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Any discussion on narcotics, prescription drugs, or other controlled substances is usually peppered with the word schedule. One substance may be Schedule I, while another is Schedule II, III, or IV. For an individual who is not familiar with controlled substances, the word may simply pass through the conversation without a second glance. To those who understand the drug industry, however, these phrases are paramount to understanding the type of substance being discussed.![Drugs Drugs](/uploads/1/2/3/9/123952386/140100721.jpg)
![Five Five](/uploads/1/2/3/9/123952386/987610486.gif)
These terms are called drug classifications. Per the Drug Enforcement Administration (DEA), medical professionals and law enforcement officials use drug classifications to delineate a substance’s legality, based on “the drug’s acceptable medical use and the drug’s abuse or dependency potential.” Simply put, classifications help to categorize current and developing drugs, which in turn helps lawmakers, law enforcers, and medical experts understand how best to handle a particular substance. In this way, scheduling narcotics, prescription medications, and other drugs makes the industry safer for everyone.
A History of the CSA
Drug classifications have officially been in place since the 1970s, when President Nixon signed the Controlled Substances Act (CSA) into law. However, the CSA is merely a chapter in the United States’ long and complicated history with addictive substances. The US has been striving to safely and effectively control drug use since the Pure Food and Drug Act of 1906. This act required food and drug manufactures to clearly label any product that contains dangerous substances – substances that included alcohol, morphine, opium, and cannabis.
The act was amended numerous times over the six decades that followed, but the greatest change took effect in the early 1970s with the CSA. A companion to Nixon’s War on Drugs, the Controlled Substances Act gave the DEA and the Food and Drug Administration (FDA) the power to determine which substances are fit for medical use.
The Classifications
The drugs that are considered the most dangerous by the DEA are known as Schedule I substances. These are drugs with no current medical use, per analysis by the DEA and FDA. These substances also carry a high potential for abuse and addiction.
Some Schedule I drugs include:
- Marijuana
- Ecstasy
Schedule II drugs are also considered highly addictive with a dangerous potential for abuse. What makes them different from Schedule I drugs? Unlike the group above, Schedule II drugs are considered medically acceptable in particular cases, like for treating chronic pain or addiction. For this reason, Schedule II drugs can be obtained with a doctor’s prescription, but the risks of long-term use are still great.
Examples of Schedule II drugs include:
- OxyContin
- Fentanyl
Schedule III drugs include:
- Vicodin
- Tylenol with codeine
- Suboxone
- Ketamine
- Anabolic steroids
The DEA classifies substances with a low to moderate potential for physical and psychological dependence under Schedule III. When misused, these drugs can still lead to abuse or addiction, but they are still less dangerous than drugs in Schedules I and II. You can purchase these drugs at a pharmacy with a prescription, but you generally will not find them available over the counter.
Schedule IV drugs include:
- Xanax
- Soma
- Klonopin
- Valium
- Ativan
Schedule IV is the next classification level down in the DEA’s roster. Once again, these drugs have clear evidence of viable medical use, and they also possess a low probability for misuse and abuse. Of course, it is important to remember that a low probability does not mean there is no probability. Schedule IV drugs could still lead to addiction if they are seriously misused or mixed with other substances of abuse.
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Schedule V drugs include:
- Robitussin AC
- Phenergan with codeine
- Ezogabine
Finally, the DEA labels the least addictive substances under Schedule V. Most Schedule V substances involve preparing the drug with a small quantity of some narcotic. A common example is cough syrup. Schedule V substances have a very low potential for abuse; however, if the substance is misused to a large degree, physical or psychological dependency could develop.
How Scheduling Works
How does the DEA and FDA know which drugs are safe and which aren’t? According to a report in Vox, various studies on the drug’s effectiveness and risks are required and reviewed. Any drug entering the market must be analyzed, whether it is a new pharmaceutical or a street drug rising in popularity. First, the DEA determines whether the drug can be abused. If the answer is “yes,” regardless of how low the probability may be, the drug moves forward in the scheduling system.
At this stage, classification can become a little murky. While any drug that is scheduled under the CSA has some potential for abuse, the probability for addiction is so vaguely defined that where a drug is scheduled depends largely on the evidence that research on the drug can yield. Drugs require large-scale clinical trials to showcase their medical merit and keep them out of Schedule I classification. If the evidence is strong enough, the DEA designates the drug in a lower schedule, which deems it acceptable for use.
Classification Controversies
Some drugs have been reclassified over the years. For example, in 2014, the DEA reclassified the drug hydrocodone, moving it from Schedule III to Schedule II. But on the whole, reclassification or unscheduling a substance is rather rare, and this has led to many controversies surrounding the Controlled Substances Act.
The most well-known controversy surrounds marijuana, a Schedule I substance that many experts believe has only a low to moderate risk for addiction and could possess great medical benefits for individuals suffering from cancer and other serious conditions. Despite a growing body of evidence in support of reclassification, the DEA decided that marijuana would retain its Schedule I status in 2016. To many, this decision was considered a holdover from the War on Drugs mentality, in which any substance once deemed illicit can find no saving grace.
Another CSA controversy surrounds specific language the act uses to exempt alcohol and cigarettes. Title 21 of the United States Code reads, “The term ‘controlled substance’ means a drug or other substance, or immediate precursor, included in Schedule I, II, III, IV, or V of part B of this subchapter. The term does not include distilled spirits, wine, malt beverages, or tobacco.” To critics, this decision seems careless; the dangers of alcohol and tobacco are well documented, and some experts argue that were it not for this exemption, these substances would be Schedule I.
