Antifungal

An antifungal medication, also known as an antimycotic medication, is a pharmaceutical fungicide or fungistatic used to treat and prevent mycosis such as athlete's foot, ringworm, candidiasis (thrush), serious systemic infections such as cryptococcal meningitis, and others. Such drugs are usually obtained by a doctor's prescription, but a few are available over the counter (OTC). The evolution of antifungal resistance is a growing threat to health globally.[1]

## Contents

* 1 Routes of administration
* 1.1 Ocular
* 1.2 Intrathecal
* 1.3 Vaginal
* 1.4 Topical
* 1.5 Oral
* 1.6 Intravenous
* 2 Classes
* 2.1 Polyenes
* 2.2 Azoles
* 2.2.1 Imidazoles
* 2.2.2 Triazoles
* 2.2.3 Thiazoles
* 2.3 Allylamines
* 2.4 Echinocandins
* 2.5 Triterpenoids
* 2.6 Others
* 3 Side effects
* 4 Resistance
* 5 References
* 6 External links

## Routes of administration

### Ocular

Indicated when the fungal infection is located in the eye. There is currently only one ocular antifungal available: natamycin. However, various other antifungal agents could be compounded in this formulation.[2]

### Intrathecal

Used occasionally when there's an infection of the central nervous system and other systemic options cannot reach the concentration required in that region for therapeutic benefit. Example(s): amphotericin B.[3]

### Vaginal

This may be used to treat some fungal infections of the vaginal region. An example of a condition they are sometimes used for is candida vulvovaginitis which is treated with intravaginal Clotrimazole.[4]

### Topical

Main article: Chemistry:Topical antifungal drugs

This is sometimes indicated when there's a fungal infection on the skin. An example is tinea pedis; this is sometimes treated with topical terbinafine.[5]

### Oral

If the antifungal has good bioavailability, this is a common route to handle a fungal infection. An example is the use of ketoconazole to treat coccidioidomycosis.[6]

### Intravenous

Like the oral route, this will reach the bloodstream and distribute throughout the body. However, it is faster and a good option if the drug has poor bioavailability. An example of this is IV amphotericin B for the treatment of coccidioidomycosis.[6]

## Classes

The available classes of antifungal drugs are still limited but as of 2021 novel classes of antifungals are being developed and are undergoing various stages of clinical trials to assess performance.[7]

### Polyenes

Main article: Chemistry:Polyene antimycotic

A polyene is a molecule with multiple conjugated double bonds. A polyene antifungal is a macrocyclic polyene with a heavily hydroxylated region on the ring opposite the conjugated system. This makes polyene antifungals amphiphilic. The polyene antimycotics bind with sterols in the fungal cell membrane, principally ergosterol. This changes the transition temperature (Tg) of the cell membrane, thereby placing the membrane in a less fluid, more crystalline state. (In ordinary circumstances membrane sterols increase the packing of the phospholipid bilayer making the plasma membrane more dense.) As a result, the cell's contents including monovalent ions (K+, Na+, H+, and Cl−) and small organic molecules leak, which is regarded as one of the primary ways a cell dies.[8] Animal cells contain cholesterol instead of ergosterol and so they are much less susceptible. However, at therapeutic doses, some amphotericin B may bind to animal membrane cholesterol, increasing the risk of human toxicity. Amphotericin B is nephrotoxic when given intravenously. As a polyene's hydrophobic chain is shortened, its sterol binding activity is increased. Therefore, further reduction of the hydrophobic chain may result in it binding to cholesterol, making it toxic to animals. * Amphotericin B

* Candicidin
* Filipin – 35 carbons, binds to cholesterol (toxic)
* Hamycin
* Natamycin – 33 carbons, binds well to ergosterol
* Nystatin
* Rimocidin

### Azoles

Azole antifungals inhibit the conversion of lanosterol to ergosterol by inhibiting lanosterol 14α-demethylase.[9] These compounds have a five-membered ring containing two or three nitrogen atoms.[10] The imidazole antifungals contain a 1,3-diazole (imidazole) ring (two nitrogen atoms), whereas the triazole antifungals have a ring with three nitrogen atoms.[11][10]

