiment, the ACEi is combined with a β-blocker, wherein the β-blocker is a combination of enantiomers, preferably comprising a higher proportion of (R)-enantiomers. In another embodiment, the ACEi is used with a β-blocker, wherein the β-blocker is substantially in the (R)-enantiomer form. In a preferred embodiment, the ACEi is used with a β-blocker, wherein the β-blocker is substantially in the (R)-enantiomer form. In some embodiments, the method includes administering an ACEi and a β-blocker selected from the group consisting of cilazapril, trandopril, ramipril, quinapril, lisinopril, benazepril, or captopril, and the β-blocker selected from the group consisting of (RS)-propranolol, (R)-propranolol, (S)-propranolol, (RS)-timolol, (R)-timolol, (S)-timolol, (RS)-atenolol, (R)-atenolol, and (S)-atenolol. In some embodiments, the method includes administering cilazapril and (S)-propranolol, a combination of cilazapril and (S / R)-propranolol, or in one specific embodiment, a combination of cilazapril and (R)-propranolol. In other embodiments, the method includes administering cilazapril and R-timolol, or cilazapril and S-timolol.

[0271] In a specific implementation, the method includes administering the following combinations: lisinopril and propranolol; lisinopril and timolol; lisinopril and atenolol; ramipril and propranolol; ramipril and timolol; ramipril and atenolol; quinapril and propranolol; quinapril and timolol; quinapril and atenolol; enalapril and propranolol; enalapril and timolol; or enalapril and atenolol.

[0272] In a specific embodiment, the method includes administering a combination of ACEi and ATIIR2 antagonists. In a specific embodiment, the method includes administering: cilazapril and EMA401; cilazapril and L-159686 (SMM02); lisinopril and EMA401; lisinopril and L-159686 (SMM02); ramipril and EMA401; ramipril and L-159686 (SMM02); quinapril and EMA401; quinapril and L-159686 (SMM02); enalapril and EMA401; or enalapril and L-159686 (SMM02). In one embodiment, the method includes administering cilapril and EMA401. In another embodiment, the method includes administering cilapril and SMM02.

[0273] In a specific embodiment, the method includes administering a combination of an ATIIR2 antagonist and a β-blocker, such as: EMA401 and propranolol; EMA401 and timolol; EMA401 and atenolol; L-159686(SMM02) and propranolol; L-159686(SMM02) and timolol; L-159686(SMM02) and atenolol. In one embodiment, the ATIIR2 antagonist and the β-blocker are administered, the β-blocker being in a racemic form. In another embodiment, the β-blocker is a combination of enantiomers comprising a higher proportion of (R)-enantiomers. In yet another embodiment, the β-blocker is substantially in (R)-enantiomer form. In one embodiment, the β-blocker is a non-selective β-blocker. In one embodiment, the method includes administering (R / S)-propranolol and SMM02, (S)-propranolol and SMM02, or in one embodiment, administering (R)-propranolol and SMM02. In another embodiment, the method includes administering (R / S)-propranolol and EMA401, (S)-propranolol and EMA401, or in one embodiment, administering (R)-propranolol and EMA401.

[0274] In specific embodiments, the method includes administering a combination of ACE inhibitors, beta-blockers, and ATIIR2 antagonists. In some embodiments, the method includes administering: lisinopril, propranolol, and EMA401; lisinopril, timolol, and EMA401; lisinopril, atenolol, and EMA401; lisinopril, propranolol, and L-159686 (SMM02); lisinopril, timolol, and L-159686 (SMM02); lisinopril, atenolol, and L-159686 (SMM02); ramipril, propranolol, and EMA401; ramipril, timolol, and EMA401; ramipril, atenolol, and EMA401; ramipril, propranolol, and L-159686 (SMM02); ramipril, timolol, and L-159686 (SMM02); ramipril, timolol, and L-159686 (SMM02). 9686 (SMM02); Ramipril, Atenolol and L-159686 (SMM02); Dopamine, Propranolol and EMA401; Dopamine, Timolol and EMA401; Dopamine, Atenolol and EMA401; Dopamine, Propranolol and L-159686 (SMM02); Dopamine, Timolol and L-159686 (SMM02); Dopamine, Atenolol and L-159686 (SMM02); Cilabapril, Propranolol and EMA401; Cilabapril, Timolol and EMA401; Cilabapril, Atenolol and EMA401; Cilabapril, Propranolol and L-159686 (SMM02); SMM02); Cilabapril, Timolol and L-159686 (SMM02); Cilabapril, Atenolol and L-159686 (SMM02); Benazepril, Propranolol and EMA401; Benazepril, Timolol and EMA401; Benazepril, Atenolol and EMA401; Benazepril, Propranolol and L-159686 (SMM02); Benazepril, Timolol and L-159686 (SMM02); Benazepril, Atenolol and L-159686 (SMM02); Quinapril, Propranolol and EMA401; Quinapril, Timolol and EMA401; Quinapril, Atenolol and EMA401 1; Quinapril, propranolol and L-159686 (SMM02); Quinapril, timolol and L-159686 (SMM02); Quinapril, atenolol and L-159686 (SMM02); Captopril, propranolol and EMA401; Captopril, timolol and EMA401; Captopril, atenolol and EMA401; Captopril, propranolol and L-159686 (SMM02); Captopril, timolol and L-159686 (SMM02); Captopril, atenolol and L-159686L; Enalapril, propranolol and EMA401; Enalapril, timolol and EMA401;Enalapril, atenolol, and EMA401; enalapril, propranolol, and L-159686 (SMM02); enalapril, timolol, and L-159686 (SMM02); or enalapril, atenolol, and L-159686 (SMM02). β-blockers can be used in any isomer form (including racemic mixtures). In one embodiment, the β-blocker comprises a combination of enantiomers, preferably comprising a higher proportion of (R)-enantiomers. In another embodiment, the β-blocker is substantially in (S)-enantiomer form. In a preferred embodiment, the β-blocker is substantially in (R)-enantiomer form. In one embodiment, the β-blocker is selected from the group consisting of non-selective β-blockers.

[0275] In other embodiments, these methods include administering one or more combinations of specific agents as described and illustrated elsewhere herein.

[0276] In some embodiments, these methods include topical administration: cilazapril and R-propranolol; a) ramipril or enalapril or trandalopril and b) R-propranolol; a) cilazapril and b) S-propranolol or racemic (R / S) propranolol; a) ramipril or enalapril or trandalopril and b) S-propranolol or racemic (R / S) propranolol; cilazapril and timolol; a) ramipril a) enalapril or quinaldopril and b) timolol; a) SMM02 or EMA401 and b) R-propranolol; a) SMM02 or EMA401 and b) S-propranolol or racemic (R / S) propranolol; a) SMM02 or EMA401 and b) timolol; a) SMM02 or EMA401 and b) cilazapril; or a) SMM02 or EMA401 and b) ramipril or enalapril or quinaldopril.

[0277] In some embodiments, these methods include systemic administration: cilazapril and R-propranolol; enalapril and R-propranolol; a) ramipril or enalapril or quindolapril and b) R-propranolol; a) cilazapril or ramipril or enalapril or quindolapril and b) R-timolol; a) cilazapril or enalapril and b) racemic (R / S) propranolol or S-propranolol; SMM02 and R-propranolol; or SMM02 and racemic (R / S) propranolol.

[0278] In some embodiments, these methods include: topical administration of cilazapril and systemic administration of propranolol (racemic (R / S) or R-); topical administration of ramipril or enalapril or quindolapril and systemic administration of propranolol (racemic (R / S) or R-); topical administration of R-propranolol and systemic administration of cilazapril or captopril or enalapril; topical administration of timolol and systemic administration of cilazapril or captopril or enalapril; topical administration of S-propranolol. MM02 or EMA401 and systemic propranolol (racemic (R / S) or R-); topical SMM02 or EMA401 and systemic cilazapril or captopril or enalapril; systemic SMM02 or EMA401 and topical propranolol (racemic (R / S) or R-) or timolol; or systemic SMM02 or EMA401 and topical cilazapril or captopril or enalapril.

[0279] Dosage Forms and Compositions

[0280] Local

[0281] As described above, in some aspects, the present invention provides methods for treating hemangiomas by locally delivering the following: ACEi; ATIIR2 antagonists; combinations of ACEi and β-blockers; combinations of ACEi and ATIIR2 antagonists; combinations of β-blockers and ATIIR2 antagonists; or combinations of ACEi, β-blockers, and ATIIR2 antagonists. In one embodiment, preferably, these agents are formulated as compositions suitable for local administration.

[0282] The compositions used in this invention will comprise at least one active agent (selected from the group consisting of ACEi, β-blockers, and ATIIR2 antagonists) and, in a preferred embodiment, one or more pharmaceutically acceptable carriers, diluents, and / or excipients. In one embodiment, the composition comprises a single type of active agent (e.g., ACEi, β-blockers, or ATIIR2 antagonists). In another embodiment, the composition comprises a combination of two or more different types of active agents. As an example, in one embodiment, the composition used in this invention comprises ACEi. In another embodiment, the composition used in this invention comprises a β-blocker. In another embodiment, the composition used in this invention comprises an ATIIR2 antagonist. In another embodiment, the composition comprises a combination of ACEi and a β-blocker. In another embodiment, the composition comprises a combination of ACEi and an ATIIR2 antagonist. In another embodiment, the composition comprises a combination of a β-blocker and an ATIIR2 antagonist. In yet another embodiment, the composition comprises a combination of ACEi, a β-blocker, and an ATIIR2 antagonist.

[0283] Any ACEi, ATIIR2 antagonist, and β-blocker mentioned herein can be formulated as a composition for topical administration. However, in one embodiment, the ACEi is selected from the group of ACEi in prodrug form, such as enalapril, ramipril, trandopril, cilazapril, benazepril, perindopril, imidapril, fosinopril, zolfenpril, and quinapril and / or any pharmaceutically acceptable salt of any of them. In another preferred embodiment, the ACEi is selected from the group consisting of ramipril, trandopril, cilazapril, and quinapril and / or any pharmaceutically acceptable salt of any of them. In one specific embodiment, the composition is formulated for topical administration, and the ACEi is selected from the group of ACEi in prodrug form, such as enalapril, ramipril, trandopril, cilazapril, benazepril, and quinapril and / or any pharmaceutically acceptable salt of any of them. In another preferred embodiment, the composition is formulated for topical administration, and the ACEi is selected from the group consisting of ramipril, trandopril, cilazapril, and quinapril. In another preferred embodiment, wherein the composition is formulated for topical administration, the β-blocker is selected from the group consisting of timolol, propranolol, atenolol, betalol, bisoprolol, naldolol, carvedilol, carazolol, and / or a pharmaceutically acceptable salt of any of these. The β-blocker can be used in any isomer form (including racemic mixtures). In one embodiment, the β-blocker comprises a combination of enantiomers, preferably comprising a higher proportion of (R)-enantiomers. In one embodiment, one or more β-blockers are substantially in (S)-enantiomer form. In a preferred embodiment, one or more β-blockers are substantially in (R)-enantiomer form. In one embodiment, the β-blocker is R-propranolol. In one embodiment, the β-blocker is selected from the group comprising non-selective β-blockers. In another preferred embodiment, wherein the composition is formulated for topical administration, the ATIIR2 antagonist is selected from the group comprising: ololigan (EMA401), PD123177, L-159686 (SMM02), PD123319, PD126055, EXP801 and L161638 and / or a pharmaceutically acceptable salt of any one thereof.