Despite its flaws, the drug classification system is an efficient way to help medical professionals, lawmakers, other officials, and laypeople across the country assess the benefits and dangers of various drugs and medications.
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Abortifacient Agents (17)
Abortifacient Agents, Nonsteroidal (13) • Non-steroidal chemical compounds with abortifacient activity. MeSH
Abortifacient Agents, Steroidal (3) • Steroidal compounds with abortifacient activity. MeSH
Acaricides (7) • A pesticide or chemical agent that kills mites and ticks. This is a large class that includes carbamates, formamides, organochlorines, organophosphates, etc, that act as antibiotics or growth regulators. MeSH
Acetaldehyde Dehydrogenase Inhibitors (1) • Compounds that bind to and inhibit the enzymatic activity of acetaldehyde dehydrogenases. MeSH
Acetylcholine Release Inhibitors (3)
Acetylcholinesterase Inhibitors (0) see Cholinesterase Inhibitors
Acid Cysteine Proteinase Inhibitors (0) see Cysteine Proteinase Inhibitors
Acid Sensing Ion Channel Blockers (2) • A subclass of sodium channel blockers that are specific for ACID-SENSING SODIUM CHANNELS. MeSH
Action Diuretics (1)
Adenosine A1 Receptor Antagonists (3) • Compounds that bind to and block the stimulation of ADENOSINE A1 RECEPTORS. MeSH
Adenosine A2 Receptor Agonists (4) • Compounds that selectively bind to and activate ADENOSINE A2 RECEPTORS. MeSH
Adenosine A2 Receptor Antagonists (9) • Compounds that selectively bind to and block the activation of ADENOSINE A2 RECEPTORS. MeSH
Adenosine A2A Receptor Agonists (0) see Adenosine A2 Receptor Agonists
Adenosine A2A Receptor Antagonists (0) see Adenosine A2 Receptor Antagonists
Adenosine A2B Receptor Agonists (0) see Adenosine A2 Receptor Agonists
Adenosine A2B Receptor Antagonists (0) see Adenosine A2 Receptor Antagonists
Adenosine A3 Receptor Antagonists (1)
Adenosine Deaminase Inhibitors (8) • Drugs that inhibit ADENOSINE DEAMINASE activity. MeSH
Adenosine Diphosphate Receptor Antagonists (0) see Purinergic P2Y Receptor Antagonists
Adenylyl Cyclase Inhibitors (3) • Compounds that bind to and inhibit the action of ADENYLYL CYCLASES. MeSH
Adhesives (2)
Adjuvants, Anesthesia (21) • Agents that are administered in association with anesthetics to increase effectiveness, improve delivery, or decrease required dosage. MeSH
Adjuvants, Immunologic (129) • Substances that augment, stimulate, activate, potentiate, or modulate the immune response at either the cellular or humoral level. The classical agents (Freund's adjuvant, BCG, Corynebacterium parvum, et al.) contain bacterial antigens. Some are endogenous (e.g., histamine, interferon, transfer factor, tuftsin, interleukin-1). Their mode of action is either non-specific, resulting in increased immune responsiveness to a wide variety of antigens, or antigen-specific, i.e., affecting a restricted type of immune response to a narrow group of antigens. The therapeutic efficacy of many biological response modifiers is related to their antigen-specific immunoadjuvanticity. MeSH
Adjuvants, Pharmaceutic (2) • Agents that aid or increase the action of the principle drug (DRUG SYNERGISM) or that affect the absorption, mechanism of action, metabolism, or excretion of the primary drug (PHARMACOKINETICS) in such a way as to enhance its effects. MeSH
Adrenal Cortex Hormones (53)
Adrenal Steroid Synthesis Inhibitors (0) see Steroid Synthesis Inhibitors
Adrenergic Agents (281) • Drugs that act on adrenergic receptors or affect the life cycle of adrenergic transmitters. Included here are adrenergic agonists and antagonists and agents that affect the synthesis, storage, uptake, metabolism, or release of adrenergic transmitters. MeSH
Adrenergic Agonists (109) • Drugs that bind to and activate adrenergic receptors. MeSH
Adrenergic alpha-1 Receptor Agonists (8) • Compounds that bind to and activate ADRENERGIC ALPHA-1 RECEPTORS. MeSH
Adrenergic alpha-1 Receptor Antagonists (18) • Drugs that bind to and block the activation of ADRENERGIC ALPHA-1 RECEPTORS. MeSH
Adrenergic alpha-2 Receptor Agonists (21) • Compounds that bind to and activate ADRENERGIC ALPHA-2 RECEPTORS. MeSH
Adrenergic alpha-2 Receptor Antagonists (6) • Drugs that bind to and block the activation of ADRENERGIC ALPHA-2 RECEPTORS. MeSH
Adrenergic alpha-Agonists (53) • Drugs that selectively bind to and activate alpha adrenergic receptors. MeSH
Adrenergic alpha-Antagonists (67) • Drugs that bind to but do not activate alpha-adrenergic receptors thereby blocking the actions of endogenous or exogenous adrenergic agonists. Adrenergic alpha-antagonists are used in the treatment of hypertension, vasospasm, peripheral vascular disease, shock, and pheochromocytoma. MeSH
Adrenergic Antagonists (134) • Drugs that bind to but do not activate ADRENERGIC RECEPTORS. Adrenergic antagonists block the actions of the endogenous adrenergic transmitters EPINEPHRINE and NOREPINEPHRINE. MeSH
Adrenergic beta-1 Receptor Agonists (6) • Compounds that bind to and activate ADRENERGIC BETA-1 RECEPTORS. MeSH
Adrenergic beta-1 Receptor Antagonists (10) • Drugs that bind to and block the activation of ADRENERGIC BETA-1 RECEPTORS. MeSH
Adrenergic beta-2 Receptor Agonists (17) • Compounds bind to and activate ADRENERGIC BETA-2 RECEPTORS. MeSH