#### Imidazoles

* Bifonazole
* Butoconazole
* Clotrimazole
* Econazole
* Fenticonazole
* Isoconazole
* Ketoconazole
* Luliconazole
* Miconazole
* Omoconazole
* Oxiconazole
* Sertaconazole
* Sulconazole
* Tioconazole

#### Triazoles

* Albaconazole
* Cyproconazole
* Efinaconazole
* Epoxiconazole
* Fluconazole
* Isavuconazole
* Itraconazole
* Posaconazole
* Propiconazole
* Ravuconazole
* Terconazole
* Voriconazole

#### Thiazoles

* Abafungin

### Allylamines

Allylamines[12] inhibit squalene epoxidase, another enzyme required for ergosterol synthesis. Examples include butenafine, naftifine, and terbinafine.[13][14][15]

### Echinocandins

Echinocandins inhibit the creation of glucan in the fungal cell wall by inhibiting 1,3-Beta-glucan synthase:

* Anidulafungin
* Caspofungin
* Micafungin
* Rezafungin

Echinocandins are administered intravenously, particularly for the treatment of resistant Candida species.[16][17]

### Triterpenoids

* Ibrexafungerp

### Others

* Acrisorcin
* Amorolfine – a morpholine derivative used topically in dermatophytosis[18]
* Aurones – possess antifungal properties[19]
* Benzoic acid – has antifungal properties, such as in Whitfield's ointment, Friar's Balsam, and Balsam of Peru[20]
* Carbol fuchsin (Castellani's paint)
* Ciclopirox (ciclopirox olamine) – a hydroxypyridone antifungal that interferes with active membrane transport, cell membrane integrity, and fungal respiratory processes. It is most useful against tinea versicolour.[21]
* Clioquinol
* Coal tar
* Copper(II) sulfate[22]
* Crystal violet – a triarylmethane dye. It has antibacterial, antifungal, and anthelmintic properties and was formerly important as a topical antiseptic.[23]
* Chlorhexidine is a topical antibacterial and antifungal. It is commonly used in hospitals as an antiseptic. It is much more strongly antibacterial than antifungal, requiring at least a 10 times higher concentration to kill yeast compared to gram negative bacteria[24]
* Chlorophetanol
* Diiodohydroxyquinoline (Iodoquinol)
* Flucytosine (5-fluorocytosine) – an antimetabolite pyrimidine analog[25]
* Fumagillin
* Griseofulvin – binds to microtubules and inhibits mitosis[26]
* Haloprogin – discontinued due to the emergence of antifungals with fewer side effects[27]
* Miltefosine works by damaging fungal cell membranes [28]
* Nikkomycin – blocks formation of chitin present in the cell wall of fungus.
* Orotomide (F901318) – pyrimidine synthesis inhibitor[29][30]
* Piroctone olamine
* Pentanenitrile
* Potassium iodide – preferred treatment for lymphocutaneous sporotrichosis and subcutaneous zygomycosis (basidiobolomycosis). The mode of action is obscure.[31]
* Potassium permanganate \- for use only on thicker, more insensitive skin such as the soles of the feet.
* Selenium disulfide
* Sodium thiosulfate
* Sulfur
* Tolnaftate – a thiocarbamate antifungal, which inhibits fungal squalene epoxidase (similar mechanism to allylamines like terbinafine)
* Triacetin – hydrolysed to acetic acid by fungal esterases[32]
* Zinc pyrithione

## Side effects

Incidents of liver injury or failure among modern antifungal medicines are very low to non-existent. However, some can cause allergic reactions in people.[33]

There are also many drug interactions. Patients must read in detail the enclosed data sheet(s) of any medicine. For example, the azole antifungals such as ketoconazole or itraconazole can be both substrates and inhibitors of the P-glycoprotein, which (among other functions) excretes toxins and drugs into the intestines.[34] Azole antifungals are also both substrates and inhibitors of the cytochrome P450 family CYP3A4,[34] causing increased concentration when administering, for example, calcium channel blockers, immunosuppressants, chemotherapeutic drugs, benzodiazepines, tricyclic antidepressants, macrolides and SSRIs.[35]