[0284] In one embodiment, the composition of the present invention comprises an ACEi in prodrug form and a nonselective β-blocker.

[0285] In some embodiments, the compositions of the present invention comprise: lisinopril and propranolol; lisinopril and timolol; lisinopril and atenolol; ramipril and propranolol; ramipril and timolol; ramipril and atenolol; quinapril and propranolol; quinapril and timolol; quinapril and atenolol; enalapril and propranolol; enalapril and timolol; or enalapril and atenolol. In one embodiment, the β-blocker used is a non-selective β-blocker. β-blockers can be used in any isomer form (including racemic mixtures). In one embodiment, the β-blocker comprises a combination of enantiomers, preferably comprising a higher proportion of (R)-enantiomers. In one embodiment, one or more β-blockers are substantially in (R)-enantiomer form. In one embodiment, one or more β-blockers are substantially in (S)-enantiomer form. In a preferred embodiment, the β-blocker is R-propranolol. In some embodiments, the compositions of the present invention comprise: R-timolol and cilazapril; S-timolol and cilazapril; R / S-timolol and cilazapril; R-propranolol and cilazapril; S-propranolol and cilazapril; R / S-propranolol and cilazapril; SMM02 and cilazapril; EMA401 and cilazapril; R-propranolol and EMA401; S-propranolol and EMA401; R / S-propranolol and EMA401; R-propranolol and SMM02; S-propranolol and SMM02; R / S-propranolol and SMM02; EMA401 and cilazapril; SMM02 and S-timolol; SMM02 and R-timolol; EMA401 and S-timolol; or EMA401 and R-timolol.

[0286] In other embodiments, the compositions of the present invention comprise one of the combinations of specific agents described herein and illustrated by way of example as being administered or used in the methods of the present invention.

[0287] Those skilled in the art will readily understand the types of compositions suitable for topical administration, including injectable and topical compositions such as gels, suspensions, oils, emulsions, sprays, powders, creams, foams, lotions, ointments, drops, etc. In one embodiment, the composition is suitable for ocular administration (e.g., eye drops or other suitable ophthalmic compositions). In a preferred embodiment, the composition is formulated as an emulsion gel, liposome gel, liposome emulsion gel, or pro-liposome emulsion gel. In another embodiment, the invention provides a drug delivery device suitable for topical administration and comprising one or more of the active agents (including references to combinations of active agents) or compositions as described herein. In one embodiment, the drug delivery device comprises one of the combinations of specific active agents described herein and illustrated by way of example for administration or use in the methods of the invention. Those skilled in the art will readily understand suitable drug delivery devices for topical administration and methods for manufacturing them. However, by way of example, in one embodiment, the drug delivery device is a dermal patch suitable for topical administration.

[0288] Those skilled in the art will readily understand the various suitable carriers, excipients, and diluents used in formulating compositions for local delivery, including injectable and topical compositions, taking into account the nature of the invention described herein and the information disclosed in pharmaceutical texts and manuals, such as The Handbook of Pharmaceutical Excipients, Sixth edition, 2009, editors Raymond C. Rose, Paul J. Sheskey, and Marian E. Quinn. (http: / / pharmama.info / wp-content / uploads / 2018 / 10 / Excipients.pdf ).

[0289] In a preferred embodiment, the composition for topical administration includes a transdermal absorption enhancer. As referred to herein, a "transdermal absorption enhancer" is any chemical, agent, or carrier that can increase the rate of delivery of the agent across the skin and / or increase the depth of penetration of the agent into the hemangioma. Examples of transdermal absorption enhancers include, but are not limited to: mineral oils; dimethyl sulfoxide; glycols, such as propylene glycol, 1,3-butanediol, diethylene glycol monoethyl ether, and polyethylene glycol of any molecular weight; alcohols, such as ethanol and isopropanol; surfactants and emulsifiers, such as oleyl oleate. oleate), sorbitol monooleate, octyl dodecanol, isopropyl palmitate, oleyl alcohol, ethyl oleate, glyceryl monolaurate, isopropyl myristate, lauryl lactate, Span 20–Span 80, Tween 20–Tween 80, N-lauroyl sarcosine, oleic acid, sodium octyl sulfate, methyl lauryl sulfate, sodium lauryl sulfoacetate, cocoyl octanoate, cetyl alcohol, transcutol (including carboxyl styrene) Drugs may contain: phospholipids such as lecithin, soybean phosphatidylcholine, hydrogenated soybean phosphatidylcholine, DOPC, DOPE, DPPC, DPPE, DSPC, DSPE, DOPG, DPPG, DSPG; terpenes such as menthol, limonene, linalool, eucalyptol, nerolidol, farnesol, geraniol, carvone, terpinene, piracetamene, and other essential oils; or any other agent that may increase the rate of drug penetration through the skin. Furthermore, carrier systems or loading bodies such as liposomes and pro-liposomes may be used to enhance topical delivery.

[0290] The compositions used in the methods of the present invention may optionally include one or more additional ingredients that may be beneficial to the inclusion in such compositions, such as other agents that may be beneficial to the subject. For example, they may include one or more additional active agents that are beneficial to the treatment of hemangiomas or otherwise beneficial to the health or cosmetic appearance of the subject.

[0291] The composition may include any suitable amount of an active agent (ACEi, β-blocker, and / or ATIIR2 antagonist), taking into account the desired dose to be delivered to the subject (as described elsewhere herein) and the chemical properties of the agent, as will be understood by those skilled in the art in light of the description herein. However, as an example, for compositions intended for topical administration (e.g., external application), the total amount of the active agent (ACEi, β-blocker, and / or ATIIR2 antagonist) present in the composition may be from about 0.01% to about 20% (w / w). In specific embodiments, the following ranges may be used for external compositions: about 0.01% to about 19.99%, preferably about 0.1% to about 10% or about 8% of ACEi; about 0.01% to about 19.99%, preferably about 0.1% to about 10% or about 8% of β-blockers; and about 0.01% to about 19.99%, preferably about 0.1% to about 5% of ATIIR2 antagonists.

[0292] In embodiments of the invention, two or more different agents are combined in a single composition (e.g., ACEi and a β-blocker, ACEi and ATIIR2, ATIIR2 and a β-blocker, or ACEi, ATIIR2 and a β-blocker), and they can be combined in any suitable ratio. For example, ACEi and a β-blocker can be combined in a ratio of about 10:1 to 1:10; ACEi and an ATIIR2 antagonist can be combined in a ratio of about 10:1 to 1:10; or, a β-blocker and an ATIIR2 antagonist can be combined in a ratio of about 10:1 to 1:10.

[0293] In one specific embodiment, the combination of a topical fixed-dose ACE inhibitor and a β-blocker comprises a larger proportion of the ACE inhibitor relative to the β-blocker, because the inventors have surprisingly confirmed that the β-blocker is absorbed through the skin more rapidly than the ACE inhibitor. In one embodiment, the ratio of ACE inhibitor to β-blocker in the topical composition is approximately 1:1 to approximately 10:1. In other embodiments, the ratio is approximately 2:1 to approximately 10:1. In other embodiments, the ratio of ACE inhibitor to β-blocker in the composition is approximately 3:1 to approximately 9:1, approximately 4:1 to approximately 8:1, or approximately 3:1 to approximately 7:1. In other embodiments, the ratio is approximately 1:1, approximately 2:1, approximately 3:1, approximately 4:1, approximately 5:1, approximately 6:1, approximately 7:1, approximately 8:1, approximately 9:1, or approximately 10:1. In other embodiments, a larger proportion of the β-blocker relative to the ACE inhibitor may be present in the composition.

[0294] In a specific embodiment, the ratio of the β-blocker to the ATIIR2 antagonist in the composition is from about 1:2 to about 1:10, for example, about 1:2, about 1:3, about 1:4, about 1:5, about 1:6, about 1:7, about 1:8, about 1:9 or about 1:10.

[0295] In a specific embodiment, the ratio of the β-blocker to ACEi in the composition is from about 1:2 to about 1:9, for example, about 1:2, about 1:3, about 1:4, about 1:5, about 1:6, about 1:7, about 1:8 or about 1:9.

[0296] In a specific embodiment, the ratio of the ATIIR2 antagonist to ACEi in the composition is from about 1:1 to about 1:5, for example, about 1:1, about 1:2, about 1:3, about 1:4 or about 1:5.

[0297] In some embodiments, the ratio of the β-blocker to the ATIIR2 antagonist in the composition is about 1:2.5, about 1:5, or about 1:10.

[0298] In some embodiments, the ratio of the β-blocker to ACEi in the composition is about 1:2, about 1:4, or about 1:9.

[0299] In some embodiments, the ratio of the ATIIR2 antagonist to ACEi in the composition is about 1:2, about 1:1, or about 1:4.

[0300] In specific embodiments, compositions for topical administration include: cilazapril and timolol in a ratio of approximately 1:1, approximately 1:10, or approximately 10:1; timolol and EMA401 in a ratio of approximately 1:10 or approximately 1:1; cilazapril and EMA401 in a ratio of approximately 1:10 or approximately 1:1; ramipril and propranolol in a ratio of approximately 1:1; ramipril and propranolol in a ratio of approximately 1:1; or triamcinolone and timolol in a ratio of approximately 4:1. In other embodiments, compositions comprising a combination of two or more agents for topical administration include combinations of compounds in ratios approximately as specified in the examples and Table 6 below.

[0301] Compositions for topical administration can be manufactured according to standard techniques, as can be found in standard references such as, for example, Gennaro AR: Remington: The Science and Practice of Pharmacy, 22nd ed., Lippincott, Williams & Wilkins. In preferred embodiments, the formulations and methods described and illustrated herein can be used.

[0302] In one specific embodiment, the active agent used in this invention is administered topically as an emulsion gel. In one embodiment, the composition comprises an ACE inhibitor selected from the group described above (e.g., lisinopril, enalapril, ramipril, trandopril, cilazapril, benazepril, perindopril, midapril, fosinopril, zolfenpril, captopril, and / or quinapril), alone or in combination with a β-blocker selected from the group described above (e.g., propranolol, timolol, atenolol, betalol, naldolol), and is prepared as an emulsion gel for topical application. The concentration range of the ACE inhibitor and the β-blocker can be from about 0.01 to about 20 wt.%. Preferably, the concentration range of the ACE inhibitor and / or the β-blocker can be from about 0.1 wt.% (or about 0.5 wt%) to about 5 wt%, and more preferably from about 0.2 wt% (or about 0.5 wt%) to about 2 wt%. The gel may be selected from carbomer, carboxymethyl cellulose, hydroxypropyl carboxymethyl cellulose, polyvinylpyrrolidone, polyvinyl acetate, chitosan, succinylated chitosan, dextran, alginate, xanthan gum, or any other gelling agent suitable for pharmaceutical preparation. Preferably, the gel may be carbomer, or more preferably, selected from carbopol ultrez 10 or carbopol ultrez 30. Furthermore, the formulation may contain a transdermal absorption enhancer selected from the group described above (e.g., a combination of isopropanol, propylene glycol, cocoyl oleate, mineral oil, and Tween 80) in a ratio sufficient to maximize the penetration of the active ingredient. The formulation may further contain agents that increase the solubility of ACE inhibitors and / or β-blockers (e.g., cyclodextrin, particularly 2-hydroxypropyl-β-cyclodextrin) and may contain a basic agent (e.g., sodium hydroxide, potassium hydroxide, or ammonia) to neutralize the mixture to a final acidity of pH 6–8. To extend the shelf life of a pharmaceutical preparation, preservatives may be included (e.g., parabens, in a preferred embodiment, methylparaben and / or propylparaben).