Adrenergic beta-2 Receptor Antagonists (1) • Drugs that bind to and block the activation of ADRENERGIC BETA-2 RECEPTORS. MeSH
Adrenergic beta-3 Receptor Agonists (5) • Compounds that bind to and activate ADRENERGIC BETA-3 RECEPTORS. MeSH
Adrenergic beta-3 Receptor Antagonists (1)
Adrenergic beta-Agonists (61) • Drugs that selectively bind to and activate beta-adrenergic receptors. MeSH
Adrenergic beta-Antagonists (75) • Drugs that bind to but do not activate beta-adrenergic receptors thereby blocking the actions of beta-adrenergic agonists. Adrenergic beta-antagonists are used for treatment of hypertension, cardiac arrhythmias, angina pectoris, glaucoma, migraine headaches, and anxiety. MeSH
Adrenergic Effect (0) see Adrenergic Agents
Adrenergic Neurohumor Depleters (0) see Adrenergic Agents
Adrenergic Neuron Agents (0) see Adrenergic Agents
Adrenergic Release Inhibitors (0) see Adrenergic Agents
Adrenergic Synthesis Inhibitors (0) see Adrenergic Agents
Adrenergic Uptake Inhibitors (32) • Drugs that block the transport of adrenergic transmitters into axon terminals or into storage vesicles within terminals. The tricyclic antidepressants (ANTIDEPRESSIVE AGENTS, TRICYCLIC) and amphetamines are among the therapeutically important drugs that may act via inhibition of adrenergic transport. Many of these drugs also block transport of serotonin. MeSH
Aerosol Propellants (1) • Compressed gases or vapors in a container which, upon release of pressure and expansion through a valve, carry another substance from the container. They are used for cosmetics, household cleaners, and so on. Examples are BUTANES; CARBON DIOXIDE; FLUOROCARBONS; NITROGEN; and PROPANE. (McGraw-Hill Dictionary of Scientific and Technical Terms, 4th ed) MeSH
Affinity Labels (40) • Analogs of those substrates or compounds which bind naturally at the active sites of proteins, enzymes, antibodies, steroids, or physiological receptors. These analogs form a stable covalent bond at the binding site, thereby acting as inhibitors of the proteins or steroids. MeSH
Agglutinins (1)
Aggregation Inhibitors (1)
Agrochemicals (7)
Air Pollutants (15) • Any substance in the air which could, if present in high enough concentration, harm humans, animals, vegetation or material. Substances include GASES; PARTICULATE MATTER; and volatile ORGANIC CHEMICALS. MeSH
Air Pollutants, Environmental (0) see Air Pollutants
Air Pollutants, Occupational (4) • Air pollutants found in the work area. They are usually produced by the specific nature of the occupation. MeSH
Air Pollutants, Radioactive (1) • Pollutants, present in air, which exhibit radioactivity. MeSH
Alcohol Deterrents (6) • Substances interfering with the metabolism of ethyl alcohol, causing unpleasant side effects thought to discourage the drinking of alcoholic beverages. Alcohol deterrents are used in the treatment of alcoholism. MeSH
Aldosterone Antagonists (2) see Mineralocorticoid Receptor Antagonists
Alkylating Agents (73) • Highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning. Many are used as antineoplastic agents, but most are very toxic, with carcinogenic, mutagenic, teratogenic, and immunosuppressant actions. They have also been used as components in poison gases. MeSH
alpha-Cysteine Protease Inhibitors (0) see Cysteine Proteinase Inhibitors
alpha-Glucosidase Inhibitors (0) see Glycoside Hydrolase Inhibitors
Alpha-Neurotoxins (0) see Neurotoxins
Amebicides (13) • Agents which are destructive to amebae, especially the parasitic species causing AMEBIASIS in man and animal. MeSH
Amines, Sympathomimetic (0) see Sympathomimetics
Amphiphilic Agents (0) see Surface-Active Agents
Ampholytes (0) see Buffers
Amylin Mimetics (0) see Amylin Receptor Agonists
Amylin Receptor Agonists (1) • Compounds that stimulate the activity of AMYMIN RECEPTORS. Included under this heading is the endogenous form of ISLET AMYLOID POLYPEPTIDE and synthetic compounds that mimic its effect. MeSH
Anabolic Agents (27) • These compounds stimulate anabolism and inhibit catabolism. They stimulate the development of muscle mass, strength, and power. MeSH
Anabolic Effect (0) see Anabolic Agents
Analeptics (0) see Central Nervous System Stimulants
Analgesics (443) • Compounds capable of relieving pain without the loss of CONSCIOUSNESS. MeSH
Analgesics, Anti-Inflammatory (0) see Anti-Inflammatory Agents, Non-Steroidal
Analgesics, Non-Narcotic (295) • A subclass of analgesic agents that typically do not bind to OPIOID RECEPTORS and are not addictive. Many non-narcotic analgesics are offered as NONPRESCRIPTION DRUGS. MeSH
Analgesics, Opioid (75) • Compounds with activity like OPIATE ALKALOIDS, acting at OPIOID RECEPTORS. Properties include induction of ANALGESIA or NARCOSIS. MeSH
Androgen Antagonists (18) • Compounds which inhibit or antagonize the biosynthesis or actions of androgens. MeSH
Androgen Effect (0) see Androgens
Androgen Receptor Antagonists (2)
Androgen Synthesis Inhibitors (0) see Steroid Synthesis Inhibitors
Androgens (12) • Compounds that interact with ANDROGEN RECEPTORS in target tissues to bring about the effects similar to those of TESTOSTERONE. Depending on the target tissues, androgenic effects can be on SEX DIFFERENTIATION; male reproductive organs, SPERMATOGENESIS; secondary male SEX CHARACTERISTICS; LIBIDO; development of muscle mass, strength, and power. MeSH
Anesthetic Effect (0) see Anesthetics
