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Chemotherapy (often abbreviated to chemo) is the treatment of cancer with one or more cytotoxic antineoplastic drugs ("chemotherapeutic agents") as part of a standardized regimen. Chemotherapy may be given with a curative intent or it may aim to prolong life or to palliate symptoms. It is often used in conjunction with other cancer treatments, such as radiation therapy or surgery. Certain chemotherapeutic agents also have a role in the treatment of other conditions, including ankylosing spondylitis, multiple sclerosis, Crohn's disease, psoriasis, psoriatic arthritis, systemic lupus erythematosus, rheumatoid arthritis, and scleroderma.

Traditional chemotherapeutic agents act by killing cells that divide rapidly, one of the main properties of most cancer cells. This means that chemotherapy also harms cells that divide rapidly under normal circumstances: cells in the bone marrow, digestive tract, and hair follicles. This results in the most common side-effects of chemotherapy: myelosuppression (decreased production of blood cells, hence also immunosuppression), mucositis (inflammation of the lining of the digestive tract), and alopecia (hair loss).

Some newer anticancer drugs (for example, various monoclonal antibodies) are not indiscriminately cytotoxic, but rather target proteins that are abnormally expressed in cancer cells and that are essential for their growth. Such treatments are often referred to as targeted therapy (as distinct from classic chemotherapy) and are often used alongside traditional chemotherapeutic agents in antineoplastic treatment regimens.

An older and broader usage of the word chemotherapy encompassed any chemical treatment of disease (for example, treatment of infections with antimicrobial agents). However, this usage has become archaic.

History

The first use of drugs to treat cancer was in the early 20th century, although it was not originally intended for that purpose. Mustard gas was used as a chemical warfare agent during World War I and was discovered to be a potent suppressor of hematopoiesis (blood production).^[1] A similar family of compounds known as nitrogen mustards were studied further during World War II at Yale University.^[2] It was reasoned that an agent that damaged the rapidly growing white blood cells might have a similar effect on cancer. Therefore, in December 1942, several patients with advanced lymphomas (cancers of certain white blood cells) were given the drug by vein, rather than by breathing the irritating gas.^[2] Their improvement, although temporary, was remarkable.^[3]^[4]Concurrently, during a military operation in World War II, following a German air raid on the Italian harbour of Bari, several hundred people were accidentally exposed to mustard gas, which had been transported there by the Allied forces to prepare for possible retaliation in the event of German use of chemical warfare. The survivors were later found to have very low white blood cell counts.^[5]^[6] After WWII was over and the reports declassified, the experiences converged and led researchers to look for other substances that might have similar effects against cancer. The first chemotherapy drug to be developed from this line of research was mustine. Since then, many other drugs have been developed to treat cancer, and drug development has exploded into a multibillion-dollar industry, although the principles and limitations of chemotherapy discovered by the early researchers still apply.^[7]

The term chemotherapy

The word "chemotherapy" without a modifier usually refers to cancer treatment, but its historical meaning is broader. The term was historically used for non-oncological references, such as the use of antibiotics (antibacterial chemotherapy). The first modern chemotherapeutic agent was arsphenamine, an arsenic compound discovered in 1909 and used to treat syphilis.^[8] This was later followed by sulfonamides (sulfa drugs) and penicillin. Other uses that have been termed chemotherapy are the treatment of autoimmune diseases such as multiple sclerosis, dermatomyositis, polymyositis, lupus, and rheumatoid arthritis.^{[citation needed]}

General mode of action in cancer

Cancer is the uncontrolled growth of cells coupled with malignant behaviour: invasion and metastasis (among other features).^[9] It is caused by the interaction between genetic susceptibility and environmental factors.^[10]^[11] These factors lead to accumulations of genetic mutations in oncogenes (genes that promote cancer) and tumor supressor genes (genes that help to prevent cancer), which gives cancer cells their malignant characteristics, such as uncontrolled growth.^[12]

In the broad sense, most chemotherapeutic drugs work by impairing mitosis (cell division), effectively targeting fast-dividing cells. As these drugs cause damage to cells, they are termed cytotoxic. They prevent mitosis by various mechanisms including damaging DNA and inhibition of the cellular machinary involved in cell division.^[13]^[14] One theory as to why these drugs kill cancer cells is that they induce a programmed form of cell death known as apoptosis.^[15]

As chemotherapy affects cell division, tumors with high growth rates (such as acute myelogenous leukemia and the aggressive lymphomas, including Hodgkin's disease) are more sensitive to chemotherapy, as a larger proportion of the targeted cells are undergoing cell division at any time. Malignancies with slower growth rates, such as indolent lymphomas, tend to respond to chemotherapy much more modestly.^[16]

Types

Alkylating agents

Alkylating agents are the oldest group of chemotherapeutics in use today. Originally derived from mustard gas used in the war, there are now many types of alkylating agents in use.^[16] They are so named because of their ability to alkylate many molecules, including proteins, RNA and DNA. This ability to bind covalently to DNA via their alkyl group is the primary cause for their anti-cancer effects.^[18] DNA is made of two strands and the molecules may either bind twice to one strand of DNA (intrastrand crosslink) or may bind once to both strands (interstrand crosslink). If the cell tries to replicate crosslinked DNA during cell division, or tries to repair it, the DNA strands can break. This leads to a form of programmed cell death called apoptosis.^[19]^[17] Alkylating agents will work at any point in the cell cycle and thus are known as cell cycle-independent drugs. For this reason the effect on the cell is dose dependent; the fraction of cells that die is directly proportional to the dose of drug.^[14]

The subtypes of alkylating agents are the nitrogen mustards, nitrosoureas, tetrazines, aziridines, cisplatins and derivatives, and non-classical alkylating agents. Nitrogen mustards include mechlorethamine, cyclophosphamide, melphalan, chlorambucil, ifosfamide and busulfan. Nitrosoureas include N-Nitroso-N-methylurea (MNU), carmustine (BCNU), lomustine (CCNU) and semustine (MeCCNU), fotemustine and streptozotocin. Tetrazines include dacarbazine, mitozolomide and temozolomide. Aziridines include thiotepa, mytomycin and diaziquone (AZQ). Cisplatin and derivatives include cisplatin, carboplatin and oxaliplatin.^[19]^[18] They impair cell function by forming covalent bonds with the amino, carboxyl, sulfhydryl, and phosphate groups in biologically important molecules.^[20] Non-classical alkylating agents include procarbazine and hexamethylmelamine.^[19]^[18]