Before oral antifungal therapies are used to treat nail disease, a confirmation of the fungal infection should be made.[36] Approximately half of suspected cases of fungal infection in nails have a non-fungal cause.[36] The side effects of oral treatment are significant and people without an infection should not take these drugs.[36]

Azoles are the group of antifungals which act on the cell membrane of fungi. They inhibit the enzyme 14-alpha-sterol demethylase, a microsomal CYP, which is required for the biosynthesis of ergosterol for the cytoplasmic membrane. This leads to the accumulation of 14-alpha-methylsterols resulting in impairment of function of certain membrane-bound enzymes and disruption of close packing of acyl chains of phospholipids, thus inhibiting growth of the fungi. Some azoles directly increase permeability of the fungal cell membrane.[37]

## Resistance

Antifungal resistance is a subset of antimicrobial resistance, that specifically applies to fungi that have become resistant to antifungals. Resistance to antifungals can arise naturally, for example by genetic mutation or through aneuploidy. Extended use of antifungals leads to the development of antifungal resistance through various mechanisms.[1]

Some species of fungi exhibit intrinsic resistance to certain antifungal drugs or classes (e.g. Candida krusei and fluconazole), whereas other species may develop antifungal resistance due to external pressures. Antifungal resistance is a One Health concern, driven by multiple extrinsic factors, including extensive fungicidal use, overuse of clinical antifungals, environmental change and host factors.[1]

Like resistance to antibacterials, antifungal resistance can be driven by antifungal use in agriculture. Currently there is no regulation on the use of similar antifungal classes in agriculture and the clinic.[1][38][39]

The emergence of Candida auris as a potential human pathogen that sometimes exhibits multi-class antifungal drug resistance is concerning and has been associated with several outbreaks globally. The WHO has released a priority fungal pathogen list, including pathogens with antifungal resistance.[40]