Anesthetic Gases (0) see Anesthetics, Inhalation
Anesthetics (91) • Agents that are capable of inducing a total or partial loss of sensation, especially tactile sensation and pain. They may act to induce general ANESTHESIA, in which an unconscious state is achieved, or may act locally to induce numbness or lack of sensation at a targeted site. MeSH
Anesthetics, Combined (4) • The use of two or more chemicals simultaneously or sequentially to induce anesthesia. The drugs need not be in the same dosage form. MeSH
Anesthetics, Dissociative (4) • Intravenous anesthetics that induce a state of sedation, immobility, amnesia, and marked analgesia. Subjects may experience a strong feeling of dissociation from the environment. The condition produced is similar to NEUROLEPTANALGESIA, but is brought about by the administration of a single drug. (From Gilman et al., Goodman and Gilman's The Pharmacological Basis of Therapeutics, 8th ed) MeSH
Anesthetics, General (30)
Anesthetics, Inhalation (11) • Gases or volatile liquids that vary in the rate at which they induce anesthesia; potency; the degree of circulation, respiratory, or neuromuscular depression they produce; and analgesic effects. Inhalation anesthetics have advantages over intravenous agents in that the depth of anesthesia can be changed rapidly by altering the inhaled concentration. Because of their rapid elimination, any postoperative respiratory depression is of relatively short duration. (From AMA Drug Evaluations Annual, 1994, p173) MeSH
Anesthetics, Intravenous (19) • Ultrashort-acting anesthetics that are used for induction. Loss of consciousness is rapid and induction is pleasant, but there is no muscle relaxation and reflexes frequently are not reduced adequately. Repeated administration results in accumulation and prolongs the recovery time. Since these agents have little if any analgesic activity, they are seldom used alone except in brief minor procedures. (From AMA Drug Evaluations Annual, 1994, p174) MeSH
Anesthetics, Local (38) • Drugs that block nerve conduction when applied locally to nerve tissue in appropriate concentrations. They act on any part of the nervous system and on every type of nerve fiber. In contact with a nerve trunk, these anesthetics can cause both sensory and motor paralysis in the innervated area. Their action is completely reversible. (From Gilman AG, et. al., Goodman and Gilman's The Pharmacological Basis of Therapeutics, 8th ed) Nearly all local anesthetics act by reducing the tendency of voltage-dependent sodium channels to activate. MeSH
Anesthetics, Topical (0) see Anesthetics, Local
Angiogenesis Factor Inhibitors (0) see Angiogenesis Inhibitors
Angiogenesis Inducing Agents (2)
Angiogenesis Inhibitors (31) • Agents and endogenous substances that antagonize or inhibit the development of new blood vessels. MeSH
Angiogenesis Modulating Agents (31)
Angiotensin II Type 1 Receptor Blockers (22) • Agents that antagonize ANGIOTENSIN II TYPE 1 RECEPTOR. Included are ANGIOTENSIN II analogs such as SARALASIN and biphenylimidazoles such as LOSARTAN. Some are used as ANTIHYPERTENSIVE AGENTS. MeSH
![Five Five](/uploads/1/2/3/9/123952386/987610486.gif)
Angiotensin II Type 2 Receptor Blockers (2) • Agents that antagonize the ANGIOTENSIN II TYPE 2 RECEPTOR. MeSH
Angiotensin Receptor Antagonists (27)
Angiotensin-Converting Enzyme Inhibitors (51) • A class of drugs whose main indications are the treatment of hypertension and heart failure. They exert their hemodynamic effect mainly by inhibiting the renin-angiotensin system. They also modulate sympathetic nervous system activity and increase prostaglandin synthesis. They cause mainly vasodilation and mild natriuresis without affecting heart rate and contractility. MeSH
Anion Exchange Resins (3) • High-molecular-weight insoluble polymers that contain functional cationic groups capable of undergoing exchange reactions with anions. MeSH
Antacids (21) • Substances that counteract or neutralize acidity of the GASTROINTESTINAL TRACT. MeSH
Anthelmintics (107) • Agents destructive to parasitic worms. They are used therapeutically in the treatment of HELMINTHIASIS in man and animal. MeSH
Anti-Allergic Agents (49) • Agents that are used to treat allergic reactions. Most of these drugs act by preventing the release of inflammatory mediators or inhibiting the actions of released mediators on their target cells. (From AMA Drug Evaluations Annual, 1994, p475) MeSH
Anti-Androgen Effect (0) see Androgen Antagonists
Anti-Angiogenesis Effect (0) see Angiogenesis Inhibitors
Anti-Anxiety Agents (91) • Agents that alleviate ANXIETY, tension, and ANXIETY DISORDERS, promote sedation, and have a calming effect without affecting clarity of consciousness or neurologic conditions. ADRENERGIC BETA-ANTAGONISTS are commonly used in the symptomatic treatment of anxiety but are not included here. MeSH
Anti-Anxiety Effect (0) see Anti-Anxiety Agents
Anti-Arrhythmia Agents (153) • Agents used for the treatment or prevention of cardiac arrhythmias. They may affect the polarization-repolarization phase of the action potential, its excitability or refractoriness, or impulse conduction or membrane responsiveness within cardiac fibers. Anti-arrhythmia agents are often classed into four main groups according to their mechanism of action: sodium channel blockade, beta-adrenergic blockade, repolarization prolongation, or calcium channel blockade. MeSH