Anti-metabolites

Anti-metabolites are a group of molecules that impede DNA and RNA synthesis. Many of them have a similar structure to the building blocks of DNA and RNA. The building blocks are nucleotides; a molecule comprising a nucleobase, a sugar and a phosphate group. The nucleobases are divided into purines (guanine and adenine) and pyrimidines (cytosine, thymine and uracil). Anti-metabolites resemble either nucleobases or nucleosides (a nucleotide without the phosphate group), but have altered chemical groups.^[21] These drugs exert their effect by either blocking the enzymes required for DNA synthesis or becoming incorperated into DNA or RNA. By inhibiting the enzymes involved in DNA sythesis, they prevent mitosis because the DNA cannot duplicate itself. Also, after misincorperation of the molecules into DNA, DNA damage can occur and programmed cell death (apoptosis) is induced. Unlike alkylating agents, anti-metabolites are cell cycle dependent. This means that they only work during a specific part of the cell cycle, in this case S-phase (the DNA synthesis phase). For this reason, at a certain dose, the effect plateaus and proportionally no more cell death occurs with increased doses. Subtypes of the anti-metabolites are the anti-folates, fluoropyrimidines, deoxynucleoside analogues and thiopurines,.^[21]^[18]

The anti-foaltes include methotrexate and pemetrexed. Methotrexate inhibits dihydrofolate reductase (DHFR), an enzyme that regenerates tetrahydrofolate from dihydrofolate. When the enzyme is inhibited by methotrexate, the cellular levels of folate coenzymes diminish. These are required for thymidylate and purine production, which are both essential for DNA synthesis and cell division.^[22]^[23] Pemetrexed is another anti-metabolite that affects purine and pyrimidine production, and therefore also inhibits DNA synthesis. It primarily inhibits the enzyme thymidylate synthase, but also has effects on DHFR, aminoimidazole carboxamide ribonucleotide formyltransferase and glycinamide ribonucleotide formyltransferase.^[24] The fluoropyrimidines include fluorouracil and capecitabine. Fluorouracil is a nucleobase analogue that is metabolised in cells to form at least two active products; 5-fluourouridine monophosphate (FUMP) and 5-fluoro-2'-deoxyuridine 5'-phosphate (fdUMP). FUMP becomes incorperated into RNA and fdUMP inhibits the enzyme thymidylate synthase; both of which lead to cell death.^[22] Capecitabine is a prodrug of 5-fluorouracil that is broken down in cells to produce the active drug.^[25] The deoxynucleoside analogues include cytarabine, gemcitabine, decitabine, Vidaza, fludarabine, nelarabine, cladribine, clofarabine and pentostatin. The thiopurines include thioguanine and mercaptopurine.^[21]^[18]

Anti-microtubule agents

Anti-microtubule agents are plant-derived chemicals that block cell division by preventing microtubule function. Microtubules are an important cellular structure composed of two proteins; α-tubulin and β-tubulin. They are hollow rod shaped structures that are required for cell division, among other cellular functions.^[26] Microtubules are dynamic structures, which means that they are permanently in a state of assembly and disassembly. Vinca alkaloids and taxanes are the two main groups of anti-microtubule agents, and although both of these groups of drugs cause microtubule disfunction, their mechanisms of action are completely opposite. The vinca alkaloids prevent the formation of the microtubules, whereas the taxanes prevent the microtubule disassembly. By doing so, they prevent the cancer cells from completing mitosis. Following this, cell cycle arrest occurs, which induces programed cell death (apoptosis).^[18]^[27] Also, these drugs can affect blood vessel growth; an essential process that tumours utilise in order to grow and metastasise.^[27]

Vinca alkaloids are derived from the Madagascar periwinkle, Catharanthus roseus (formerly known as Vinca rosea). They bind to specific sites on tubulin, inhibiting the assembly of tubulin into microtubules. The original vinca alkaloids are completely natural chemicals, which include; vincristine and vinblastine. Following the success of these drugs, semi-synthetic vinca alkaloids were produced; vinorelbine, vindesine and vinflunine.^[27] These drugs are cell cycle specific. They bind to the tubulin molecules in S-phase and provent proper microtubule formation required for M-phase.^[14]

Taxanes are natural and semi-synthetic drugs. The first drug of their class, paclitaxel, was originally extracted from the Pacific Yew tree, Taxus brevifolia. Now this drug and another in this class, docetaxel, are produced semi-synthetically from a chemical found in the bark of another Yew tree; Taxus baccata. These drugs promote microtubule stability, preventing their disassembly. Paclitaxel prevents the cell cycle at the boundary of G2-M, whereas docetaxel exerts its effect during S-phase. Taxanes present difficulties in formulation as medicines because they are poorly soluble in water.^[27]

Podophyllotoxin is an anti-neoplastic lignan primarily obtained from the American Mayapple (Podophyllum peltatum) and Himalayan Mayapple (Podophyllum hexandrum or Podophyllum emodi). It has anti-microtubule activity, and its mechanism is similar to that of vinca alkaloids in that they bind to tubulin, inhibiting microtubule formation. Podophyllotoxin is used to produce two other drugs with different mechanisms of action; etoposide and teniposide.^[28]^[29]

Topoisomerase inhibitors

Topoisomerase inhibitors are drugs that affect the activity of two enzymes; topoisomerase I and topoisomerase II. When the DNA double stranded helix is unwound, during DNA replication or translation for example, the adjacent unopened DNA winds tighter (supercoils), like opening the middle of a twisted rope. The stress caused by this effect is in part aided by the topoisomerase enzymes. They produce single or double strand breaks into DNA, reducing the tension in the DNA strand. This allows the normal unwinding of DNA to occur during replication or translation. Inhibition of topoisomerase I or II interferes with both of these processes.^[30]^[31]

Two topoisomerase I inhibitors, irinotecan and topotecan, are semi-synthetically derived from camptothecin, which is obtained from the Chinese ornamental tree Camptotheca acuminata.^[14] Drugs that target topoisomerase II can be divided into two groups. The topoisomerase II poisons cause increased levels enzymes bound to DNA. This prevents DNA replication and translation, causes DNA strand breaks, and leads to programmed cell death (apoptosis). These agents include etoposide, doxorubicin, mitoxantrone and teniposide. The second group, catalytic inhibitors, are drugs that block the activity of topoisomerase II, and therefore prevent DNA synthesis and translation because the DNA cannot unwind properly. This group includes novobiocin, merbarone, and aclarubicin, which also have other significant mechanisms of action.^[32]