## References

1. ↑ 1.0 1.1 1.2 1.3 Fisher, Matthew C.; Alastruey-Izquierdo, Ana; Berman, Judith; Bicanic, Tihana; Bignell, Elaine M.; Bowyer, Paul; Bromley, Michael; Brüggemann, Roger et al. (29 March 2022). "Tackling the emerging threat of antifungal resistance to human health" (in en). Nature Reviews Microbiology 20 (9): 557–571. doi:10.1038/s41579-022-00720-1. ISSN 1740-1526. PMID 35352028.
2. ↑ Mcgee, Karen (2019). "Chapter 68 - Ocular pharmacology". Naplex review guide (3rd ed.). United states: McGraw Hill Medical. ISBN 978-1-260-13592-3.
3. ↑ Nau, Roland; Blei, Claudia; Eiffert, Helmut (2020-06-17). "Intrathecal Antibacterial and Antifungal Therapies" (in en). Clinical Microbiology Reviews 33 (3): e00190–19. doi:10.1128/CMR.00190-19. ISSN 0893-8512. PMID 32349999.
4. ↑ Sobel, Jack. "Candida vulvovaginitis: Treatment". https://www.uptodate.com/login.
5. ↑ Ward, Harry; Parkes, Nicholas; Smith, Carolyn; Kluzek, Stefan; Pearson, Richard (April 2022). "Consensus for the Treatment of Tinea Pedis: A Systematic Review of Randomised Controlled Trials" (in en). Journal of Fungi 8 (4): 351. doi:10.3390/jof8040351. ISSN 2309-608X. PMID 35448582.
6. ↑ 6.0 6.1 Carver, Peggy. Pharmacotherapy: a pathophysiological approach (11th ed.).
7. ↑ Hoenigl, Martin; Sprute, Rosanne; Egger, Matthias; Arastehfar, Amir; Cornely, Oliver A.; Krause, Robert; Lass-Flörl, Cornelia; Prattes, Juergen et al. (9 October 2021). "The Antifungal Pipeline: Fosmanogepix, Ibrexafungerp, Olorofim, Opelconazole, and Rezafungin" (in en). Drugs 81 (15): 1703–1729. doi:10.1007/s40265-021-01611-0. ISSN 0012-6667. PMID 34626339.
8. ↑ "Amphotericin B and its new derivatives - mode of action". Current Drug Metabolism 10 (5): 459–69. June 2009. doi:10.2174/138920009788898019. PMID 19689243.
9. ↑ "Current and emerging azole antifungal agents". Clinical Microbiology Reviews 12 (1): 40–79. January 1999. doi:10.1128/cmr.12.1.40. PMID 9880474.
10. ↑ 10.0 10.1 Dixon, Dennis M.; Walsh, Thomas J. (1996), Baron, Samuel, ed., "Antifungal Agents", Medical Microbiology (Galveston (TX): University of Texas Medical Branch at Galveston), ISBN 978-0-9631172-1-2, PMID 21413319, https://www.ncbi.nlm.nih.gov/books/NBK8263/, retrieved 2022-12-02
11. ↑ PubChem. "Imidazole" (in en). https://pubchem.ncbi.nlm.nih.gov/compound/795.
12. ↑ "Epidemiology of superficial fungal infections". Clinics in Dermatology (Elsevier Inc.) 28 (2): 197–201. March 2010. doi:10.1016/j.clindermatol.2009.12.005. PMID 20347663.
13. ↑ "As Fungal Infections Expand, so Does Market | GEN Magazine Articles | GEN". 15 February 2012. http://www.genengnews.com/gen-articles/as-fungal-infections-expand-so-does-market/4003/.
14. ↑ "Research and Markets: Global Antifungal Therapeutics (Polyenes, Azoles, Echinocandins, Allylamines) Market:Trends and Opportunities (2014-2019) | Business Wire". 28 August 2014. http://www.businesswire.com/news/home/20140828005518/en/Research-Markets-Global-Antifungal-Therapeutics-Polyenes-Azoles.
15. ↑ "Tinea Cruris". http://nurse-practitioners-and-physician-assistants.advanceweb.com/Web-Extras/NADNP/Tinea-Cruris.aspx.
16. ↑ "Echinocandins for the treatment of systemic fungal infection | Canadian Antimicrobial Resistance Alliance (CARA)". http://www.can-r.com/mediaResources/Echinocandins.pdf.
17. ↑ "The echinocandins". Pharmacotherapy 27 (3): 369–88. March 2007. doi:10.1592/phco.27.3.369. PMID 17316149.
18. ↑ Polak, Annemarie (1983). "Antifungal activity in vitro of Ro 14-4767/002, a phenylpropyl-morpholine". Medical Mycology 21 (3): 205–213. doi:10.1080/00362178385380321. ISSN 1369-3786. PMID 6635894.
19. ↑ "Antifungal activity of substituted aurones". Bioorganic & Medicinal Chemistry Letters 27 (4): 901–903. February 2017. doi:10.1016/j.bmcl.2017.01.012. PMID 28094180.
20. ↑ Wilson, Gisvold; Block, Beale (2004). Wilson and Gisvold's Textbook of Organic Medicinal and Pharmaceutical Chemistry. Philadelphia, Pa.: Lippincott Williams & Wilkins. ISBN 0-7817-3481-9. https://books.google.com/books?id=CIpWhgWV5q0C&q="benzoic+acid"+antifungal+tinea&pg=RA1-PA234. Retrieved 8 November 2020.
21. ↑ Long, Scott F.. "Anti-Fungals". Southwestern Oklahoma State University. http://faculty.swosu.edu/scott.long/phcl/antifung.htm.
22. ↑ "Using Copper to Improve the Well-Being of the Skin". Current Chemical Biology 8 (2): 89–102. August 2014. doi:10.2174/2212796809666150227223857. PMID 26361585.