Anti-Arrhythmia AgentsE (1)
Anti-Asthmatic Agents (101) • Drugs that are used to treat asthma. MeSH
Anti-Bacterial Agents (471) • Substances that reduce the growth or reproduction of BACTERIA. MeSH
Anti-Dyskinesia Agents (55) • Drugs used in the treatment of movement disorders. Most of these act centrally on dopaminergic or cholinergic systems. Among the most important clinically are those used for the treatment of Parkinson disease (ANTIPARKINSON AGENTS) and those for the tardive dyskinesias. MeSH
Anti-HIV Agents (87) • Agents used to treat AIDS and/or stop the spread of the HIV infection. These do not include drugs used to treat symptoms or opportunistic infections associated with AIDS. MeSH
Anti-Infective Agents (1267) • Substances that prevent infectious agents or organisms from spreading or kill infectious agents in order to prevent the spread of infection. MeSH
Anti-Infective Agents, Local (77) • Substances used on humans and other animals that destroy harmful microorganisms or inhibit their activity. They are distinguished from DISINFECTANTS, which are used on inanimate objects. MeSH
Anti-Infective Agents, Urinary (33) • Substances capable of killing agents causing urinary tract infections or of preventing them from spreading. MeSH
Anti-Inflammatory Agents (349) • Substances that reduce or suppress INFLAMMATION. MeSH
Anti-Inflammatory Agents, Non-Steroidal (258) • Anti-inflammatory agents that are non-steroidal in nature. In addition to anti-inflammatory actions, they have analgesic, antipyretic, and platelet-inhibitory actions.They act by blocking the synthesis of prostaglandins by inhibiting cyclooxygenase, which converts arachidonic acid to cyclic endoperoxides, precursors of prostaglandins. Inhibition of prostaglandin synthesis accounts for their analgesic, antipyretic, and platelet-inhibitory actions; other mechanisms may contribute to their anti-inflammatory effects. MeSH
Anti-Mycobacterial Agents (0) see Anti-Bacterial Agents
Anti-Obesity Agents (28) • Agents that increase energy expenditure and weight loss by neural and chemical regulation. Beta-adrenergic agents and serotoninergic drugs have been experimentally used in patients with non-insulin dependent diabetes mellitus (NIDDM) to treat obesity. MeSH
Anti-Retroviral Agents (102)
Anti-Rheumatic Agents, Non-Steroidal (0) see Anti-Inflammatory Agents, Non-Steroidal
Anti-Ulcer Agents (79) • Various agents with different action mechanisms used to treat or ameliorate PEPTIC ULCER or irritation of the gastrointestinal tract. This has included ANTIBIOTICS to treat HELICOBACTER INFECTIONS; HISTAMINE H2 ANTAGONISTS to reduce GASTRIC ACID secretion; and ANTACIDS for symptomatic relief. MeSH
Antibiotics (0) see Anti-Bacterial Agents
Antibiotics, Antifungal (10) see Antifungal Agents
Antibiotics, Antineoplastic (102) • Chemical substances, produced by microorganisms, inhibiting or preventing the proliferation of neoplasms. MeSH
Antibiotics, Antitubercular (11) • Substances obtained from various species of microorganisms that are, alone or in combination with other agents, of use in treating various forms of tuberculosis; most of these agents are merely bacteriostatic, induce resistance in the organisms, and may be toxic. MeSH
Antibiotics, Cytotoxic (0) see Antibiotics, Antineoplastic
Anticarcinogenic Agents (36) • Agents that reduce the frequency or rate of spontaneous or induced tumors independently of the mechanism involved. MeSH
Anticarcinogenic Effect (0) see Anticarcinogenic Agents
Anticestodal Agents (5) • Agents used to treat tapeworm infestations in man or animals. MeSH
Anticholesteremic Agents (59) • Substances used to lower plasma CHOLESTEROL levels. MeSH
Anticholinergic Agents (0) see Cholinergic Antagonists
Anticoagulants (85) • Agents that prevent clotting. MeSH
Anticoccidial Agents (0) see Coccidiostats
Anticonvulsants (130) • Drugs used to prevent SEIZURES or reduce their severity. MeSH
Antidepressive Agents (105) • Mood-stimulating drugs used primarily in the treatment of affective disorders and related conditions. Several MONOAMINE OXIDASE INHIBITORS are useful as antidepressants apparently as a long-term consequence of their modulation of catecholamine levels. The tricyclic compounds useful as antidepressive agents (ANTIDEPRESSIVE AGENTS, TRICYCLIC) also appear to act through brain catecholamine systems. A third group (ANTIDEPRESSIVE AGENTS, SECOND-GENERATION) is a diverse group of drugs including some that act specifically on serotonergic systems. MeSH
Antidepressive Agents, Second-Generation (21) • A structurally and mechanistically diverse group of drugs that are not tricyclics or monoamine oxidase inhibitors. The most clinically important appear to act selectively on serotonergic systems, especially by inhibiting serotonin reuptake. MeSH
Antidepressive Agents, Tricyclic (27) • Substances that contain a fused three-ring moiety and are used in the treatment of depression. These drugs block the uptake of norepinephrine and serotonin into axon terminals and may block some subtypes of serotonin, adrenergic, and histamine receptors. However the mechanism of their antidepressant effects is not clear because the therapeutic effects usually take weeks to develop and may reflect compensatory changes in the central nervous system. MeSH