Cytotoxic antibiotics

The cytotoxic antibiotics are a varied group of drugs that have various mechanisms of action. The group includes the anthracyclines and other drugs including actinomycin, bleomycin, plicamycin and mitomycin. Doxorubicin and daunorubicin were the first two anthracyclines, and were obtained from the bacterium Streptomyces peucetius. Derivitives of these compounds include epirubicin and idarubicin. Other clinically used drugs in the anthracyline group are pirarubicin, aclarubicin and mitoxantrone. The mechanisms of anthracyclines include DNA intercalation (molecules insert between the two strands of DNA), generation of highly reactive free radicals that damage intercellular molecules and topoisomerase inhibition.^[33] Actinomycin is a complex molecule that intercalates DNA and prevents RNA synthesis.^[34] Bleomycin, a glycopeptide isolated from Streptomyces verticillus, also intercalates DNA, but produces free radicals that damage DNA. This occurs when bleomycin binds to a metal ion, becomes chemically reduced and reacts with oxygen.^[35]^[36] Mitomycin is a cytotoxic antibiotic with the ability to alkylate DNA.^[37]

Treatment strategies

Common combination chemotherapy regimens^[16]
Cancer type	Drugs	Acronym
Breast cancer	Cyclophosphamide, methotrexate, 5-fluorouracil	CMF
Breast cancer	Doxorubicin, cyclophosphamide	AC
Hodgkin's disease	Mustine, vincristine, procarbazine, prednisolone	MOPP
Hodgkin's disease	Doxorubicin, bleomycin, vinblastine, dacarbazine	ABVD
Non-Hodgkin's lymphoma	Cyclophosphamide, doxorubicin, vincristine, prednisolone	CHOP
Germ cell tumor	Bleomycin, etoposide, cisplatin	BEP
Stomach cancer	Epirubicin, cisplatin, 5-fluorouracil	ECF
Stomach cancer	Epirubicin, cisplatin, capecitabine	ECX
Bladder cancer	Methotrexate, vincristine, doxorubicin, cisplatin	MVAC
Lung cancer	Cyclophosphamide, doxorubicin, vincristine,	CAV
Colorectal cancer	5-fluorouracil, folinic acid, oxaliplatin	FOLFOX

There are a number of strategies in the administration of chemotherapeutic drugs used today. Chemotherapy may be given with a curative intent or it may aim to prolong life or to palliate symptoms.

Combined modality chemotherapy is the use of drugs with other cancer treatments, such as radiation therapy or surgery.
Induction chemotherapy is the first line treatment of cancer with a chemotherapeutic drug. This type of chemotherapy is used for curative intent.^[23]
Consololidation chemotherapy is the given after remission in order to prolong the overall disease free time and improve overall survival. The drug that is administered is the same as the drug that achieved remission.^[23]
Intensification chemotherapy is identical to consolidation chemotherapy but a different drug than the induction chemotherapy is used.^[23]
Combination chemotherapy involves treating a patient with a number of different drugs simultaneously. The drugs differ in their mechanism and side effects. The biggest advantage is minimising the chances of resistance developing to any one agent. Also, the drugs can often be used at lower doses, reducing toxicity.^[22]^[23]
Neoadjuvant chemotherapy is given prior to a local treatment such as surgery, and is designed to shrink the primary tumor.^[23] It is also given to cancers with a high risk of micrometastatic disease.^[38]
Adjuvant chemotherapy is given after a local treatment (radiotherapy or surgery). It can be used when there is little evidence of cancer present, but there is risk of recurrence.^[23] It is also useful in killing any cancerous cells that have spread to other parts of the body. These micrometastases can be treated with adjuvant chemotherapy and can reduce relapse rates caused by these disseminated cells.^[39]
Maintenance chemotherapy is a repeated low-dose treatment to prolong remission.^[23]
Salvage chemotherapy or palliative chemotherapy is given without curative intent, but simply to decrease tumor load and increase life expectancy. For these regimens, a better toxicity profile is generally expected.^[23]

All chemotherapy regimens require that the patient be capable of undergoing the treatment. Performance status is often used as a measure to determine whether a patient can receive chemotherapy, or whether dose reduction is required. Because only a fraction of the cells in a tumor die with each treatment (fractional kill), repeated doses must be administered to continue to reduce the size of the tumor.^[40] Current chemotherapy regimens apply drug treatment in cycles, with the frequency and duration of treatments limited by toxicity to the patient.^[41]

Dosage

Dosage of chemotherapy can be difficult: If the dose is too low, it will be ineffective against the tumor, whereas, at excessive doses, the toxicity (side-effects) will be intolerable to the patient.^[16] This has led to the formation of detailed "dosing schemes" in most hospitals, which give guidance on the correct dose and adjustment in case of toxicity.^{[citation needed]} In immunotherapy (treatment of autoimmune disorders), they are in principle used in smaller dosages than in the treatment of malignant diseases.^[42]

The standard method of calculating dosage is based on calculated body surface area (BSA), a measure that correlates with blood volume. The BSA is usually calculated with a mathematical formula or a nomogram, using a patient's weight and height, rather than by direct measurement. This method was originally used in the 1960's to calculate a uniform dose to patients in clinical trials. Recently, the validity of this method in calculating uniform doses has been questioned. The reason for this is that the formula only takes into account the individual's weight or height. Other factors, such as drug clearance, have major effects on the actual dose to an individual on chemotherapy, which can lead to sub-optimal dosing.^[43]^[44]^[45] Also, calculating the BSA for obese patients could provide a dose that is too high (overdosing), and therefore most chemotherapy drugs are dose-capped (an upper limit of dose).^[46]

Carboplatin is one of the only drugs that is not dosed depending on the BSA method. Another method, area under the curve (AUC), is employed to individualise the dosing. In this method, the drug levels in the blood plasma are measured over time. The area under this curve is used in conjunction with the renal function of the individual receiving chemotherapy to obtain the optimal dose.^[46]

Delivery

Most chemotherapy is delivered intravenously, although a number of agents can be administered orally (e.g., melphalan, busulfan, capecitabine).