[0303] In another specific embodiment, the active agent can be administered topically in the form of a liposome gel. In one embodiment, the prepared liposomes used in the liposome gel composition are preferably deformable liposomes, hyperdeformable liposomes, or delivery systems. The phospholipid material used to prepare the liposomes can be selected from any suitable phospholipid, as will be understood by those skilled in the art. However, as examples, they can be selected from the group consisting of synthetic vesicle-forming lipids and naturally occurring vesicle-forming lipids, including, for example, phosphatidylcholine (PC), such as soybean phosphatidylcholine (SPC), 1,2-dioleoyl-sn-glycerol-3-phosphocholine (DOPC), 1,2-dipalmitoyl-sn-glycerol-3-phosphocholine (DPPC), 1,2-distearyl-sn-glycerol-2-phosphatidylcholine (DSPC), 1-myristoyl-2-stearoyl-sn-glycerol-3-phosphocholine (MSPC), hydrogenated soybean phosphatidylcholine, etc. Phosphatidylcholine (HSPC); phosphatidylinositol (PI), phosphatidylglycerol (PG), dimyristoylphosphatidylglycerol (DMPG); egg yolk phosphatidylcholine (EPC), 1-palmitoyl-2-oleoylphosphatidylcholine (POPC), distearatel phosphatidylcholine (DSPC), dimyristoylphosphatidylcholine (DMPC); phosphatidic acid (PA), phosphatidylserine (PS); 1-palmitoyl-2-oleoylphosphatidylcholine (POPC) and sphingomyelins such as sphingomyelin (SM) (an acyl or alkyl chain having 12 to 24 carbon atoms). In a preferred embodiment, the phospholipids have a low phase transition temperature (below about 37°C) because phospholipids with higher phase transition temperatures tend to form deformable, ridge-like films. For example, selected phospholipids may preferably include soybean lecithin, soybean phosphatidylcholine, egg yolk lecithin, and egg yolk phosphatidylcholine. Phospholipid materials can be used in combination with surfactants or edge activators to impart flexibility or deformability to the liposome vesicle structure. An "edge activator" is a surfactant or chemical agent capable of increasing the elasticity of the phospholipid liposome membrane and may include, for example, polysorbates, including the Tween and Span families, sorbitan monooleate, bile salts, and alcohols, including ethanol and isopropanol. Preferably, the edge activator used in the formulation is a polysorbate, such as Tween 80. Liposome suspensions can be prepared by any number of liposome preparation methods, but preferably may include a membrane rehydration method, wherein a membrane of a phospholipid / edge activator mixture is prepared. Liposomes can be passively or actively loaded by subsequently suspending the phospholipid mixture in an aqueous solution of one or more active pharmaceutical agents or active loading agents, such as ammonium sulfate, ammonium oxalate, ammonium phosphate, sucrose octasulfate, or calcium acetate. The liposome suspension can then be subjected to ultrasonic treatment or extrusion to form uniform liposomes with a controlled size in the range of about 10–1000 nm or preferably in the range of about 50–200 nm.In the case of an active loading method, the liposome suspension having uniform size is then subjected to methods such as dialysis or chromatography to create a gradient or difference in concentration of the selected active loading agent between the internal and external media of the liposomes. This can be used to load the desired active pharmaceutical agent when mixing a drug solution with the liposome suspension. The liposome suspension can be used alone or in combination with a gelling or thickening agent (e.g., carbomer) selected from the group described above for therapeutic applications. An alkaline agent, such as sodium hydroxide or ammonia, can be used to neutralize the final formulation to an acidity of pH 6–8, and preservatives, such as parabens, can be included in the preparation.

[0304] In another embodiment, liposome emulsion gels or pro-liposome gels can be used as carrier formulations for topical administration of the active agent. A suitable combination of phospholipids and a marginal activator (e.g., soybean phosphatidylcholine and polysorbate 80) can be dissolved in a solvent (e.g., ethanol, isopropanol, propylene glycol, or combinations thereof). In some cases, the solvent can additionally act as a transdermal absorption enhancer, for example, when selected from the group described above (e.g., propylene glycol, ethanol, and isopropanol). In one embodiment, the solvent preferably comprises equal amounts of propylene glycol and isopropanol. The phospholipid solution can then be combined with a suitable portion of an aqueous solution containing one or more active agents at a concentration sufficient to produce a final concentration in the formulation of about 0.1% (or about 0.01%) to about 20%, or about 0.1% to about 10%, or about 0.1% to about 8%, or preferably between about 0.5% and about 5%. The mixture can be combined with a gelling or thickening agent, such as carbomer. Alkaline agents, such as sodium hydroxide or ammonia, can be used to neutralize the final formulation to an acidity of pH 6–8, and preservatives, such as parabens, can be included in the preparation.

[0305] In another specific embodiment, one or more active agents can be applied topically in the form of a cream. The concentration range of one or more active pharmaceutical ingredients can be from about 0.01% (or about 0.1%) to about 20% (w / w), for example from about 0.1% to about 10% (or about 8%), or from about 0.1 wt% (or about 0.5%) to about 5 wt.%, and in one embodiment it can be from about 0.5% to about 2%. In this embodiment, one or more active agents are formulated with: at least one fatty alcohol emulsifier selected from the group consisting of cetyl alcohol and stearyl alcohol; an oil-in-water emulsifier; at least one preservative; at least one transdermal absorption enhancer selected from the group consisting of diethylene glycol monoethyl ether and isopropyl myristate; and an alkaline agent, such as sodium hydroxide, to neutralize the mixture to a final acidity of pH 6-8.

[0306] In specific embodiments, the topical administration is in the form of one or more active agents: a cream or gel comprising about 0.1 to about 1% of a β-blocker selected from propranolol or timolol; a cream or gel comprising about 0.1 to about 1% of an ACE inhibitor selected from the group consisting of cilazapril, ramipril, trandopril, enalapril, and quinapril; a cream or gel comprising about 0.1 to about 1% of an ACE inhibitor selected from the group consisting of cilazapril, ramipril, trandopril, enalapril, and quinapril, and about 0.1 to about 1% of an ACE inhibitor. 1% of a beta-blocker selected from the group consisting of propranolol and timolol; creams or gels comprising about 0.1 to about 1% cilazapril and about 0.1 to about 1% propranolol; creams or gels comprising about 0.1 to about 1% cilazapril and about 0.1 to about 1% timolol; creams or gels comprising about 0.1 to about 1% ramipril and about 0.1 to about 1% propranolol; or creams or gels comprising about 0.1 to about 2% triamcinolone and about 0.1 to about 0.5% timolol.

[0307] whole body

[0308] In some embodiments, the method of the present invention includes systemically administering to a subject a combination of two or more of a β-blocker, an ACE inhibitor, and an ATIIR2 antagonist, or administering one or more of these agents in addition to topical administration of an ACE inhibitor, a β-blocker, and / or an ATIIR2 antagonist. In one embodiment, preferably, these agents are formulated as a composition suitable for systemic administration. Such a composition will include at least one active agent (selected from the group consisting of an ACE inhibitor, a β-blocker, and an ATIIR2 antagonist) and, in a preferred embodiment, one or more pharmaceutically acceptable carriers, diluents, and / or excipients. In one embodiment, the composition is suitable for oral administration. For pediatric applications, a liquid formulation is preferred. In another embodiment, the composition is suitable for administration by injection; for example, subcutaneous, intramuscular, or intravenous injection.

[0309] The compositions applicable to systemic administration according to the present invention will comprise at least one active agent (selected from the group consisting of ACEi, β-blockers, and ATIIR2 antagonists) and preferably one or more pharmaceutically acceptable carriers, diluents, and / or excipients. In one embodiment, the systemic composition comprises a single type of active agent (e.g., ACEi, β-blockers, or ATIIR2 antagonists). In another embodiment, the systemic composition comprises a combination of two or more different types of active agents. As an example, in one embodiment, the composition used in the present invention comprises ACEi. In another embodiment, the composition used in the present invention comprises a β-blocker. In another embodiment, the composition used in the present invention comprises an ATIIR2 antagonist. In another embodiment, the composition comprises a combination of ACEi and a β-blocker. In another embodiment, the composition comprises a combination of ACEi and an ATIIR2 antagonist. In another embodiment, the composition comprises a combination of a β-blocker and an ATIIR2 antagonist. In another embodiment, the composition comprises a combination of ACEi, a β-blocker, and an ATIIR2 antagonist.

[0310] Any ACEi, ATIIR2 antagonist, and β-blocker mentioned herein can be formulated as a composition for systemic administration. However, in one embodiment, the ACEi is selected from the group consisting of captopril, enalapril, ramipril, trandopril, cilazapril, benazepril, perindopril, midapril, fosinopril, zolfenpril, and quinapril, and / or a pharmaceutically acceptable salt of any one thereof. In one embodiment, the ACEi is a prodrug. In one embodiment, the β-blocker is selected from the group consisting of non-selective β-blockers. In a preferred embodiment, the β-blocker is selected from the group consisting of timolol, propranolol, atenolol, betalol, bisoprolol, naldolol, carvedilol, caralolol, and / or a pharmaceutically acceptable salt of any one thereof. In one embodiment, the β-blocker is in R- or S-form or a racemic mixture of both. In one embodiment, a racemic mixture of the β-blocker having a higher proportion of the R-enantiomer isomer is present. In one embodiment, the β-blocker is substantially in the R-enantiomer form. In another embodiment, ATIIR2 is selected from the group consisting of ololigan (EMA401), PD123177, L-159686, PD123319, PD126055, EXP801, and L161638 and / or a pharmaceutically acceptable salt of any one thereof.

[0311] In a preferred embodiment, the composition for systemic administration comprises a β-blocker (e.g., propranolol and / or timolol and / or atenolol) and / or an ACEi (such as captopril, cilazapril, lisinopril, trandopril, ramipril, or enalapril) and / or ATIIR2. In one embodiment, the composition comprises an ACEi in prodrug form and a nonselective β-blocker.

[0312] In some embodiments, the systemic compositions used in this invention comprise: lisinopril and propranolol; lisinopril and timolol; lisinopril and atenolol; ramipril and propranolol; ramipril and timolol; ramipril and atenolol; quinapril and propranolol; quinapril and timolol; quinapril and atenolol; enalapril and propranolol; enalapril and timolol; or enalapril and atenolol. In one embodiment, the β-blocker is substantially in the form of an R-enantiomer.

[0313] In other embodiments, the systemic composition of the present invention comprises one combination of specific agents described herein and illustrated by way of example as being administered or used in the methods of the present invention.

[0314] The whole-body compositions used in these embodiments of the methods of the present invention may optionally include one or more additional ingredients that may be beneficial to include in such compositions, such as other agents that may be beneficial to the subject. For example, they may include one or more additional active agents that are beneficial to the treatment of hemangiomas or otherwise beneficial to the health or cosmetic appearance of the subject.