Antidiabetics (0) see Hypoglycemic Agents
Antidiarrheals (18) • Miscellaneous agents found useful in the symptomatic treatment of diarrhea. They have no effect on the agent(s) that cause diarrhea, but merely alleviate the condition. MeSH
Antidiuretic Agents (5) • Agents that reduce the excretion of URINE, most notably the octapeptide VASOPRESSINS. MeSH
Antidiuretic Effect (0) see Antidiuretic Agents
Antidiuretic Hormone Receptor Antagonists (7) • Endogenous compounds and drugs that inhibit or block the activity of ANTIDUIRETIC HORMONE RECEPTORS. MeSH
Antidotes (35) • Agents counteracting or neutralizing the action of POISONS. MeSH
Antiemetic Effect (0) see Antiemetics
Antiemetics (56) • Drugs used to prevent NAUSEA or VOMITING. MeSH
Antiepileptic Agents (0) see Anticonvulsants
Antifibrillatory Agents (0) see Anti-Arrhythmia Agents
Antifibrinolytic Agents (7) • Agents that prevent fibrinolysis or lysis of a blood clot or thrombus. Several endogenous antiplasmins are known. The drugs are used to control massive hemorrhage and in other coagulation disorders. MeSH
Antiflatulents (0) see Antifoaming Agents
Antifoaming Agents (2) • Agents used to prevent the formation of foam or to treat flatulence or bloat. MeSH
Antifungal Agents (153) • Substances that destroy fungi by suppressing their ability to grow or reproduce. They differ from FUNGICIDES, INDUSTRIAL because they defend against fungi present in human or animal tissues. MeSH
Antihemorrhagics (0) see Hemostatics
Antihistamines, Classical (0) see Histamine H1 Antagonists
Antihypertensive Agents (270) • Drugs used in the treatment of acute or chronic vascular HYPERTENSION regardless of pharmacological mechanism. Among the antihypertensive agents are DIURETICS; (especially DIURETICS, THIAZIDE); ADRENERGIC BETA-ANTAGONISTS; ADRENERGIC ALPHA-ANTAGONISTS; ANGIOTENSIN-CONVERTING ENZYME INHIBITORS; CALCIUM CHANNEL BLOCKERS; GANGLIONIC BLOCKERS; and VASODILATOR AGENTS. MeSH
Antihyperuricemics (0) see Gout Suppressants
Antilipemic Agents (19)
Antimalarials (74) • Agents used in the treatment of malaria. They are usually classified on the basis of their action against plasmodia at different stages in their life cycle in the human. (From AMA, Drug Evaluations Annual, 1992, p1585) MeSH
Antimanic Agents (6) • Agents that are used to treat bipolar disorders or mania associated with other affective disorders. MeSH
Antimanic Effect (0) see Antimanic Agents
Antimetabolites (193) • Drugs that are chemically similar to naturally occurring metabolites, but differ enough to interfere with normal metabolic pathways. (From AMA Drug Evaluations Annual, 1994, p2033) MeSH
Antimetabolites, Antineoplastic (55) • Antimetabolites that are useful in cancer chemotherapy. MeSH
Antimitotic Agents (37) • Agents that arrest cells in MITOSIS, most notably TUBULIN MODULATORS. MeSH
Antimutagenic Agents (15) • Agents that reduce the frequency or rate of spontaneous or induced mutations independently of the mechanism involved. MeSH
Antimutagenic Effect (0) see Antimutagenic Agents
Antinematodal Agents (42) • Substances used in the treatment or control of nematode infestations. They are used also in veterinary practice. MeSH
Antineoplastic Agents (976) • Substances that inhibit or prevent the proliferation of NEOPLASMS. MeSH
Antineoplastic Agents, Alkylating (47) • A class of drugs that differs from other alkylating agents used clinically in that they are monofunctional and thus unable to cross-link cellular macromolecules. Among their common properties are a requirement for metabolic activation to intermediates with antitumor efficacy and the presence in their chemical structures of N-methyl groups, that after metabolism, can covalently modify cellular DNA. The precise mechanisms by which each of these drugs acts to kill tumor cells are not completely understood. (From AMA, Drug Evaluations Annual, 1994, p2026) MeSH
Antineoplastic Agents, Hormonal (36) • Antineoplastic agents that are used to treat hormone-sensitive tumors. Hormone-sensitive tumors may be hormone-dependent, hormone-responsive, or both. A hormone-dependent tumor regresses on removal of the hormonal stimulus, by surgery or pharmacological block. Hormone-responsive tumors may regress when pharmacologic amounts of hormones are administered regardless of whether previous signs of hormone sensitivity were observed. The major hormone-responsive cancers include carcinomas of the breast, prostate, and endometrium; lymphomas; and certain leukemias. (From AMA Drug Evaluations Annual 1994, p2079) MeSH
Antineoplastic Agents, Immunological (39)
Antineoplastic Agents, Phytogenic (68) • Agents obtained from higher plants that have demonstrable cytostatic or antineoplastic activity. MeSH
Antinociceptive Agents (0) see Analgesics
Antioxidant Effect (0) see Antioxidants
Antioxidants (165) • Naturally occurring or synthetic substances that inhibit or retard the oxidation of a substance to which it is added. They counteract the harmful and damaging effects of oxidation in animal tissues. MeSH
Antiparasitic Agents (270) • Drugs used to treat or prevent parasitic infections. MeSH
Antiparkinson Agents (50) • Agents used in the treatment of Parkinson's disease. The most commonly used drugs act on the dopaminergic system in the striatum and basal ganglia or are centrally acting muscarinic antagonists. MeSH