There are many intravenous methods of drug delivery, known as vascular access devices. These include the winged infusion device, peripheral cannula, midline catheter, peripherally inserted central catheter (PICC), central venous catheter and implantable port. The devices have different applications regarding duration of chemotherapy treatment, method of delivery and types of chemotherapeutic agent.^[47]

Depending on the patient, the cancer, the stage of cancer, the type of chemotherapy, and the dosage, intravenous chemotherapy may be given on either an inpatient or an outpatient basis. For continuous, frequent or prolonged intravenous chemotherapy administration, various systems may be surgically inserted into the vasculature to maintain access.^[48] Commonly used systems are the Hickman line, the Port-a-Cath, and the PICC line. These have a lower infection risk, are much less prone to phlebitis or extravasation, and eliminate the need for repeated insertion of peripheral cannulae.^{[citation needed]}

Isolated limb perfusion (often used in melanoma),^[49] or isolated infusion of chemotherapy into the liver^[50] or the lung have been used to treat some tumors. The main purpose of these approaches is to deliver a very high dose of chemotherapy to tumor sites without causing overwhelming systemic damage.^[51] These approaches can help control solitary or limited metastases, but they are by definition not systemic, and, therefore, do not treat distributed metastases or micrometastases.

If the cancer has central nervous system involvement, or with meningeal disease, intrathecal chemotherapy may be administered.^[16]

Adverse effects

Chemotherapeutic techniques have a range of side-effects that depend on the type of medications used. The most common medications affect mainly the fast-dividing cells of the body, such as blood cells and the cells lining the mouth, stomach, and intestines. Chemotherapy related toxicities can occur acutely after administration, within hours or days, or chronically, from weeks to years.^[52] Common side-effects include:^[53]

Tendency to bleed easily. Medications that kill rapidly dividing cells or blood cells are likely to reduce the number of platelets in the blood, which can result in bruises and bleeding. Extremely low platelet counts may be temporarily boosted through platelet transfusions. Sometimes, chemotherapy treatments are postponed to allow platelet counts to recover.
Gastrointestinal distress. Nausea and vomiting are common side-effects of chemotherapeutic medications that kill fast-dividing cells. This can also produce diarrhea or constipation. Malnutrition and dehydration can result when the patient does not eat or drink enough, or when the patient vomits frequently, because of gastrointestinal damage. This can result in rapid weight loss, or occasionally in weight gain, if the patient eats too much in an effort to allay nausea or heartburn. Weight gain can also be caused by some steroid medications. These side-effects can frequently be reduced or eliminated with antiemetic drugs. Self-care measures, such as eating frequent small meals and drinking clear liquids or ginger tea, are often recommended. This is generally a temporary effect, and frequently resolves within a week of finishing treatment. However a high index of suspicion is appropriate, since diarrhea and bloating are also symptoms oftyphlitis, a very serious and potentially life-threatening medical emergency which requires immediate treatment.
Hair loss. Some medications that kill rapidly dividing cells cause dramatic hair loss; other medications may cause hair to thin. These are most often temporary effects: hair usually starts to regrow a few weeks after the last treatment, sometimes with a tendency to curl, resulting in "chemo curls." Permanent hair loss can result from some standard chemotherapy regimens. Scalp cooling offers a means of preventing both permanent and temporary hair loss.

Damage to specific organs is possible:

Cardiotoxicity (heart damage)
Hepatotoxicity (liver damage)
Nephrotoxicity (kidney damage)
Ototoxicity (damage to the inner ear), producing vertigo
Encephalopathy (brain dysfunction)

Immunosuppression and myelosuppression

Virtually all chemotherapeutic regimens can cause depression of the immune system, often by paralysing the bone marrow and leading to a decrease of white blood cells, red blood cells, and platelets. Anemia and thrombocytopenia, when they occur, are improved with blood transfusion. Neutropenia (a decrease of the neutrophil granulocyte count below 0.5 x 10⁹/litre) can be improved with synthetic G-CSF (granulocyte-colony-stimulating factor, e.g., filgrastim, lenograstim).

In very severe myelosuppression, which occurs in some regimens, almost all the bone marrow stem cells (cells that produce white and red blood cells) are destroyed, meaning allogenic or autologous bone marrow cell transplants are necessary. (In autologous BMTs, cells are removed from the patient before the treatment, multiplied and then re-injected afterward; in allogenic BMTs, the source is a donor.) However, some patients still develop diseases because of this interference with bone marrow.

Although patients are encouraged to wash their hands, avoid sick people, and take other infection-reducing steps, about 85% of infections are due to naturally occurring microorganisms in the patient's own gastrointestinal tract(including oral cavity) and skin.^[54] This may manifest as systemic infections, such as sepsis, or as localized outbreaks, such as Herpes simplex,shingles, or other members of the Herpesviridea.^[55]Sometimes, chemotherapy treatments are postponed because the immune system is suppressed to a critically low level.

In Japan, the government has approved the use of some medicinal mushrooms like Trametes versicolor, to counteract depression of the immune system in patients undergoing chemotherapy.^[56]

Typhlitis

Due to immune system suppression, typhlitis is a "life-threatening gastrointestinal complication of chemotherapy."^[57] Typhlitis is an intestinal infection which may manifest itself through symptoms including nausea, vomiting, diarrhea, a distended abdomen, fever, chills, or abdominal pain and tenderness.

Typhlitis is a medical emergency. It has a very poor prognosis and is often fatal unless promptly recognized and aggressively treated.^[58] Successful treatment hinges on early diagnosis provided by a high index of suspicion and the use of CT scanning, nonoperative treatment for uncomplicated cases, and sometimes elective right hemicolectomy to prevent recurrence.^[58]

Fatigue

Fatigue may be a consequence of the cancer or its treatment, and can last for months to years after treatment. One physiological cause of fatigue is anemia, which can be caused by chemotherapy, surgery, radiotherapy, primary and metastatic disease and/or nutritional depletion.^[59]^[60] Anaerobic exercise has been found to be beneficial in reducing fatigue in people with solid tumours.^[61] Treatments to mitigate anemia include hormones to boost blood production (erythropoietin), iron supplements, and blood transfusions.^[62]^[63]

Chemotherapy-induced nausea and vomiting (CINV)

Nausea and vomiting are two of the most feared cancer treatment-related side-effects for cancer patients and their families. In 1983, Coates et al. found that patients receiving chemotherapy ranked nausea and vomiting as the first- and second-most-severe side-effects, respectively. Up to 20% of patients receiving highly emetogenic agents in this era postponed, or even refused, potentially curative treatments.^[64] Chemotherapy-induced nausea and vomiting (CINV) are common with many treatments and some forms of cancer. Since the 1990s, several novel classes of antiemetics have been developed and commercialized, becoming a nearly universal standard in chemotherapy regimens, and helping to successfully manage these symptoms in a large portion of patients. Effective mediation of these unpleasant and sometimes-crippling symptoms results in increased quality of life for the patient and more efficient treatment cycles, due to less stoppage of treatment due to better tolerance by the patient, and due to better overall health of the patient.