[0315] Those skilled in the art will readily understand the types of compositions suitable for systemic administration, including injectable compositions, pills, capsules, gels, suspensions, oils, emulsions, sprays, powders, liquids, and the like. In one embodiment, the composition is suitable for oral administration. In a preferred embodiment, the composition is formulated as an oral liquid formulation. In another embodiment, the invention provides a drug delivery device suitable for systemic administration and comprising one or more of the active agents (including references to combinations of active agents) or compositions as described herein. In one embodiment, the drug delivery device comprises one of the combinations of specific active agents described herein and illustrated by way of example as being administered or used in the methods of the invention. Those skilled in the art will readily understand suitable drug delivery devices for systemic administration and methods for manufacturing them. In one embodiment, the drug delivery device is a transdermal patch suitable for systemic administration.

[0316] Those skilled in the art will readily understand the various suitable carriers, excipients, and diluents used in formulating compositions intended for systemic delivery, including injectable and oral compositions, for example, taking into account the nature of the invention described herein and the information disclosed in pharmaceutical texts and manuals, such as The Handbook of Pharmaceutical Excipients, Sixth edition, 2009, editors Raymond C Rose, Paul J Sheskey, and Marian E Quinn. http: / / pharmama.info / wp-content / uploads / 2018 / 10 / Excipients.pdf ).

[0317] Compositions suitable for systemic administration may include any appropriate amount of an active agent (ACEi, β-blocker, and ATIIR2 antagonist), taking into account the desired dose to be delivered to the subject (as described elsewhere herein) and the chemical properties of the agent, as will be understood by those skilled in the art in light of the description herein.

[0318] However, as an example, for compositions intended for oral administration or injectable compositions, the total amount of active agents (ACEi, β-blockers, and / or ATIIR2) present in the composition may be from about 0.001 mg to about 500 mg or about 1000 mg. In specific embodiments, the following ranges may be used for oral compositions: from about 0.1 mg to about 100 mg, preferably from about 0.5 mg to about 20 mg of ACEi; from about 0.1 mg to about 150 mg, preferably from about 0.5 mg to about 100 mg of β-blockers; and from about 0.01 mg to about 400 mg, preferably from about 0.5 mg to about 100 mg of ATIIR2 antagonists.

[0319] In embodiments of the invention, two or more different agents are combined in a single composition (e.g., ACEi and a β-blocker, ACEi and ATIIR2, ATIIR2 and a β-blocker, or ACEi, ATIIR2 and a β-blocker), and they can be combined in any suitable ratio. For example, ACEi and a β-blocker can be combined in a ratio of about 10:1 to 1:10; ACEi and an ATIIR2 antagonist can be combined in a ratio of about 10:1 to 1:10; or, a β-blocker and an ATIIR2 antagonist can be combined in a ratio of about 10:1 to 1:10.

[0320] ACEi, ATIIR2 antagonists, and β-blockers for systemic administration include any of those exemplified elsewhere herein. Similarly, exemplary ratios of one compound to another (used or administered in a single composition or as described in the methods of the invention) provided elsewhere herein may be applied to systemic compositions and delivery methods.

[0321] Compositions suitable for systemic administration can be formulated according to standard techniques, as can be found in such standard references, for example, Gennaro AR: Remington: The Science and Practice of Pharmacy, 22nd ed., Lippincott, Williams & Wilkins.

[0322] Dosage and administration regimen

[0323] The dosage, dosing period, and general dosing regimen of the administered active agent (ACEi, ATIIR2 antagonist, and / or β-blocker) or composition may vary among subjects depending on variables such as the size and / or severity of the hemangioma to be treated, the type of hemangioma to be treated, the stage of development of the hemangioma, the type of agent or composition to be administered, the route of administration, the size of the unit dose, the type of excipients, carriers, etc. used, the age and / or general health status of the subject, and other factors well known to those skilled in the art. Taking into account such factors and the information contained herein, those skilled in the art will be able to determine an appropriate dose sufficient to deliver an effective amount of one or more active agents to the subject or hemangioma. As an example, in the case of severe or rapidly proliferating hemangiomas, a larger daily dose and / or a longer treatment period may be used compared to the treatment of less severe hemangiomas. In some cases, such as when the growth of the hemangioma is particularly severe, the local treatment of hemangiomas according to the invention may be enhanced with systemically administered one or more agents (including ACEi, β-blockers, and / or ATIIR2) that may aid in the treatment of the hemangioma. In one specific embodiment, in addition to topical administration of the active agent or combination of active agents or one or more compositions including the active agent according to the invention, a β-blocker and / or ACEi are also administered systemically.

[0324] Dosing may include a single daily dose or, as appropriate, several discrete doses. Dosing regimens may also include administration of one or more of the active agents described herein, or a composition comprising an active agent.

[0325] By way of example only, ACEi, ATIIR2 antagonists, and / or β-blockers, or compositions comprising one or more of these agents, may be administered 1 to 10 times daily, preferably 1 to 5 times daily, or 1 to 3 times daily, more preferably once or twice daily (e.g., by application (preferably topically)). As another example, treatment may persist for approximately 6 to 14 months, and preferably for a prolonged period of the proliferative phase of the hemangioma, as this reduces the risk of lesion rebound or regrowth. A technician will be able to readily identify the proliferative phase of the hemangioma from the age of the hemangioma and the growth rate of the lesion. In the case of infantile hemangiomas, a technician will readily identify this phase from the infant's age and the growth rate of the lesion. However, by way of example only, for infantile hemangiomas, the proliferative phase typically occurs within the first 12 months of life. In many cases, infantile hemangiomas can reach 80% of their maximum size within the first three months.

[0326] In some embodiments, when the active agent (ACEi, β-blocker and / or ATIIR2 antagonist) is administered topically (preferably externally), it is preferred to administer the agent at a daily dose of approximately 0.01 mg / cm³ to provide one or more active agents. 2 Up to approximately 50 or approximately 100 mg / cm 2 (Measured according to the size of the hemangioma). In some embodiments, when the active agent (ACEi, β-blocker, and / or ATIIR2 antagonist) is administered topically, it is preferably administered in a sufficient amount to form a thin layer of the composition on substantially the entire surface of the hemangioma lesion (including references to the skin or other tissue surface at the hemangioma site, e.g., covering the hemangioma). In one embodiment, when the active agent (ACEi, β-blocker, and / or ATIIR2 antagonist) is administered topically by intralesional injection (or injection into the proximal tissue of the hemangioma), it is preferably administered to the subject to provide a daily dose of one or more active agents of about 0.01 mg to about 50 or about 100 mg per dose. In some embodiments, when the active agent (ACEi, β-blocker, and / or ATIIR2 antagonist) is administered by intralesional injection (or injection into the proximal tissue of the hemangioma), it is preferably administered in a manner sufficient to distribute substantially uniformly throughout the hemangioma or to administer one or more active agents.

[0327] In one specific implementation, ACEi is administered topically to the subject to provide approximately 0.01 mg / cm³. 2 Up to approximately 100 mg / cm 2 The daily dose (measured based on the size of the hemangioma).

[0328] In one specific implementation, the ATIIR2 antagonist is administered topically to the subject to provide approximately 0.01 mg / cm². 2Up to 100 mg / cm 2 The daily dose (measured based on the size of the hemangioma).

[0329] In another embodiment, the β-blocker and ACEi are administered topically to the subject. In one embodiment, the β-blocker and ACEi are administered topically to provide approximately 0.01 mg / cm³. 2 Up to approximately 100 mg / cm 2 The daily dose of the active agent (measured according to the size of the hemangioma). In one specific embodiment, the subject is administered a higher dose of ACEi relative to the dose of the administered β-blocker.

[0330] In another embodiment, the ACEi and ATIIR2 antagonists are administered topically to the subject. In one embodiment, the ACEi and ATIIR2 antagonists are administered topically to provide approximately 0.01 mg / cm³. 2 Up to approximately 100 mg / cm 2 The daily dose of the active agent (measured according to the size of the hemangioma).

[0331] In another embodiment, the β-blocker and ATIIR2 antagonist are administered topically to the subject. In one embodiment, the β-blocker and ATIIR2 antagonist are administered topically to provide approximately 0.01 mg / cm². 2 Up to approximately 100 mg / cm 2 The daily dose of the active agent (measured according to the size of the hemangioma).

[0332] In another embodiment, the ACEi, β-blocker, and ATIIR2 antagonist are administered topically to the subject. In one embodiment, the ACEi, β-blocker, and ATIIR2 antagonist are administered topically to provide approximately 0.01 mg / cm³. 2 Up to approximately 100 mg / cm 2 The daily dose (measured based on the size of the hemangioma).

[0333] In embodiments of the invention: ACEi and β-blockers are administered topically at a ratio of approximately 10:1 to 1:10; ACEi and ATIIR2 antagonists are administered topically at a ratio of approximately 10:1 to 1:10; or, β-blockers and ATIIR2 antagonists are administered topically at a ratio of approximately 10:1 to 1:10.

[0334] In one specific embodiment, the ACE inhibitor and the β-blocker are preferably administered topically to the subject, such that a larger proportion of the ACE inhibitor is administered relative to the β-blocker. In one embodiment, the ratio of the administered ACE inhibitor to the β-blocker is approximately 1:1 to approximately 10:1. In another embodiment, the ratio is approximately 2:1 to approximately 10:1. In other embodiments, the ratio of the ACE inhibitor to the β-blocker in the composition is approximately 3:1 to approximately 9:1, approximately 4:1 to approximately 8:1, or approximately 5:1 to approximately 7:1. In other embodiments, the ratio is approximately 1:1, 2:1, approximately 3:1, approximately 4:1, approximately 5:1, approximately 6:1, approximately 7:1, approximately 8:1, approximately 9:1, or approximately 10:1. In other embodiments, a larger proportion of the β-blocker relative to the ACE inhibitor may be administered.

[0335] In a specific embodiment, the ratio of the administered β-blocker to the ATIIR2 antagonist is approximately 1:2 to approximately 1:10, for example, approximately 1:2, approximately 1:3, approximately 1:4, approximately 1:5, approximately 1:6, approximately 1:7, approximately 1:8, approximately 1:9, or approximately 1:10.

[0336] In a specific implementation, the ratio of the administered β-blocker to ACEi is approximately 1:2 to approximately 1:9, for example, approximately 1:2, approximately 1:3, approximately 1:4, approximately 1:5, approximately 1:6, approximately 1:7, approximately 1:8, or approximately 1:9.

[0337] In a specific embodiment, the ratio of the administered ATIIR2 antagonist to ACEi is approximately 1:1 to approximately 1:5, for example, approximately 1:1, approximately 1:2, approximately 1:3, approximately 1:4, or approximately 1:5.

[0338] In some embodiments, the ratio of the administered β-blocker to the ATIIR2 antagonist is approximately 1:2.5, approximately 1:5, or approximately 1:10.

[0339] In some implementations, the ratio of the administered β-blocker to ACEi is approximately 1:2, approximately 1:4, or approximately 1:9.

[0340] In some implementations, the ratio of the administered ATIIR2 antagonist to ACEi is approximately 1:2, approximately 1:1, or approximately 1:4.

[0341] In specific embodiments: cialapril and timolol are administered topically at a ratio of approximately 1:1, approximately 1:10, or approximately 10:1; timolol and EMA401 are administered topically at a ratio of approximately 1:10 or approximately 1:1; cialapril and EMA401 are administered topically at a ratio of approximately 1:10 or approximately 1:1; cialapril and propranolol are administered topically at a ratio of approximately 1:1; ramipril and propranolol are administered topically at a ratio of approximately 1:1; or triamcinolone and timolol are administered topically at a ratio of approximately 4:1. In other embodiments, combinations of compounds in ratios as specified in Table 6 below may be administered topically.