Antiperistaltic Agents (0) see Antidiarrheals
Antiperspirants (2) • Agents that are put on the SKIN to reduce SWEATING or prevent excess sweating (HYPERHIDROSIS). MeSH
Antiplatelet Agents (0) see Platelet Aggregation Inhibitors
Antiplatyhelmintic Agents (30) • Agents used to treat cestode, trematode, or other flatworm infestations in man or animals. MeSH
Antiprotozoal Agents (175) • Substances that are destructive to protozoans. MeSH
Antipruritics (15) • Agents, usually topical, that relieve itching (pruritus). MeSH
Antipsychotic Agents (114) • Agents that control agitated psychotic behavior, alleviate acute psychotic states, reduce psychotic symptoms, and exert a quieting effect. They are used in SCHIZOPHRENIA; senile dementia; transient psychosis following surgery; or MYOCARDIAL INFARCTION; etc. These drugs are often referred to as neuroleptics alluding to the tendency to produce neurological side effects, but not all antipsychotics are likely to produce such effects. Many of these drugs may also be effective against nausea, emesis, and pruritus. MeSH
Antipsychotic Effect (0) see Antipsychotic Agents
Antipyretic Effect (0) see Antipyretics
Antipyretics (5) • Drugs that are used to reduce body temperature in fever. MeSH
Antiresorptive Agents (0) see Bone Density Conservation Agents
Antirheumatic Agents (314) • Drugs that are used to treat RHEUMATOID ARTHRITIS. MeSH
Antirheumatic Drugs, Disease-Modifying (0) see Antirheumatic Agents
Antischistosomal Agents (0) see Schistosomicides
Antiseptics, Urinary (0) see Anti-Infective Agents, Urinary
Antisickling Agents (6) • Agents used to prevent or reverse the pathological events leading to sickling of erythrocytes in sickle cell conditions. MeSH
Antispasmodic Effect (0) see Parasympatholytics
Antispasmodics (0) see Parasympatholytics
Antispermatogenic Agents (9) • Agents, either mechanical or chemical, which destroy spermatozoa in the male genitalia and block spermatogenesis. MeSH
Antispermatogenic Effect (0) see Antispermatogenic Agents
Antisyphilitic Agents (0) see Antitreponemal Agents
Antithrombins (29) • Endogenous factors and drugs that directly inhibit the action of THROMBIN, usually by blocking its enzymatic activity. They are distinguished from INDIRECT THROMBIN INHIBITORS, such as HEPARIN, which act by enhancing the inhibitory effects of antithrombins. MeSH
Antithrombotic Agents (0) see Fibrinolytic Agents
Antithyroid Agents (10) • Agents that are used to treat hyperthyroidism by reducing the excessive production of thyroid hormones. MeSH
Antithyroid Effect (0) see Antithyroid Agents
Antitreponemal Agents (1) • Agents used to treat infections with bacteria of the genus TREPONEMA. This includes SYPHILIS & YAWS. MeSH
Antitrichomonal Agents (6) • Agents used to treat trichomonas infections. MeSH
Antitubercular Agents (33) • Drugs used in the treatment of tuberculosis. They are divided into two main classes: 'first-line' agents, those with the greatest efficacy and acceptable degrees of toxicity used successfully in the great majority of cases; and 'second-line' drugs used in drug-resistant cases or those in which some other patient-related condition has compromised the effectiveness of primary therapy. MeSH
Antitussive Agents (33) • Agents that suppress cough. They act centrally on the medullary cough center. EXPECTORANTS, also used in the treatment of cough, act locally. MeSH
Antiviral Agents (277) • Agents used in the prophylaxis or therapy of VIRUS DISEASES. Some of the ways they may act include preventing viral replication by inhibiting viral DNA polymerase; binding to specific cell-surface receptors and inhibiting viral penetration or uncoating; inhibiting viral protein synthesis; or blocking late stages of virus assembly. MeSH
Any of several BRASSICA species that are commonly called mustard. Brassica alba is white mustard, B. juncea is brown or Chinese mustard, and B. nigra is black, brown, or red mustard (1)
Appetite Depressants (16) • Agents that are used to suppress appetite. MeSH
Appetite Stimulants (2) • Agents that are used to stimulate appetite. These drugs are frequently used to treat anorexia associated with cancer and AIDS. MeSH
Arachidonate 12-Lipoxygenase Inhibitors (0) see Lipoxygenase Inhibitors
Arachidonate 15-Lipoxygenase Inhibitors (0) see Lipoxygenase Inhibitors
Arachidonate 5-Lipoxygenase Inhibitors (0) see Lipoxygenase Inhibitors
Aromatase Inhibitors (10) • Compounds that inhibit AROMATASE in order to reduce production of estrogenic steroid hormones. MeSH
Aromatic Amino Acid Decarboxylase Inhibitors (5) • Compounds and drugs that block or inhibit the enzymatic action of AROMATIC AMINO ACID DECARBOXYLASES. Pharmaceutical agents in this category are used in conjunction with LEVODOPA in order to slow its metabolism. MeSH
Artificial Sweeteners (0) see Sweetening Agents
Aspirin-Like Agents (0) see Anti-Inflammatory Agents, Non-Steroidal
Astringent Effect (0) see Astringents
Astringents (4) • Agents, usually topical, that cause the contraction of tissues for the control of bleeding or secretions. MeSH
Autonomic Agents (316)
Aversive Agents (1)
This is the list of Schedule V drugs as defined by the United StatesControlled Substances Act.[1]The following findings are required for drugs to be placed in this schedule:[2]
- The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule IV.