Secondary neoplasm

Development of secondary neoplasia after successful chemotherapy and/or radiotherapy treatment can occur. The most common secondary neoplasm is secondary acute myeloid leukemia, which develops primarily after treatment with alkylating agents or topoisomerase inhibitors.^[65] Survivors of childhood cancer are more than 13 times as likely to get a secondary neoplasm during the 30 years after treatment than the general population.^[66] Not all of this increase can be attributed to chemotherapy.

Infertility

Some types of chemotherapy are gonadotoxic and may cause infertility.^[67] Chemotherapies with high risk include procarbazine and other alkylating drugs such as cyclophosphamide, ifosfamide, busulfan, melphalan, chlorambucil, and chlormethine.^[67] Drugs with medium risk include doxorubicin and platinum analogs such as cisplatin and carboplatin.^[67] On the other hand, therapies with low risk of gonadotoxicity include plant derivatives such as vincristine and vinblastine, antibiotics such as bleomycin and dactinomycin, and antimetabolites such as methotrexate, mercaptopurine, and 5-fluorouracil.^[67]

Female infertility by chemotherapy appears to be secondary to premature ovarian failure by loss of primordial follicles.^[68] This loss is not necessarily a direct effect of the chemotherapeutic agents, but could be due to an increased rate of growth initiation to replace damaged developing follicles.^[68]

Patients may choose between several methods of fertility preservation prior to chemotherapy, including cryopreservation of semen, ovarian tissue, oocytes, or embryos.^[69] As more than half of cancer patients are elderly, this adverse effect is only relevant for a minority of patients.

Teratogenicity

Chemotherapy is potentially teratogenic during pregnancy, especially during the first trimester, to the extent that abortion usually is recommended if pregnancy in this period is found during chemotherapy.^[70]Second- and third-trimester exposure does not usually increase the teratogenic risk and adverse effects on cognitive development, but it may increase the risk of various complications of pregnancy and fetal myelosuppression.^[70]

In males previously having undergone chemotherapy or radiotherapy, there appears to be no increase in genetic defects or congenital malformations in their children conceived after therapy.^[70] The use of assisted reproductive technologies and micromanipulation techniques might increase this risk.^[70] In females previously having undergone chemotherapy, miscarriage and congenital malformations are not increased in subsequent conceptions.^[70] However, when in vitro fertilization and embryo cryopreservationis practised between or shortly after treatment, possible genetic risks to the growing oocytes exist, and hence it has been recommended that the babies be screened.^[70]

Neurological adverse effects

Reported are cytotoxic-induced neuropathy causing pain^[71] or paralysis. Some patients report fatigue or non-specific neurocognitive problems, such as an inability to concentrate; this is sometimes called post-chemotherapy cognitive impairment, referred to as "chemo brain" by patients' groups.^[72]

Tumor lysis syndrome

In particularly large tumors and cancers with high white cell counts, such as lymphomas, teratomas, and some leukemias, some patients develop tumor lysis syndrome. The rapid breakdown of cancer cells causes the release of chemicals from the inside of the cells. Following this, high levels of uric acid, potassium, phosphate and calcium are found in the blood. This causes kidney damage and the high levels of potassium can cause cardiac arrythmia. Although prophylaxis is available and is often initiated in patients with large tumors, this is a dangerous side-effect that can lead to death if left untreated.^[73]

Other side effects

Less common side-effects include red skin (erythema), dry skin, damaged fingernails, a dry mouth (xerostomia),water retention, and sexual impotence. Some medications can trigger allergic orpseudoallergic reactions.

Specific chemotherapeutic agents are associated with organ-specific toxicities, including cardiovascular disease(e.g., doxorubicin), interstitial lung disease (e.g., bleomycin) and occasionally secondary neoplasm (e.g., MOPP therapy for Hodgkin's disease).

Limitations and resistance

Chemotherapy does not always work, and even when it is useful, it may not completely destroy the cancer. Patients frequently fail to understand its limitations. In one study of patients who had been newly diagnosed with incurable, stage 4 cancer, more than two-thirds of patients with lung cancer and more than four-fifths of patients with colorectal cancer still believed that chemotherapy was likely to cure their cancer.^[74]

The blood brain barrier poses a difficult obstacle to pass to deliver chemotherapy to the brain. This is because the brain has an extensive system in place to protect it from harmful chemicals. Drug transporters can pump out drugs from the brain and brain's blood vessel cells into the cerebrospinal fluid and blood circulation. These transporters pump out most chemotherapy drugs, which reduces their efficacy for treatment of brain tumors. Only small lipophilic alkylating agents such as temozolomide are able to cross this blood brain barrier.^[75]^[76]^[77]

Resistance is a major cause of treatment failure in chemotherapeutic drugs. There are a few possible causes of resistance in cancer, one of which is the presence of small pumps on the surface of cancer cells that actively move chemotherapy from inside the cell to the outside. Cancer cells produce high amounts of these pumps, known as p-glycoprotein, in order to protect themselves from chemotherapeutics. Research on p-glycoprotein and other such chemotherapy efflux pumps is currently ongoing. Medications to inhibit the function of p-glycoprotein are undergoing investigation, but due to toxicities and interactions with anti-cancer drugs their development has been difficult.^[78]^[79] Another mechanism of resistance is gene amplification, a process in which multiple copies of a gene are produced by cancer cells. This overcomes the effect of drugs that reduce the expression of genes involved in replication. With more copies of the gene, the drug can not prevent all expression of the gene and therefore the cell can restore its proliferative ability. Cancer cells can also cause defects in the cellular pathways of apoptosis (programmed cell death). As most chemotherapy drugs kill cancer cells in this manner, defective apoptosis allows survival of these cells, making them resistant. Many chemotherapy drugs also cause DNA damage, which can be repaired by enzymes in the cell that carry out DNA repair. Upregulation of these genes can overcome the DNA damage and prevent the induction of apoptosis. Mutations in genes that produce drug target proteins, such as tubulin, can occur which prevent the drugs from binding to the protein, leading to resistance to these types of drugs.^[80]