[0342] As mentioned above, in one embodiment, the present invention provides a first-line method / medication for the early treatment or intervention of hemangioma development. For example, the inventors have also considered providing a method / medication for treating rebound hemangiomas, and / or for secondary treatment of refractory hemangiomas that have not responded adequately to oral β-blockers (e.g., propranolol) alone. In areas where the lesion is not severe, the present invention can be used alone as an ACE inhibitor (or, in one embodiment, alone as an ATIIR2 antagonist), applied to a topical formulation to manage or control lesion growth. In cases where faster regression is required, or where additional enhancement therapy is desired, an ACE inhibitor can be used in combination with a β-blocker to treat, manage, or control lesion growth. In other embodiments, an ACE inhibitor can be combined with an ATIIR2 antagonist, or with both an ATIIR2 antagonist and a β-blocker. In yet another embodiment, a β-blocker and an ATIIR2 antagonist can be combined. In another embodiment, where the lesion is very severe or the response to local administration is less than or slower than expected, the local administration according to the invention can be combined with a suitable systemic agent (such as ACEi, β-blockers, and / or ATIIR2). In one embodiment, the local administration according to the invention is combined with a systemic β-blocker and / or ACEi. In one embodiment, it is combined with an oral administration of an agent such as a β-blocker and / or ACEi. Considering the information contained herein and the disclosed information regarding systemic treatment of hemangiomas, those skilled in the art will readily understand the appropriate dosage and formulation of the agent for systemic administration. However, as an example, an oral β-blocker formulation, such as 3.75 mg / mL propranolol solution or... Solutions, or oral solutions of ACE inhibitors such as cislacpril or captopril. The inventors considered that this would provide additional synergistic effects.

[0343] In some embodiments of the invention, the composition is administered systemically to the subject, preferably orally, in combination of at least two of the β-blockers, ACEi, and ATIIR2 antagonists. In one embodiment, the composition is preferably administered to the subject to provide a daily dose of one or more active agents at a dose of about 0.01 mg / kg (or about 0.1 mg / kg) to about 100 mg / kg for each individual agent. In one embodiment, the combination of at least two of the β-blockers, ACEi, and ATIIR2 antagonists is administered systemically to the subject by injection (e.g., subcutaneous, intramuscular, or intravenous) to provide a daily dose of one or more active agents at a dose of about 0.01 mg / kg (or about 0.1 mg / kg) to about 100 mg / kg for each individual agent.

[0344] Reagent test kit

[0345] Active agents (ACEi, β-blockers, and / or ATIIR2 antagonists) and compositions comprising them can be provided and used in kit form for the treatment of hemangiomas. Such kits will include at least one active agent, and preferably a combination of active agents, in one or more suitable containers. The agents can be formulated into pharmaceutical compositions ready for direct administration to a subject. Alternatively, the kit may include one or more active agents in one container and a drug carrier composition in one or more other containers; the contents of each container are mixed together prior to administration. The kit may also include add-ons and compositions in additional separate containers as may be required for a particular application. Furthermore, the kits of the present invention may also include instructions for the use and administration of the kit components. Any container suitable for storing and / or administering the pharmaceutical composition can be used in the kits of the present invention. Those skilled in the art will understand suitable containers. Examples of suitable containers include vials and syringes. Containers may be suitably sterilized and airtightly sealed. Example

[0346] All inhibitors used in the following examples, except for SMM02, were purchased from Sigma Aldrich (www.sigmaaldrich.com), AK Scientific (www.aksci.com), and MedChemExpress (…). www.medchemexpress.com ), or MedKoo ( www.medkoo.com SMM02(L-159,686,(S)-1,4-bis(N,N-diphenylcarbamoyl)piperazine-2-carboxylic acid) was synthesized as previously described in US5292726.

[0347] Example 1: In vitro cell culture model of infantile hemangioma.

[0348] An in vitro cell culture model of infantile hemangioma was developed to evaluate the effects of renin-angiotensin system inhibitors on cell proliferation. Primary cell lines of proliferative infantile hemangioma cells, comprising hemangioma stem cells, were derived from tissue biopsies obtained from patients during the proliferative phase of the disease. Cells were cultured in 25 cm⁻¹ culture media using standard culture media and conditions. 2 Primary cell lines were cultured in flasks. The cultured cells were used to seed cells in 96-well plates at a concentration of 2500 or 5000 cells per well, with an additional 200 μL of culture medium. All studies were performed in triplicate.

[0349] Incubate the plates overnight to allow cells to adhere to the wells. Photograph the wells to determine cell adhesion and confluence. Then add one or more appropriate drugs to be examined to the wells. After 24 hours, stop the reaction with a set of plates (experimental and blank). Aspirate the culture medium from each well and freeze for possible future analysis. Add the culture medium to the wells and perform an MTT assay according to a standard protocol. This was repeated at 48 and 72 hours.

[0350] The mean ± standard deviation was calculated for each incubation at three replicates for each drug concentration, and for all controls. Net viability (optical density value) was calculated by subtracting the appropriate blank mean from each cell culture. The percentage of cells present at each drug concentration after each culture was determined based on MTT data.

[0351] Example 2: Effects of β-blockers and ACE inhibitors on the proliferation of hemangioma cells in in vitro proliferative infantile hemangioma cells from patients.

[0352] Using an in vitro model of proliferative infantile hemangioma (Example 1), timolol and cilapril were used as model β-blockers and ACE inhibitors, respectively, to investigate the effects of locally administered β-blockers and ACE inhibitors (ACEi). This model encapsulates the process of directly administering drugs locally to the hemangioma microenvironment, representing drug diffusion across the skin to reach target cells.

[0353] A single dose of timolol or cilapril (100 μM) was added to primary cell lines containing hemangioma cells and stem cells, and cell viability was subsequently assessed by MTT assay at 24, 48, and 72 hours. Surprisingly, compared with timolol, a 7-fold increase in hemangioma cell proliferation inhibition was observed 24 hours after drug exposure to cilapril. Figure 1 This contrasts with the current state of knowledge and clinical trial observations that report ACE inhibitors as less effective than beta-blockers in treating infantile hemangiomas. Furthermore, these results suggest that high local concentrations of timolol alone have a limited effect on attenuating hemangioma tissue and support the limited clinical efficacy of currently applied beta-blocker products and formulations.

[0354] The positive results seen with topical administration of cialapril are also surprising, given that it is a prodrug. It is well understood in the art that ACEi prodrugs require activation via hepatic biotransformation, suggesting that systemic administration would be the only effective delivery method.

[0355] Interestingly, the observations demonstrated that although a single dose of the ACE inhibitor cilapril had a greater inhibitory effect on IH cell proliferation than the β-blocker timolol, the inhibitory effect of timolol remained consistent, while the inhibitory effect of cilapril diminished over time, suggesting that continuous dosing would be beneficial in helping to maintain constant inhibition.

[0356] In summary, this surprisingly demonstrates that ACE inhibitors are significantly more effective than beta-blockers in inhibiting hemangioma tissue proliferation. Therefore, when applied topically to hemangiomas, such as through topical application, ACE inhibitors, including those in prodrug form, can treat proliferative hemangiomas more effectively. These findings inform therapeutic dosing regimens for topical ACE inhibitor products.

[0357] Example 3: The effect of the combination of β-blockers and ACE inhibitors on the proliferation of hemangioma cells.

[0358] Since β-blockers and ACE inhibitors produced significantly different inhibitory profiles, the combination of ACE inhibitors and β-blockers was used to investigate the inhibition of proliferative hemangioma cells using an in vitro hemangioma culture model (Example 1) and cilazapril and timolol as the model ACE inhibitor and β-blocker, respectively.

[0359] Cialapril and timolol were incubated with proliferative hemangioma cells at different low drug concentrations (0.1–10 μM), drug:drug ratios of 1:1 and 10:1 (as single doses or daily doses), with hemangioma cell concentrations of 2500 or 5000 cells / well. Cell viability was assessed by MTT assay at 24, 48, and 72 hours.

[0360] Surprisingly, the combination of cilapril and timolol produced a greater and longer inhibition of hemangioma cell proliferation, which could be achieved at lower drug concentrations, especially with daily dosing. Figure 2 (5000 cells / well). Furthermore, even at lower drug concentrations (10 μM), and with higher initial cell concentrations (5000 cells / well), prolonged and significant inhibition of hemangioma cell proliferation were achieved. This was not achieved with a single drug.

[0361] In summary, these results demonstrate that the combination of ACE inhibitors and beta-blockers is significantly more effective in reducing proliferative hemangiomas and inform the development of effective topical treatments for this disease.

[0362] Example 4: Effect of a combination of ACE inhibitors, β-blockers and angiotensin receptor blockers on the proliferation of hemangioma cells in various patient cell lines.

[0363] Following the studies described in Examples 1-3, the inhibitory effects of β-blockers, ACE inhibitors, and angiotensin II type 1 (AT1) and type 2 (AT2) receptor inhibitors on hemangioma cell proliferation were confirmed in a variety of proliferative hemangioma cell lines derived from patient biopsies obtained from five patients between two and ten months of age (Table 2).

[0364] Table 2:

[0365]

[0366] *Results from multiple experiments

[0367] The experimental protocol was followed as described in Example 1. Briefly, cells were seeded at a concentration of 2500 cells / well in 96-well plates, triplet for each drug and drug combination. One or more drugs were added to each well 24 hours after seeding, and re-dosing was performed every 24 hours. Cell viability was assessed at 24, 48, and 72 hours by MTT assay. All plates were tripletted. Drugs, individually and in combination, were evaluated as described in Table 3. Timolol was used as a model β-blocker (BB), cilaprol as a model ACE inhibitor (ACEi), losartan as a model angiotensin II type 1 receptor inhibitor (AT1Ri), and EMA401 and SMM02 (L-159686) as models AT2Ri. A summary of the results at 72 hours is shown in Table 4.

[0368] Table 3:

[0369]

[0370] Table 4:

[0371]

[0372] The following treatment significantly suppressed all five hemangioma cell lines from the patient: beta-blocker (timolol). Figure 3 Angiotensin-converting enzyme inhibitors (cilacpril, Figure 4 ); Angiotensin II type 2 receptor inhibitors (EMA401) Figure 5 and 6 ) and SMM02 ( Figure 7 and 8 However, it is not through angiotensin II type 1 receptor inhibitors (losartan, Figure 9Control wells containing only cells, as well as cells and an adjuvant for dissolving appropriate drug candidates, showed no change in cell viability. Figure 10 Furthermore, the following combination was found to be superior to single-agent use and appeared to enhance the inhibitory effect on proliferative hemangioma cells through synergistic action: a beta-blocker (timolol) and an angiotensin-converting enzyme inhibitor (cilactin-1), Figure 11 ), beta-blockers (timolol) and angiotensin II type 2 receptor inhibitors (EMA401) Figure 12 ) and SMM02 ( Figure 13 ), as well as angiotensin-converting enzyme inhibitors (cilacpril) and angiotensin II type 2 receptor inhibitors (EMA401). Figure 14 ) and SMM02 ( Figure 15 Compared to using a single agent, combinations produce better responses at the same or lower doses.