23. ↑ "The metabolism and mode of action of gentian violet". Drug Metabolism Reviews 22 (2–3): 161–78. 1990. doi:10.3109/03602539009041083. PMID 2272286.
24. ↑ Leikin, Jerrold B.; Paloucek, Frank P., eds (2007-08-10). Poisoning and Toxicology Handbook. CRC Press. doi:10.3109/9781420044805. ISBN 978-0-429-19564-8.
25. ↑ "Flucytosine: a review of its pharmacology, clinical indications, pharmacokinetics, toxicity and drug interactions". The Journal of Antimicrobial Chemotherapy 46 (2): 171–9. August 2000. doi:10.1093/jac/46.2.171. PMID 10933638.
26. ↑ Olson, Jazmine M.; Troxell, Todd (2021). Griseofulvin. StatPearls Publishing. PMID 30726008. https://www.ncbi.nlm.nih.gov/books/NBK537323/. Retrieved 22 June 2021.
27. ↑ "Haloprogin". DrugBank. University of Alberta. 6 November 2006. http://redpoll.pharmacy.ualberta.ca/drugbank/cgi-bin/getCard.cgi?CARD=APRD01011.txt.
28. ↑ "In vitro antifungal activity of miltefosine and levamisole: their impact on ergosterol biosynthesis and cell permeability of dimorphic fungi". Journal of Applied Microbiology 119 (4): 962–9. October 2015. doi:10.1111/jam.12891. PMID 26178247.
29. ↑ "F901318 represents a novel class of antifungal drug that inhibits dihydroorotate dehydrogenase". Proceedings of the National Academy of Sciences of the United States of America 113 (45): 12809–12814. November 2016. doi:10.1073/pnas.1608304113. PMID 27791100. Bibcode: 2016PNAS..11312809O.
30. ↑ "Aspergillus fumigatus: New Opportunities for Treatment of Multidrug-Resistant Fungal Disease". mBio 8 (4): e01157-17. August 2017. doi:10.1128/mBio.01157-17. PMID 28830945.
31. ↑ "Systemic Therapy". Rook's Textbook of Dermatology. 4 (8th ed.). 2010. p. 74.48.
32. ↑ Gendimenico, Gerard J. (2007). "Dermatotherapeutic Agents". Ullmann's Encyclopedia of Industrial Chemistry (7th ed.). doi:10.1002/14356007.a08_301.pub2. ISBN 978-3-527-30673-2.
33. ↑ "Clinical hepatotoxicity associated with antifungal agents". Expert Opinion on Drug Safety 16 (2): 149–165. February 2017. doi:10.1080/14740338.2017.1270264. PMID 27927037.
34. ↑ 34.0 34.1 Lewis, Russell E.. "Antifungal Drug Interactions". doctorfungus. http://www.doctorfungus.org/thedrugs/antif_interaction.htm.
35. ↑ Research, Center for Drug Evaluation and (2022-08-24). "Drug Development and Drug Interactions | Table of Substrates, Inhibitors and Inducers" (in en). FDA. https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-inducers. Retrieved 17 April 2023.
36. ↑ 36.0 36.1 36.2 "Five Things Physicians and Patients Should Question". Choosing Wisely: an initiative of the ABIM Foundation. American Academy of Dermatology. February 2013. http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-dermatology/. , which cites
* "Guidelines for treatment of onychomycosis". The British Journal of Dermatology 148 (3): 402–10. March 2003. doi:10.1046/j.1365-2133.2003.05242.x. PMID 12653730.
* "The cost effectiveness of testing for onychomycosis versus empiric treatment of onychodystrophies with oral antifungal agents". Cutis 64 (6): 407–10. December 1999. PMID 10626104.
37. ↑ Herrick, Elizabeth J.; Patel, Preeti; Hashmi, Muhammad F. (2024), "Antifungal Ergosterol Synthesis Inhibitors", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 31869062, https://www.ncbi.nlm.nih.gov/books/NBK551581/#:~:text=The general mechanism of action,in cell lysis and death., retrieved 2024-08-26
38. ↑ Manyi-Loh, Christy; Mamphweli, Sampson; Meyer, Edson; Okoh, Anthony (2018-03-30). "Antibiotic Use in Agriculture and Its Consequential Resistance in Environmental Sources: Potential Public Health Implications". Molecules 23 (4): 795. doi:10.3390/molecules23040795. ISSN 1420-3049. PMID 29601469.
39. ↑ Verweij, Paul E.; Arendrup, Maiken C.; Alastruey-Izquierdo, Ana; Gold, Jeremy A.W.; Lockhart, Shawn R.; Chiller, Tom; White, P.Lewis (20 October 2022). "Dual use of antifungals in medicine and agriculture: How do we help prevent resistance developing in human pathogens?" (in en). Drug Resistance Updates 65. doi:10.1016/j.drup.2022.100885. PMID 36283187.
40. ↑ (in En) (PDF) WHO fungal priority pathogens list to guide research, development and public health action. World Health Organization. 25 October 2022. ISBN 978-92-4-006024-1. https://www.who.int/publications/i/item/9789240060241. Retrieved 27 October 2022.