Cytotoxics and targeted therapies

Targeted therapies are a relatively new class of cancer drugs that can overcome many of the issues seen with the use of cytotoxics. They are divided into two groups: small molecule and antibodies. The massive toxicity seen with the use of cytotoxics is due to the lack of cell specificity of the drugs. They will kill any rapidly dividing cell, tumor or normal. Targeted therapies are designed to affect cellular proteins or processes that are utilised by the cancer cells. This allows a high dose to cancer tissues with a relatively low dose to other tissues. As different proteins are utilised by different cancer types, the targeted therapy drugs are used on a cancer type specific, or even on a patient specific basis. Although the side effects are often less severe than that seen of cytotoxic chemotherapeutics, life-threatening effects can occur. Initially, the targeted therapeutics were supposed to be solely selective for one protein. Now it is clear that there is often a range of protein targets that the drug can bind. An example target for targeted therapy is the protein produced by the Philadelphia chromosome, a genetic lesion found commonly in chronic myelomonocytic leukemia. This fusion protein has enzyme activity that can be inhibited by imatinib, a small molecule drug.^[81]^[82]^[83]^[84]

Newer and experimental approaches

Targeted therapies

Specially targeted delivery vehicles aim to increase effective levels of chemotherapy for tumor cells while reducing effective levels for other cells. This should result in an increased tumor kill and/or reduced toxicity.^[85]

Antibody-drug conjugates

Antibody-drug conjugates (ADCs) comprise an antibody, drug and a linker between them. The antibody will be targeted at a preferentially expressed protein in the tumour cells (known as a tumor antigen) or on cells that the tumor can utilise, such as blood vessel endothelial cells. They bind to the tumor antigen and are internalised, where the linker releases the drug into the cell. These specially targeted delivery vehicles vary in their stability, selectivity, and choice of target, but, in essence, they all aim to increase the maximum effective dose that can be delivered to the tumor cells.^[86] Reduced systemic toxicity means that they can also be used in sicker patients, and that they can carry new chemotherapeutic agents that would have been far too toxic to deliver via traditional systemic approaches.^{[citation needed]}

The first approved drug of this type was gemtuzumab ozogamicin (Mylotarg), released by Wyeth (now Pfizer). The drug was approved to treat acute myeloid leukemia, but has now been withdrawn from the market because the drug did not meet efficacy targets in further clinical trials.^[87]^[88] Two other drugs, trastuzumab emtansine and brentuximab vedotin, are both in late clinical trials, and the latter has been granted accelerated aproval for the treatment of refractory Hodgkins lymphoma and systemic anaplastic large cell lymphoma.^[86]

Nanoparticles

Nanoparticles are 1-1000 nanometer (nm) sized particles that can promote tumor selectivity and aid in delivering low-solubility drugs. Nanoparticles can be targeted passively or actively. Passive targeting exploits the difference between tumor blood vessels and normal blood vessels. Blood vessels in tumors are "leaky" because they have gaps from 200-2000nm, which allow nanoparticles to escape into the tumor. Active targeting uses biological molecules (antibodies, proteins, DNA and receptor ligands) to preferentially target the nanoparticles to the tumor cells. There are many types of nanoparticle delivery systems, such as silica, polymers, liposomes and magnetic particles. Nanoparticles made of magnetic material can also be used to concentrate agents at tumor sites using an externally applied magnetic field.^[85] They have emerged as a useful vehicle for poorly soluble agents such as paclitaxel.^[89]

Electrochemotherapy

Electrochemotherapy has been successfully used for treatment of cutaneous and subcutaneous tumors irrespective of their histological origin.^[90]^[91]^[92]^[93]^[94]^[95]^[96] The method has been reported as safe, simple and highly effective in all reports on clinical use of electrochemotherapy. According to the ESOPE project (European Standard Operating Procedures of Electrochemotherapy), the Standard Operating Procedures (SOP) for electrochemotherapy were prepared, based on the experience of the leading European cancer centres on electrochemotherapy.^[92]^[97] Recently, new electrochemotherapy modalities have been developed for treatment of internal tumors using surgical procedures, endoscopic routes or percutaneous approaches to gain access to the treatment area.^[98]^[99]

Use in other diseases

Some chemotherapy drugs are used in diseases other than cancer. Methotrexate is used in the treatment of rheumtoid arthritis (RA). The anti-inflammatory response seen in RA is thought to be due to increases in adenosine, which causes immunosuppression; effects on immuno-regulatory cyclooxygenase-2 enzyme pathways; reduction in pro-inflammatory cytokines; and anti-proliferative properties.^[100] Cyclophosphamide is used to treat lupus nephritis.^[101]

Occupational precautions

Healthcare workers exposed to anti-neoplastic agents take precautions to keep their exposure to a minimum. There is a limitation in cytotoxics dissolution in Australia and the United States to 20 dissolutions per pharmacist/nurse,^{[citation needed]} since pharmacists that prepare these drugs or nurses that may prepare or administer them are the two occupational groups with the highest potential exposure to antineoplastic agents. In addition, physicians and operating room personnel may also be exposed through the treatment of patients. Hospital staff, such as shipping and receiving personnel, custodial workers, laundry workers, and waste handlers, all have potential exposure to these drugs during the course of their work. The increased use of antineoplastic agents in veterinary oncology also puts these workers at risk for exposure to these drugs.^[102] Routes of entry into the users body are skin absorption, inhalation and ingestion. The long term effects of exposure include chromosomal abnormalities and infertility.^[103]

In other animals

Chemotherapy is used in veterinary medicine similar to in human medicine.^[104]