[0373] Figure 3-15 This study illustrates both the mean response and the variation in response among five primary hemangioma cell lines derived from different patients during the proliferative phase, when treated with a single agent or a combination of agents. The extent of the variation in response, particularly in the case of timolol, reflects the clinically observed changes between patients when treated with oral or topical beta-blockers or oral ACE inhibitors. However, overall, the results ( Figures 3 to 15 This indicates that synergistic effects were observed with various drug combinations, and that combination therapy with agents showed a more consistent response among primary hemangioma cell lines when used at concentrations >1 μM. Furthermore, the inhibitory effect of each agent improved over time, suggesting that multiple doses or daily doses can be beneficial for treating patients. This was particularly evident at the 24-hour time point, which showed significant variation in response among each cell line from the patient. It should be noted that negative inhibitory values ​​(such as those observed in some cell lines at different time points, or when using the lowest concentration of agent (1 μM)) should be interpreted as zero or negligible inhibition.

[0374] Example 5: Study on the combination of R- and S-β blockers with ACE inhibitors and the effect of β blockers on hemangioma cell proliferation.

[0375] Further studies were conducted using ACE inhibitors alone and in combination with β-blockers to establish their effects at low individual concentrations and to investigate the effects of enantiomers of different β-blockers.

[0376] The experimental protocol was followed as described in Example 1. Briefly, cells were seeded at a concentration of 2500 cells / well in 96-well plates, triplet for each drug and drug combination. One or more drugs were added to each well 24 hours after seeding, and then quantitatively administered every 24 hours. Cell viability was assessed by MTT assay at 24, 48, and 72 hours. All plates were tripletted. Drugs were evaluated individually and in combination at concentrations between 1 and 30 μM. Figure 16-18 Timolol and propranolol are used as model beta-blockers, and cilap is used as a model ACE inhibitor.

[0377] The effects of R-timolol, S-timolol, R-propranolol, S-propranolol, and R / S-propranolol, alone and in combination with cislapril, were investigated. R- and S-propranolol were found to be superior to R- and S-timolol in attenuating hemangioma cell proliferation, especially at low concentrations of 1–5 μM. However, surprisingly, a small difference was found between the R-β blockers and S-β blockers in their ability to inhibit proliferative hemangioma cells. Figure 16 It was also noted, surprisingly, that the single isomers R- and S-propranolol alone were as effective as the racemic mixture, currently prescribed for the treatment of proliferative infantile hemangiomas requiring systemic therapy, under the brand name [Brand Name Missing]. This is an important finding because the R-enantiomers of timolol and propranolol do not exert the same degree of blood pressure effect as the S-enantiomers.

[0378] The effects of combining beta-blocker enantiomers with ACE inhibitors on hemangioma proliferation were subsequently investigated. Cilapril was used as an exemplary ACE inhibitor. The combination of a beta-blocker and cilapril provided a greater effect on inhibiting proliferative hemangioma cells than either agent alone (e.g., as shown in the image). Figure 17 and Figure 18 As shown in the figure (72 hours). Combinations of R-timolol / cilacpril and S-timolol / cilacpril showed similar potency, as did combinations of R-propranolol / cilacpril, S-propranolol / cilacpril, and R / S-propranolol / cilacpril. The beneficial therapeutic effect of R-β blockers with ACE inhibitors is a surprising and clinically important finding, as it demonstrates that these agents can be combined without increasing the risk of cardiovascular side effects.

[0379] Example 6: The synergistic effect of a combination of ACE inhibitors, β-blockers and angiotensin II type 2 receptor blockers in inhibiting proliferative hemangiomas.

[0380] Studies were conducted using a combination of ACE inhibitors, beta-blockers, and angiotensin II type 2 receptor blockers to inhibit proliferative hemangioma cells. An expanded study using multiple primary hemangioma cell lines (n=9) obtained via biopsy from patients during the proliferative phase confirmed the inhibitory effect of these agents, both individually and in combination. Patient histories for each cell line are described in Table 5.

[0381] Table 5: Patient biopsy history used for primary cell culture.

[0382]

[0383] *Results from multiple experiments

[0384] The experimental protocol was followed as described in Example 1. Briefly, cells were seeded at a concentration of 2500 cells / well in 96-well plates, triplet for each drug and drug combination. One or more drugs were added to each well 24 hours after seeding, and re-dosing was performed every 24 hours. Cell viability was assessed at 24, 48, and 72 hours by MTT assay. All plates were tripletted. Drugs, individually and in combination, were evaluated as described in Table 6. Propranolol was used as a model β-blocker, cilaprolol as a model ACE inhibitor, and SMM02 (L-159686) as a model AT2Ri. Synergistic effects were measured using the CompuSyn open-source software protocol, which quantifies synergistic and antagonistic effects by generating a combination index using the median-effect equation and the law of mass action. www.compusyn.com Synergistic, cumulative, and antagonistic effects are defined as CI<1, CI=1, and CI>1, respectively.

[0385] The ACE inhibitor cisapride and the beta-blockers R-propranolol and S-propranolol showed typical dose-response in all cell lines between 1 and 10 μM (e.g., as shown in the figure). Figure 19 As shown in the figure, 72 hours). Interestingly, the AT2R antagonist SMM02 demonstrated a non-linear dose-response in all cell lines, with small differences in the degree of inhibition observed between 2.5 μM and 10 μM, suggesting a more “threshold” or “saturation” effect, where maximum inhibition is achieved once a minimum concentration is reached. Furthermore, when treated at threshold concentrations above 2.5 μM, treatment of cells with the AT2R antagonist SMM02 as a single agent demonstrated a more consistent inhibitory response in all patient cell lines than with other agents. These results are consistent with the observations in Example 4 ( Figure 3-8 ).

[0386] Table 6: Drug combinations, concentrations, and ratios tested.

[0387]

[0388] Typically, inhibitory combinations (cilapril + SMM02; cilapril + R-propranolol; cilapril + S-propranolol; R-propranolol + SMM02; and S-propranolol + SMM02) have demonstrated higher levels of inhibition than the corresponding concentrations of single agents, especially when using lower concentrations of the agent (e.g., ...). Figure 19-26 As shown in the figure, 72 hours). Surprisingly, the combination of inhibitors also demonstrated more consistent levels of inhibition across different cell lines from patients. In contrast, single-agent inhibition tended to show greater variability across cell lines. These results provide unique insights into the development of effective fixed-dose combination therapies for topical treatment of hemangiomas and are consistent with the observations in Example 3 ( Figure 3-15 ).

[0389] Surprisingly, all combinations (SMM02 / cilapapril, R / S-propranolol / cilapapril, R-propranolol / cilapapril, S-propranolol / cilapapril, R / S-propranolol / SMM02, R-propranolol / SMM02, and S-propranolol / SMM02) demonstrated synergistic inhibition of proliferative hemangioma cells in vitro. Figure 27-31 This is most evident at the 72-hour time point (which represents a possible clinical situation where multiple doses are administered to subjects over time) and at low individual concentrations.

[0390] The demonstrated synergistic therapeutic benefit of using ACE inhibitors, beta-blockers, and AT2 receptor inhibitors to suppress proliferative hemangiomas is an important finding and could provide substantial benefits for the treatment of infantile hemangiomas. Of particular importance are the combinations of R-propranolol and cialapril, and R-propranolol with AT2 receptor inhibitors (e.g., SMM02 or EMA401). The former, the combination of R-propranolol with an ACE inhibitor, can provide synergistic benefits in the treatment of infantile hemangiomas, reducing the required dose and minimizing the possibility of cardiovascular side effects. The latter, the combination of R-propranolol with an AT2 receptor inhibitor (e.g., SMM02 or EMA401), can provide synergistic therapeutic benefits at low doses without any cardiovascular side effects, as R-propranolol or AT2 receptor inhibitors are known to largely not regulate blood pressure.

[0391] These combinations, including cilazapril and propranolol, also provided significantly increased levels of inhibition, with high consistency among individual patient cell lines compared to single-agent therapy. Based on these observations, the inventors considered that combinations of ACE inhibitors with beta-blockers, combinations of AT2 antagonists or beta-blockers, and combinations of AT2 antagonists with ACE inhibitors could provide more effective treatment than beta-blockers alone, and deliver a more consistent response across patient populations. This could be particularly useful as first-line topical therapy to prevent small hemangiomas from developing into large hemangiomas, causing permanent disfigurement, life-threatening or functional impairment, and requiring invasive systemic or surgical treatment, or as secondary treatment for rebound hemangiomas or hemangiomas that have not fully responded to beta-blocker monotherapy.

[0392] Experiment 7: Investigating the effects of different ACEi and BB on proliferative hemangioma cell lines.

[0393] A study was conducted to investigate the effects of different ACE inhibitors and beta-blockers on the inhibition of proliferative hemangioma cells, based on the observation of synergistic inhibition of proliferative hemangioma cells using a combination of drugs containing the ACE inhibitor cilazapril and the beta-blockers propranolol and timolol.

[0394] The experimental protocol of Example 1 was followed using a primary hemangioma cell line derived from biopsies of individual patients during the proliferative phase. Briefly, cells were seeded at a concentration of 2500 cells / well in 96-well plates, triplet for each drug and drug combination. One or more drugs were added to each well 24 hours after seeding, and redosed every 24 hours. Cell viability was assessed by MTT assay at 24, 48, and 72 hours. All plates were tripletted. The β-blockers used in the study were (±)-propranolol, R-propranolol, S-propranolol, timolol, and betalol. The ACE inhibitors used in the study were cilazapril, ramipril, trandopril, enalapril, lisinopril, and quinapril. A summary of the results is provided in Table 7 and Figures 32-33 middle.

[0395] The β-blockers timolol and propranolol, as a racemic mixture or as single enantiomers, both showed consistent levels of inhibition (45%–57% inhibition). Surprisingly, however, the β-blocker betalol showed no response at low concentrations (1 μM) or high concentrations (10 μM). Figure 32 (Table 7). Not wanting to be bound by theory, the inventors considered that the difference in inhibition was due to the difference in receptor selectivity; timolol and propranolol are both non-selective β-blockers, while betalol is a β1-selective β-blocker.

[0396] ACE inhibitors cilazapril, ramipril, trandopril, enalapril, and quinapril also showed good and similar inhibitory levels against proliferative hemangioma cells. Figure 33 (Table 7). Interestingly, these ACE inhibitors are all ethyl ester prodrugs of their active metabolites, typically produced via first-pass metabolism after oral ingestion. Furthermore, it is generally understood that each ACE inhibitor in its ethyl ester prodrug form has a lower chemical affinity for ACE compared to its active carboxylic acid metabolite. In contrast, the non-prodrug ACE inhibitor lisinopril has no effect on proliferative hemangioma cells (…). Figure 33 (See Table 7). This is a surprising result, as it would have been expected that using non-prodrug forms of ACE inhibitors would have produced better or at least equivalent effects.

[0397] These results indicate that non-selective beta-blockers and ACE inhibitors in prodrug form are preferred for carrying out the present invention, or at least produce the best results. Furthermore, since the beta-blockers propranolol and timolol, and their individual enantiomers, as well as the ACE inhibitors cilazapril, ramipril, quinapril, and enalapril, exhibit equivalent efficacy, the inventors contemplate that the present invention can be carried out equivalently by exchanging combinations of these agents.

[0398] Table 7: Summary of results: Effects of different β-blockers and ACE inhibitors on the inhibition of proliferative hemangioma cells at 72 hours.