## External links

* Antifungal Drugs – Detailed information on antifungals from the Fungal Guide written by R. Thomas and K. Barber
* "Clotrimazole". Clotrimazole (Canesten). Bayer Philippines. https://www.canesten.com.ph/canesten-cream.

* v
* t
* e

Antifungals (D01 and J02)

Wall/
membrane|

| Ergosterol
inhibitors|

| Azoles (lanosterol 14α-
demethylase inhibitors)|

| Imidazoles|

* Topical: bifonazole‡
* butoconazole
* chlormidazole‡
* clotrimazole#
* croconazole‡
* eberconazole
* econazole
* fenticonazole‡
* flutrimazole
* isoconazole
* ketoconazole
* luliconazole
* miconazole#
* neticonazole‡
* omoconazole‡
* oxiconazole
* sertaconazole
* sulconazole
* tioconazole

* Systemic: ketoconazole

|

Triazoles|

* Topical: efinaconazole
* fluconazole#
* terconazole

* Systemic: fluconazole#
* hexaconazole‡
* fosfluconazole
* isavuconazole
* itraconazole
* posaconazole
* voriconazole

* Unknown: albaconazole‡
* ravuconazole†

Thiazoles|

* Topical: abafungin‡

Polyene antimycotics
(ergosterol binding)|

* Topical: hamycin‡
* natamycin
* nystatin#
Systemic: amphotericin B#, hamycin‡

Squalene monooxygenase
inhibitors|

| Allylamines|

* Topical: naftifine
* terbinafine
Systemic: terbinafine

|

Benzylamines|

* Topical: butenafine

Others|

* Topical: amorolfine

β-glucan synthase
inhibitors|

* Systemic: echinocandins (anidulafungin
* biafungin
* caspofungin
* cilofungin
* micafungin)

Intracellular|

| Pyrimidine analogues/
thymidylate synthase inhibitors|

* Systemic: flucytosine#

|

Mitotic inhibitors|

* Systemic: griseofulvin#

Aminoacyl tRNA synthetase inhibitors|

* Topical: tavaborole

Others|

* bromochlorosalicylanilide
* chlorophetanol
* chlorphenesin
* ciclopirox
* crystal violet
* dimazole
* ethylparaben
* haloprogin‡
* polynoxylin
* potassium iodide#
* salicylic acid
* selenium disulfide#
* sodium thiosulfate#
* sulbentine
* taurolidine
* ticlatone
* tolciclate
* tolnaftate
* tribromometacresol
* undecylenic acid
* Whitfield's ointment#

* citronella oil
* lemon grass
* lemon myrtle
* orange oil
* patchouli
* tea tree oil
* PCP: atovaquone
* dapsone
* pentamidine

* #WHO-EM
* ‡Withdrawn from market
* Clinical trials:
* †Phase III
* §Never to phase III

* v
* t
* e

Pharmacology: major drug groups

Gastrointestinal tract/
metabolism (A)|

* stomach acid
* Antacids
* H2 antagonists
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* Antiemetics
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* Antidiarrhoeals/Antipropulsives
* Anti-obesity drugs
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Blood and blood
forming organs (B)|

* Antithrombotics
* Antiplatelets
* Anticoagulants
* Thrombolytics/fibrinolytics
* Antihemorrhagics
* Platelets
* Coagulants
* Antifibrinolytics

Cardiovascular
system (C)|

* cardiac therapy/antianginals
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* Beta blockers
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* Antimicrobials: Antibacterials (Antimycobacterials)
* Antifungals
* Antivirals
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(L03–L04)|

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and joints (M)|

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nervous system (N)|

* Analgesics
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* General
* Local
* Anorectics
* Anti-ADHD agents
* Antiaddictives
* Anticonvulsants
* Antidementia agents
* Antidepressants
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* Antiparkinson agents
* Antipsychotics
* Anxiolytics
* Aphrodisiacs
* Depressants
* Entactogens
* Entheogens
* Euphoriants
* Hallucinogens
* Psychedelics
* Dissociatives
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* 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

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