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@@ Line 154: / Line 154: @@
 [[Chemotherapeutic]] techniques have a range of side-effects that depend on the type of medications used. The most common medications affect mainly the [[fast-dividing cells]] of the body, such as blood cells and the cells lining the mouth, stomach, and intestines. Chemotherapy related toxicities can occur acutely after administration, within hours or days, or chronically, from weeks to years.<ref name="isbn0-470-09254-8 2">{{cite book |author=Rachel Airley |title=Cancer chemotherapy |publisher=Wiley-Blackwell|location= |year=2009 |pages=265 |isbn=0-470-09254-8 |oclc= |doi= |accessdate=}}</ref> Common [[adverse effect|side-effects]] include:<ref>[http://www.cancer.org/docroot/MBC/content/MBC_2_2X_What_Are_Common_Side_Effects.asp?sitearea=MBC What are Common Side Effects?] from the [[American Cancer Society]]</ref>
-* Depression of the [[immune system]], which can result in potentially fatal [[infection]]s such as [[typhlitis]]. Although patients are encouraged to wash their hands, avoid sick people, and take other infection-reducing steps, about 85% of infections are due to naturally occurring microorganisms in the patient's own [[gastrointestinal tract]](including [[oral cavity]]) and skin.<ref name="internal_medicine_a05">{{Cite book  | last1 = Huang | first1 = Elbert S. | title = Internal medicine: handbook for clinicians, resident survival guide | year = 2000 | publisher = Scrub Hill Press | location = Arlington, VA  | isbn = 978-0-9645467-5-2 | page = 130}}</ref>  This may manifest as systemic infections, such as [[sepsis]], or as localized outbreaks, such as [[Herpes simplex]], [[shingles]], or other members of the [[human herpes virus|Herpesviridea]].<ref name="HSV">{{cite journal |author=Elad S, Zadik Y, Hewson I, ''et al.'' |title=A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea |journal=Support Care Cancer |volume=18 |issue=8 |pages=993–1006 |year=2010 |month=August|pmid=20544224 |url=http://www.springerlink.com/content/g476114717852h80/ |doi=10.1007/s00520-010-0900-3}}</ref>Sometimes, chemotherapy treatments are postponed because the immune system is suppressed to a critically low level.
-* [[Cancer-related fatigue|Fatigue]]. The treatment can be physically exhausting for the patient, who might already be very tired from cancer-related fatigue.  It may produce mild to severe [[anemia]].  Treatments to mitigate anemia include hormones to boost blood production ([[erythropoietin]]), [[iron supplement]]s, and [[blood transfusion]]s.
 * Tendency to bleed easily. Medications that kill rapidly dividing cells or blood cells are likely to reduce the number of [[platelet]]s in the blood, which can result in [[Hematoma|bruises]] and [[Hemorrhage|bleeding]]. Extremely low platelet counts may be temporarily boosted through [[platelet transfusion]]s. Sometimes, chemotherapy treatments are postponed to allow platelet counts to recover.
 * Gastrointestinal distress. [[Nausea]] and [[vomiting]] are common side-effects of chemotherapeutic medications that kill fast-dividing cells.  This can also produce [[diarrhea]] or [[constipation]]. [[Malnutrition]] and [[dehydration]] can result when the patient does not eat or drink enough, or when the patient vomits frequently, because of gastrointestinal damage.  This can result in rapid weight loss, or occasionally in weight gain, if the patient eats too much in an effort to allay nausea or heartburn. Weight gain can also be caused by some steroid medications.  These side-effects can frequently be reduced or eliminated with [[antiemetic]] drugs. Self-care measures, such as eating frequent small meals and drinking clear liquids or [[Ginger#Medicinal use|ginger]] tea, are often recommended.  This is generally a temporary effect, and frequently resolves within a week of finishing treatment. However a high [[index of suspicion]] is appropriate, since [[diarrhea]] and bloating are also symptoms of[[typhlitis]], a very serious and potentially life-threatening [[medical emergency]] which requires immediate treatment.
@@ Line 169: / Line 167: @@
 ===Immunosuppression and myelosuppression===
 Virtually all chemotherapeutic regimens can cause depression of the [[immune system]], often by paralysing the [[bone marrow]] and leading to a decrease of [[white blood cell]]s, [[red blood cell]]s, and [[platelet]]s.
-[[Anemia]] and [[thrombocytopenia]], when they occur, are improved with [[blood transfusion]]. [[Neutropenia]] (a decrease of the [[neutrophil granulocyte]] count below 0.5 x 10<sup>9</sup>/[[litre]]) can be improved with synthetic [[G-CSF]] ([[granulocyte]]-colony-stimulating factor, e.g., [[filgrastim]], [[lenograstim]].
+[[Anemia]] and [[thrombocytopenia]], when they occur, are improved with [[blood transfusion]]. [[Neutropenia]] (a decrease of the [[neutrophil granulocyte]] count below 0.5 x 10<sup>9</sup>/[[litre]]) can be improved with synthetic [[G-CSF]] ([[granulocyte]]-colony-stimulating factor, e.g., [[filgrastim]], [[lenograstim]]).
 In very severe [[myelosuppression]], which occurs in some regimens, almost all the bone marrow [[stem cell]]s (cells that produce [[white blood cells|white]] and [[red blood cell]]s) are destroyed, meaning ''allogenic'' or ''[[autologous]]'' [[bone marrow transplant|bone marrow cell transplants]] are necessary. (In autologous BMTs, cells are removed from the patient before the treatment, multiplied and then re-injected afterward; in ''allogenic'' BMTs, the source is a donor.) However, some patients still develop diseases because of this interference with bone marrow.
+Although patients are encouraged to wash their hands, avoid sick people, and take other infection-reducing steps, about 85% of infections are due to naturally occurring microorganisms in the patient's own [[gastrointestinal tract]](including [[oral cavity]]) and skin.<ref name="internal_medicine_a05">{{Cite book  | last1 = Huang | first1 = Elbert S. | title = Internal medicine: handbook for clinicians, resident survival guide | year = 2000 | publisher = Scrub Hill Press | location = Arlington, VA  | isbn = 978-0-9645467-5-2 | page = 130}}</ref>  This may manifest as systemic infections, such as [[sepsis]], or as localized outbreaks, such as [[Herpes simplex]],[[shingles]], or other members of the [[human herpes virus|Herpesviridea]].<ref name="HSV">{{cite journal |author=Elad S, Zadik Y, Hewson I, ''et al.'' |title=A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea |journal=Support Care Cancer |volume=18 |issue=8 |pages=993–1006 |year=2010 |month=August|pmid=20544224|url=http://www.springerlink.com/content/g476114717852h80/ |doi=10.1007/s00520-010-0900-3}}</ref>Sometimes, chemotherapy treatments are postponed because the immune system is suppressed to a critically low level.
 In [[Japan]], the government has approved the use of some [[medicinal mushrooms]] like ''[[Trametes versicolor]]'', to counteract depression of the immune system in patients undergoing chemotherapy.<ref name="psk">{{cite web|url=http://www.cancer.org/docroot/ETO/content/ETO_5_3X_Coriolous_Versicolor.asp |title=Coriolus Versicolor |publisher=Cancer.org|date=2008-06-10 |accessdate=2012-08-07}}</ref>
@@ Line 180: / Line 180: @@
 [[Typhlitis]] is a [[medical emergency]]. It has a very poor [[prognosis]] and is often fatal unless promptly recognized and aggressively treated.<ref name="Keidan 1989 206–9">{{cite journal|last=Keidan|first=RD|coauthors=Fanning, Gatenby, Weese|title=Recurrent typhlitis. A disease resulting from aggressive chemotherapy|journal=Dis Colon Rectum|year=1989|month=Mar|volume=32(3)|pages=206–9|pmid=2920627|accessdate=26 August 2012}}</ref> Successful treatment hinges on early diagnosis provided by a high index of suspicion and the use of CT scanning, nonoperative treatment for uncomplicated cases, and sometimes elective right [[hemicolectomy]] to prevent recurrence.<ref name="Keidan 1989 206–9"/>
+===Fatigue===
+[[Cancer-related fatigue|Fatigue]] may be a consequence of the cancer or its treatment, and can last for months to years after treatment. One physiological cause of fatigue is [[anemia]], which can be caused by chemotherapy, [[surgery]], [[radiotherapy]], primary and metastatic disease and/or nutritional depletion.<ref name="pmid20870636">{{cite journal |author=Berger AM, Abernethy AP, Atkinson A, ''et al.'' |title=Cancer-related fatigue |journal=J Natl Compr Canc Netw |volume=8 |issue=8 |pages=904–31 |year=2010 |month=August |pmid=20870636 |doi= |url=}}</ref><ref name="pmid16500197">{{cite journal |author=Franklin DJ, Packel L |title=Cancer-related fatigue |journal=Arch Phys Med Rehabil |volume=87 |issue=3 Suppl 1 |pages=S91–3; quiz S94–5 |year=2006 |month=March |pmid=16500197 |doi=10.1016/j.apmr.2005.12.015 |url=}}</ref> [[Anaerobic exercise]] has been found to be beneficial in reducing fatigue in people with [[solid tumour]]s.<ref name="pmid23152233">{{cite journal |author=Cramp F, Byron-Daniel J |title=Exercise for the management of cancer-related fatigue in adults |journal=Cochrane Database Syst Rev |volume=11 |issue= |pages=CD006145 |year=2012 |pmid=23152233 |doi=10.1002/14651858.CD006145.pub3 |url=}}</ref> Treatments to mitigate anemia include hormones to boost blood production ([[erythropoietin]]), [[iron supplement]]s, and [[blood transfusion]]s.<ref name="pmid10511589">{{cite journal |author=Groopman JE, Itri LM |title=Chemotherapy-induced anemia in adults: incidence and treatment |journal=J. Natl. Cancer Inst. |volume=91 |issue=19 |pages=1616–34 |year=1999 |month=October |pmid=10511589 |doi= |url=}}</ref><ref name="pmid16925107">{{cite journal |author=Henry DH |title=The role of intravenous iron in cancer-related anemia |journal=Oncology (Williston Park, N.Y.) |volume=20 |issue=8 Suppl 6 |pages=21–4 |year=2006 |month=July |pmid=16925107 |doi= |url=}}</ref>
 === Chemotherapy-induced nausea and vomiting (CINV) ===
 {{Further|Chemotherapy-induced nausea and vomiting}}
@@ Line 228: / Line 230: @@
 ==Newer and experimental approaches==
-[[File:Mesoporous silica SEM.jpg|thumb|[[Scanning electron micrograph]] of [[mesoporous silica]]; a type of[[nanoparticle]] used in the delivery of chemotherapeutic drugs.]]
+[[File:Mesoporous silica SEM.jpg|thumb|[[Scanning electron micrograph]] of [[mesoporous silica]]; a type of [[nanoparticle]] used in the delivery of chemotherapeutic drugs.]]
 {{Main|Experimental cancer treatments}}
 ===Targeted therapies===