[0399]

[0400] Example 8: Establishment of an in vitro model system for transdermal screening.

[0401] A series of experiments were conducted to demonstrate the transdermal and dermal absorption capabilities of β-blockers and ACE inhibitors. First, a custom-designed Franz diffusion cell was constructed internally. Figure 34 A), consisting of a donor chamber and a receiver chamber, and equipped with a water jacket to allow for temperature control to simulate physiological conditions. Use A synthetic membrane designed to mimic the permeability properties of human skin was used for initial screening studies. This model system was employed as a screening tool to improve the success of subsequent permeability studies conducted on excised animal skin.

[0402] The system was validated by studying the permeability of the water-soluble fluorescent dye carboxyfluorescein, which exhibits poor transdermal properties. A carboxyfluorescein solution (100 mM, 20 mM Na₂HPO₄, pH 7.4, 2 mL) was applied to the donor chamber, and fluorescence in the receiver chamber was monitored over a 120-hour period. During this time period, no permeation of the aqueous carboxyfluorescein across the skin model membrane was observed. Figure 34B, rhomboid). In contrast, carboxyfluorescein was encapsulated in soybean phosphatidylcholine with a phospholipid membrane composition of 80:20 mol% ( Liposomes were prepared by dissolving the membrane component (20 mM total concentration; phospholipon 90G and polysorbate 80; 80:20 mol% ratio) in chloroform and removing the solvent under vacuum to form a thin lipid membrane. The membrane was rehydrated with a carboxyfluorescein solution (100 mM carboxyfluorescein, 20 mM Na2HPO4, pH 7.4) and extruded through a 100 nm polycarbonate membrane to produce 100 nm deformable liposomes encapsulated with carboxyfluorescein. Unencapsulated carboxyfluorescein was removed by dialysis with phosphate buffer (20 mM, pH 7.4). Even at low concentrations (<1 mM), the carboxyfluorescein-encapsulated deformable liposome formulation significantly accelerated the encapsulation of carboxyfluorescein in the same time period. Permeation on the skin model membrane ( Figure 34 B, square).

[0403] In addition, an emulsion-gel formulation containing 0.5% carboxyfluorescein was formulated and tested in a permeation system. The formulation is described in Table 8. Carbomer was combined with water and carboxyfluorescein and dispersed. The organic components were combined and thoroughly mixed. The organic phase was then combined with the aqueous phase and homogenized, followed by the addition of an ammonia solution to initiate gelation.

[0404] Place 2 mL of carboxyfluorescein emulsion gel into the container equipped with The fluorescein was placed in the receiving chamber of a Franz diffusion cell within the membrane, and its permeation across the membrane was monitored over time and quantified using fluorescence spectroscopy. This formulation was synthesized... The membrane system exhibits rapid permeation characteristics, with a carboxyfluorescein flux of 4.6 μg / cm³. -1 hr -1 ( Figure 34 C). This is related to the use of When used in emulsions or gels, the flux of diclofenac is equivalent across the full thickness of human skin.

[0405] In summary, an in vitro assay system for determining the penetration of active agents into human skin was established and validated. Furthermore, emulsion-gel formulations showed enhanced penetration of the active agent.

[0406] Table 8: Examples of emulsion-gels containing carboxyfluorescein.

[0407] Element quantity Isopropanol 1.25mL Propylene glycol 1.25mL Coconut oil alcohol-octanoate 0.25mL Liquid paraffin 0.25mL Polysorbate 80 0.2mL Carbomer 0.24g ammonia 0.194mL Sodium carboxyfluorescein 2.7 mL (100 mM carboxyfluorescein) water 4mL

[0408] Example 9: An emulsion gel formulation for topical application of a β-blocker and an ACE inhibitor.

[0409] A range of formulations for topical application of β-blockers and ACE inhibitors to strawberry birthmarks were investigated (Table 9 below). The most successful were emulsion-gel formulations in terms of ease of manufacture, preliminary stability, and compatibility with active pharmaceutical ingredients (APIs). These formulations used carbopol (Carbopol Ultrez 10 or 30) as the gel base, isopropanol and propylene glycol as transdermal absorption enhancers, liquid paraffin as the oil phase, and cocoyl oleate as an emollient. Other gel bases were tested, including carboxymethyl cellulose, hydroxypropyl carboxymethyl cellulose, and chitosan; however, these tended to only increase viscosity rather than gel.

[0410] A scalable gel preparation route has been established, which employs a simple procedure ( Figure 35 A). First, the API is dissolved in water to create an aqueous phase, followed by the dispersion of the carbomer gel into the aqueous phase. The organic components, namely paraffin liquid, isopropanol, propylene glycol, cocoyl octanoate, and polysorbate 80, are combined and thoroughly mixed to create an organic phase. The organic phase is then slowly added to the aqueous phase and thoroughly mixed using a high-shear homogenizer to form a homogeneous emulsion. The final stage involves the addition of an alkali, such as ammonia or sodium hydroxide, to neutralize the mixture and initiate gelation. Figure 35 B). Optical microscopy of the gel after 3 months showed that the emulsion was stable. Figure 35 C), cryofracture transmission electron microscopy of the samples showed that the emulsion droplet diameter was approximately 0.5–2 μm. Figure 35 D).

[0411] Table 9: Examples of topical formulations of beta-blockers and ACE inhibitors

[0412]

[0413] Using the same formulations as described above, basic gel formulations were tested with the ACE inhibitors enalapril and lisinopril, and the β-blocker propranolol. Both ACE inhibitors could be readily formulated by dissolving the drugs in the aqueous phase prior to addition to the organic phase. However, the inclusion of 0.5–1 wt% propranolol resulted in precipitation rather than gelation in the final alkalization step. It was found that the inclusion of 2-hydroxypropyl-β-cyclodextrin at a cyclodextrin:propranolol mass ratio of 5:1 inhibited this effect and allowed for stable gel formation. Furthermore, lisinopril and propranolol could be co-formulated at a concentration of 1 wt% if 2-hydroxypropyl-β-cyclodextrin was included to prevent precipitation of propranolol. These formulations are also applicable to a range of other beta-blockers and ACE inhibitors, including timolol, nadolol, indolol, sotalol, atenolol, betalol, ramipril, ramipril, quinapril, quinapril, captopril, quindopril, quindopril, enalapril, enalapril, cilazapril, cilazapril, benazepril, and benazepril.

[0414] In summary, a range of topical creams and emulsion-gel formulations were formulated, prepared, and tested. This is an important demonstration that both beta-blockers and ACE inhibitors can be formulated into stable compositions suitable for topical application, both individually as single agents and as combinations of beta-blockers and ACE inhibitors.

[0415] Example 10: Liposome gel formulation for topical application of β-blockers and ACE inhibitors.

[0416] In addition to emulsion-gel formulations for the application of ACE inhibitors and β-blockers, deformable liposomes and their incorporation into topical gel substrates, as well as scalable preparation routes, have been developed. A lipid composition of 80:20 soybean phosphatidylcholine and polysorbate 80 was used, as this proved to be optimal in terms of both drug encapsulation and deformability. A custom-designed high-volume pressure extruder was developed. Figure 36 A) to improve liposome production capacity. This method reproducibly produces liposomes in batches up to 60 mL per run (cf1 mL / run under manual extrusion), with good size control and polydispersity. Figure 36 (A and B).

[0417] A five-step procedure was developed to prepare deformable liposomes in gel form, which can be applied topically to strawberry birthmarks. Figure 37A). First, the lipid components of the deformable liposomes, namely soybean lecithin and polysorbate 80, were dissolved in isopropanol, while the API (ACE inhibitor, β-blocker, or a combination thereof) was dissolved in an aqueous solution containing sodium phosphate buffered to pH 7.4. The organic phase was slowly added to the aqueous phase under stirring, and subsequently extruded through a 100 nm membrane using a custom-designed high-volume pressure extruder. Figure 36 A). The extruded liposome suspension is combined with a carbomer suspension to obtain a final carbomer concentration in the range of 0.2-1.5 wt%. The mixture is thoroughly mixed to obtain a homogeneous formulation, and then gelled with the addition of an alkali such as sodium hydroxide, ammonia, or diethylamine. Figure 37 B). Cryofracture transmission electron microscopy was performed on the gel samples to study the morphology of the gel, revealing liposomes of approximately 100-300 nm embedded in the gel matrix. Figure 37 C).

[0418] In summary, scalable preparation routes for deformable liposome gels suitable for topical application have been developed. These formulations and methods are applicable to formulations containing a variety of renin-angiotensin system inhibitors, such as β-blockers and ACE inhibitors and ATIIR2 antagonists, either alone or in combination.

[0419] Example 11: Detection of transdermal delivery of β-blockers and ACE inhibitors

[0420] Fluorescence detection of the ACE inhibitor lisinopril.

[0421] We attempted to quantify lisinopril penetration using fluorescence spectroscopy because the detection limit of mass spectrometry was too high for in vitro skin penetration studies. Lisinopril was chosen as a model ACE inhibitor due to its ease of chemical functionalization, and thus, in vitro quantification was performed.

[0422] The assay was developed using fluorescein (a non-fluorescent spiroalkane compound). Fluorescein readily reacts with primary amines (typically amino acids and peptides) under mild alkaline conditions to form stable and highly fluorescent conjugates. Figure 38 A). A reproducible linear relationship between fluorescence intensity and lisinopril concentration can be achieved. Figure 38 B), where the detection limit is 0.1 μg mL. -1 This was sufficient to quantify lisinopril in the receiving chamber of the Franz diffusion experiment. Therefore, a protocol was developed that combines the receiving chamber solution sample with an alkaline buffer and a fluorescent amine acetone solution, and compares it with known amounts of lisinopril.

[0423] The analytical procedure was developed as described. First, the following solutions were prepared:

[0424] 0.2 mg mL -1Fluorescent amines in acetone;

[0425] 0.1 mg mL -1 A lisinopril solution in deionized water;

[0426] • 0.1M borate buffer, pH 9.5;

[0427] • 20 mm Na₂HPO₄ buffer solution at pH 7.4 (for osmosis experiments); and

[0428] • A series of clean and dry 10mL volumetric flasks.

[0429] The fluorescence standard curve was prepared by the following procedure ( Figure 9 B). Add the following to each 10-mL volumetric flask:

[0430] 1. 0.5 mL borate buffer;

[0431] 2. 0, 10, 20, 40, 60, 80, and 100 μL of 0.05 mg / mL -1 Lisinopril solution;

[0432] 3. 0.6 mL – V (with added lisinopril solution) of pH 7.4 phosphate buffer solution;

[0433] 4. 1 mL of fluorescein solution; and

[0434] 5. Add enough ethanol to bring the total to 10 mL.

[0435] 6. Wait 10 minutes, then measure the fluorescence intensity using fluorescence spectroscopy at excitation and emission wavelengths of 390 nm and 487 nm, respectively.

[0436] The quantification procedure for lisinopril in the receiving chamber of the Franz diffusion cell was modified by replacing steps 2 and 3 with 0.6 mL of receiving solution at the desired time points.

[0437] In summary, a sensitive and reproducible fluorescence assay for the detection of the ACE inhibitor lisinopril has been developed. This assay is used to quantify and confirm the penetration of the ACE inhibitor across the skin and skin model membranes.

[0438] Example 12: Lisinopril delivery across the skin from topical liposomes and emulsion gel formulations.

[0439] The permeation characteristics of lisinopril liposome gel and lisinopril emulsion gel formulations were evaluated using the Franz diffusion assay system combined with a developed fluorescence assay for quantification of lisinopril. Lisinopril was chosen as a model ACE inhibitor due to its ease of chemical functionalization, and therefore, in vitro quantification was performed.

[0440] For these experiments, the water jacket of the Franz diffusion cell was maintained at physiological temperature (37 degrees Celsius). A membrane was used for permeation experiments—a synthetic membrane that mimics the permeability of human skin. The membrane consists of two diffusion-resistant polyethersulfone (PES) layers on top of a more open and diffuse layer of polyolefin. These polymer layers create a porous structure with a pore size gradient and diffusivity across the membrane, which is further impregnated with a proprietary blend of synthetic lipids to produce additional skin-like properties. The model system was used to minimize the complexity of any primary amine-containing contaminants generated in the receiving solution due to skin necrosis and to allow for comparison of results with earlier permeation studies using an emulsion gel containing 1% carboxyfluorescein. It was observed that the deformable liposome gel formulation was able to achieve permeation at 5.6 μg cm⁻¹. -2 hr -1 The rate at which lisinopril is transported across the model membrane ( Figure 39 B). 5.3 μg cm⁻¹ was observed using a 1% lisinopril emulsion gel. -2 hr -1 Comparable permeation rates ( Figure 39 B), whose composition is similar to (Diclofenac) emulsion gel, a commercially available gel formulation known for its rapid absorption in the presence of its API, diclofenac.

[0441] In comparison, our previous study using a 1% carboxyfluorescein emulsion gel with a similar composition produced a permeation rate of 4.6 μg cm⁻¹. -2 hr -1 However, long lag times were observed for lisinopril diffusion from deformable liposome gels and emulsion gels, approximately 30 and 37 hours, respectively, while in the same in vitro system, a lag time of approximately 5 hours was observed for the permeation of carboxyfluorescein. This is because lisinopril and carboxyfluorescein have comparable solubility and molecular weight (>100 mg / mL at pH 7.4). -1 and respectively 376g mol -1 and 405g mol -1 The prolonged hysteresis time is likely due to differences in lipophilicity (log P values ​​of 2.9 for carboxyfluorescein and -1.01 for lisinopril). Given that lisinopril is a highly potent and long-acting ACE inhibitor, the inventors believe that the in vitro hysteresis time observed in this model system is unlikely to be clinically significant. However, this demonstrates that other highly potent ACE inhibitors with more favorable lipophilicity for transdermal transport (log P values ​​of 2.9, 3.5, 0.8, and 3.2, respectively) could be preferred for formulations in topical creams and emulsion gel systems for the treatment of hemangiomas.

[0442] In summary, the results of this study demonstrate that lisinopril, a model ACE inhibitor, can be efficiently transported across the membrane of a human skin model. Both the emulsion gel and deformable liposome gel formulations exhibited similar diffusion rates, demonstrating that the drug diffusion rate is primarily related to the drug concentration in the formulation. Furthermore, the hysteresis time observed for the water-soluble ACE inhibitor lisinopril (logP = -1.01) was greater than that for the water-soluble carboxyfluorescein (logP = 2.9), suggesting that other ACE inhibitors with more favorable lipophilicity may be better suited for rapid absorption during topical application. Overall, these results inform the design of topical compositions of ACE inhibitors suitable for treating skin conditions such as infantile hemangiomas.

[0443] Example 13: In vitro permeation of propranolol across the skin model membrane.

[0444] Since the combination of ACE inhibitors and beta-blockers has been shown to produce a significant improvement in the reduction of hemangioma cell proliferation, studies were conducted to determine the penetration rate of beta-blockers across the skin. Propranolol was selected as the model beta-blocker because it can be accurately and rapidly quantified using UV-Vis spectroscopy.

[0445] By serial dilution to produce 0.5, 0.05, 0.025, 0.0125, and 0.00625 mg / mL -1 The concentration range of propranolol solution (0.5 mg / mL) was measured. -1 A standard curve for propranolol was constructed using the absorbance at 288 nm of a solution containing 20 mM Na₂HPO₄ (pH 7.4). The dilution series showed a linear correlation with absorbance, and the correlation coefficient (R²) was [value missing]. 2 The value is 0.99791. Figure 40 A).

[0446] Prepare 1% propranolol emulsion gel and 1% propranolol cream containing 2-hydroxypropyl-β-cyclodextrin according to Table 10 below for subsequent penetration studies.

[0447] In short, a 1% propranolol emulsion gel was prepared by combining appropriate proportions of organic components (isopropanol, propylene glycol, cocoyl octanoate, liquid paraffin, and polysorbate 80). 2-hydroxypropyl-β-cyclodextrin was dissolved in the aqueous component, followed by the dissolution of propranolol hydrochloride. Carbomer was then dispersed in the propranolol aqueous solution, and the organic phase was incorporated into this solution under vigorous mixing / homogenization. Subsequently, sodium hydroxide (1M solution) was added dropwise with stirring until a pH of 6-7 was achieved and the solution formed a gel.

[0448] 1% propranolol cream is prepared by the following procedure.

[0449] 1. Combine cetyl alcohol, stearyl alcohol, polysorbate 60 and isopropyl myristate in a suitable container and heat to 65-70 degrees Celsius while mixing.

[0450] 2. Then add propylparaben to the mixture and mix to ensure complete dissolution, while maintaining a temperature of 65-70 degrees Celsius.

[0451] 3. Add carbitol P to a separate container and heat to 60-65 degrees Celsius. Add propranolol hydrochloride and mix until dissolved to form a slurry.

[0452] 4. Then combine it with the molten organic mixture from step 2 at 60-75 degrees Celsius.

[0453] 5. Using a mixer, add purified water to the heated container. Stir and heat to 65-70 degrees Celsius. Add EDTA and mix until dissolved. Add methylparaben and mix until dissolved. Maintain the temperature at 65-70 degrees Celsius.

[0454] 6. Combine the aqueous and organic phases and homogenize them using a high-shear homogenizer for 30 minutes while maintaining the temperature at 65-70 degrees Celsius. Preferably, this is done under vacuum.

[0455] 7. Adjust the pH to 5-5.6 with 1M sodium hydroxide, measure at 25 degrees Celsius, and then homogenize for 5 minutes between each addition.

[0456] 8. Transfer the final solution to a suitable container for storage. The mixture will thicken over time to form a semi-solid cream consistency.

[0457] The permeation of propranolol across membranes in an in vitro skin model was evaluated. 2-mL volumes of an appropriate load (cream versus emulsion / gel) were placed in the donor chamber of a Franz diffusion cell, and the concentration of propranolol in the receiver chamber was determined by UV-Vis spectroscopy at frequent time intervals over 60 hours. The permeation rate of propranolol from the emulsion / gel load was greater than that from the cream load. Figure 40 B and C) demonstrate that the emulsion gel support promotes the absorption of β-blockers to a greater and faster extent. A 1% propranolol emulsion gel was also compared to an emulsion gel containing a 1% concentration of the ACE inhibitor lisinopril. Similar drug flux rates were evident from both the propranolol and lisinopril samples. However, the penetration of the β-blocker was significantly faster than that of the ACE inhibitor, showing a smaller lag time (…). Figure 40 D).

[0458] In summary, the permeation of the beta-blocker propranolol across the skin membrane was investigated, demonstrating that propranolol can be rapidly absorbed through the skin when formulated as emulsions, gels, and creams, suitable for topical application. Furthermore, these results demonstrate that beta-blockers are surprisingly absorbed faster than ACE inhibitors. Therefore, topical fixed-dose compositions of ACE inhibitors and beta-blockers will require a larger proportion of ACE inhibitor relative to the beta-blocker in their manufacture to achieve similar absorption rates. These results provide crucial insights into the formulation of fixed-dose combination products containing ACE inhibitors and beta-blockers for the treatment of hemangiomas.

[0459] Table 10: Exemplary formulations of creams and lotions-gels containing propranolol for external application.

[0460]

[0461] Example 14: Fixed-dose topical combination cream.

[0462] This embodiment relates to a formulation of a topical, fixed-dose combination product comprising an ACE inhibitor and a beta-blocker for the treatment of hemangiomas. The described formulations are for illustrative purposes only and are not intended to limit the scope of the invention in any way. These formulations have been found to have good stability.

[0463] Exemplary fixed-dose topical formulations can be manufactured via the following procedures.

[0464] 1. Combine cetyl alcohol, stearyl alcohol, polysorbate 60 and isopropyl myristate in a suitable container and heat to 65-70 degrees Celsius while mixing.

[0465] 2. Add propylparaben to the mixture and mix to ensure complete dissolution, while maintaining a temperature of 65-70 degrees Celsius.

[0466] 3. Add carbitol P to a separate container and heat to 60-65 degrees Celsius. Add an appropriate amount of β-blocker and / or ACE inhibitor and mix until dissolved to form a slurry.

[0467] 4. Combine the slurry with the molten organic mixture from step 2 at 60-75 degrees Celsius.

[0468] 5. Using a mixer, add purified water to the heated container. Stir and heat to 65-70 degrees Celsius. Add EDTA and mix until dissolved. Add methylparaben and mix until dissolved. Maintain the temperature at 65-70 degrees Celsius.

[0469] 6. Combine the aqueous and organic phases and homogenize them using a high-shear homogenizer for 30 minutes while maintaining the temperature at 65-70 degrees Celsius. Preferably, this is done under vacuum.

[0470] 7. Adjust the pH to 5-5.6 or 6-7 with 1M sodium hydroxide, measure at 25 degrees Celsius, and then homogenize for 5 minutes between each addition.

[0471] 8. Transfer the final solution to a suitable container for storage. The mixture will thicken over time to form a semi-solid cream consistency.

[0472] Table 11: Examples of fixed-dose β-blockers and ACE inhibitor formulations for topical application.

[0473]

[0474]

[0475] All disclosures of all applications, patents, and publications cited above and below (if any) are incorporated herein by reference. However, any reference to any application, patent, or publication in this specification is not to be construed as, and should not be construed as, an admission or in any way an implication that it constitutes valid prior art or forms part of common general knowledge in any country of the world.

[0476] Throughout this specification and any subsequent claims, unless the context otherwise requires, the words “comprise”, “comprising”, etc., shall be interpreted in a sense of inclusion, meaning “including but not limited to”, contrary to the sense of exclusivity.

[0477] This document provides names, titles, etc. to enhance the reader's understanding of the document, and should not be construed as limiting the scope of the invention.

Claims

1. Use of a prodrug ACEi in the manufacture of a medicament for the topical treatment of hemangiomas, wherein the medicament is formulated to be suitable for the topical delivery of the prodrug ACEi to a human subject, and wherein the prodrug ACEi is selected from the group consisting of cilazapril, ramipril, trandolapril, enalapril, quinapril, and fosinopril.

2. Use according to claim 1, wherein, The medicament includes a beta-blocker.

3. Use according to claim 1 or 2, wherein, The prodrug ACEi is selected to be fosinopril.

4. The use according to claim 2, wherein, The beta-blocker is a non-selective beta-blocker.

5. The use according to claim 2, wherein, The beta-blocker is R-propranolol or R / S-propranolol.

6. The use according to claim 2, wherein, The prodrug ACEi is selected to be fosinopril and the beta-blocker is a non-selective beta-blocker.

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