v t e Major chemical drug groups – based upon the Anatomical Therapeutic Chemical Classification System
gastrointestinal tract / metabolism (A)	stomach acid Antacids H₂ antagonists Proton-pump inhibitors Antiemetics Laxatives Antidiarrhoeals / Antipropulsives Anti-obesity drugs Diabetes medication Vitamins Dietary minerals
blood and blood forming organs (B)	Antithrombotics Antiplatelets Anticoagulants Thrombolytics / fibrinolytics Antihemorrhagics Platelets Coagulants Antifibrinolytics
cardiovascular system (C)	cardiac therapy / antianginals Cardiac glycosides Antiarrhythmics Cardiac stimulants Antihypertensives Diuretics Vasodilators Beta blockers Calcium channel blockers renin–angiotensin system ACE inhibitors Angiotensin II receptor antagonists Renin inhibitors Antihyperlipidemics Statins Fibrates Bile acid sequestrants
skin (D)	Emollients Cicatrizants Antipruritics Antipsoriatics Medicated dressings
genitourinary system (G)	Hormonal contraception Fertility agents Selective estrogen receptor modulators Sex hormones
endocrine system (H)	Hypothalamic–pituitary hormones Corticosteroids Glucocorticoids Mineralocorticoids Sex hormones Thyroid hormones / Antithyroid agents
infections and infestations (J, P, QI)	Antimicrobials: Antibacterials (Antimycobacterials) Antifungals Antivirals Antiparasitics Antiprotozoals Anthelmintics Ectoparasiticides Intravenous immunoglobulin Vaccines
malignant disease (L01–L02)	Anticancer agents Antimetabolites Alkylating Spindle poisons Antineoplastic Topoisomerase inhibitors
immune disease (L03–L04)	Immunomodulators Immunostimulants Immunosuppressants
muscles, bones, and joints (M)	Anabolic steroids Anti-inflammatories Non-steroidal anti-inflammatory drugs Antirheumatics Corticosteroids Muscle relaxants Bisphosphonates
brain and nervous system (N)	Analgesics Anesthetics General Local Anorectics Anti-ADHD agents Antiaddictives Anticonvulsants Antidementia agents Antidepressants Antimigraine agents Antiparkinson agents Antipsychotics Anxiolytics Aphrodisiacs Depressants Entactogens Entheogens Euphoriants Hallucinogens Psychedelics Dissociatives Deliriants Hypnotics / Sedatives Mood stabilizers Neuroprotectives Nootropics Neurotoxins Orexigenics Serenics Stimulants Wakefulness-promoting agents
respiratory system (R)	Decongestants Bronchodilators Cough medicines H₁ antagonists
sensory organs (S)	Ophthalmologicals Otologicals
other ATC (V)	Antidotes Contrast media Radiopharmaceuticals Dressings Senotherapeutics
Drugs Pharmacological classification systems ATC codes Medicine portal