- The drug or other substance has a currently accepted medical use in treatment in the United States.
- Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule IV.
The complete list of Schedule V drugs follows.[1] The Administrative Controlled Substances Code Number for each drug is included.
Opiates and opioids[edit]
ACSCN | Drug |
---|---|
N/A | Not more than 200 milligrams of codeine per 100 milliliters or per 100 grams |
N/A | Not more than 100 milligrams of dihydrocodeine per 100 milliliters or per 100 grams |
N/A | Not more than 100 milligrams of ethylmorphine per 100 milliliters or per 100 grams |
N/A | Not more than 2.5 milligrams of diphenoxylate and not less than 25 micrograms of atropine sulfate per dosage unit |
N/A | Not more than 100 milligrams of opium per 100 milliliters or per 100 grams |
N/A | Not more than 0.5 milligram of difenoxin and not less than 25 micrograms of atropine sulfate per dosage unit |
Stimulants[edit]
ACSCN | Drug |
---|---|
1485 | Pyrovalerone |
Cannabinoids[edit]
ACSCN | Drug |
---|---|
1485 | Cannabidiol, only in a marijuana-derived pharmaceutical formulation marketed by GW Pharmaceuticals as Epidiolex. Cannabidiol derived from industrial hemp remains schedule 1.[3] |
Others[edit]
ACSCN | Drug |
---|---|
2710 | Brivaracetam ((2S)-2-[(4R)-2-oxo-4-propylpyrrolidin-1-yl] butanamide)) |
2779 | Ezogabine (N-[2-amino-4-(4-fluorobenzylamino)-phenyl]-carbamic acid ethyl ester) |
2746 | Lacosamide ([R]-2-acetoamido-N-benzyl-3-methoxy-propionamide) |
2782 | Pregabalin ([S]-3-(aminomethyl)-5-methylhexanoic acid] |
References[edit]
- ^ ab21 CFR1308.15 (CSA Sched V) with changes through 77 FR64032 (Oct 18, 2012). Retrieved September 6, 2013.
- ^21 U.S.C.§ 812(b)(5) retrieved October 7, 2007
- ^https://www.westword.com/marijuana/colorado-law-firm-upset-over-deas-rescheduling-of-cbd-medication-epidiolex-10844306
Retrieved from 'https://en.wikipedia.org/w/index.php?title=List_of_Schedule_V_drugs_(US)&oldid=862920237'
The Controlled Substances Act was passed in 1970 to help the United States Drug Enforcement Administration (DEA) enforce drugs which could pose a risk to society if used improperly. Under the CSA, a controlled substance is any drug with a potential for abuse;drugs which do not pose an addiction risk are not regulated by the CSA, although they are by other agencies. The CSA was one of the early building blocks in the “war on drugs,” as it gave a law enforcement agency specific powers when it came to the issue of drug abuse.
Under the CSA, a controlled substance falls into one of five schedules, depending on how addictive it is. Drugs are also grouped in five classes: narcotics, depressants, stimulants, anabolic steroids, and hallucinogens are all regulated under the CSA. The DEA also monitors the growth, sale, and use of Cannabis sativa, or marijuana. When a new drug is released on the market, part of the testing involves a determination of how potentially addictive it is, so that it can be classified and regulated under the CSA, if necessary. A drug which is listed as a controlled substance has to be handled with care in a clinical environment, and usually requires a prescription for use outside a clinic.
Antihypertensives are a class of drugs that are used to treat hypertension (high blood pressure).[1] Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke and myocardial infarction. Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease.[2] There are many classes of antihypertensives, which lower blood pressure by different means. Among the most important and most widely used drugs are thiazidediuretics, calcium channel blockers, ACE inhibitors, angiotensin II receptor antagonists (ARBs), and beta blockers.
Which type of medication to use initially for hypertension has been the subject of several large studies and resulting national guidelines. The fundamental goal of treatment should be the prevention of the important endpoints of hypertension, such as heart attack, stroke and heart failure. Patient age, associated clinical conditions and end-organ damage also play a part in determining dosage and type of medication administered.[3] The several classes of antihypertensives differ in side effect profiles, ability to prevent endpoints, and cost. The choice of more expensive agents, where cheaper ones would be equally effective, may have negative impacts on national healthcare budgets.[4] As of 2018, the best available evidence favors low-dose thiazide diuretics as the first-line treatment of choice for high blood pressure when drugs are necessary.[5] Although clinical evidence shows calcium channel blockers and thiazide-type diuretics are preferred first-line treatments for most people (from both efficacy and cost points of view), an ACE inhibitor is recommended by NICE in the UK for those under 55 years old.[6]
- 11Choice of initial medication
- 13Research
Diuretics[edit]
Hydrochlorothiazide, a popular thiazide diuretic
Diuretics help the kidneys eliminate excess salt and water from the body's tissues and blood.
Different Classes Of Drugs And Examples
- Loop diuretics:
- Thiazide diuretics:
- hydrochlorothiazide and chlorothiazide
- Thiazide-like diuretics:
- Potassium-sparing diuretics:
In the United States, the JNC8 (Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends thiazide-type diuretics to be one of the first-line drug treatments for hypertension, either as monotherapy or in combination with calcium channel blockers, ACE inhibitors, or angiotensin II receptor antagonists.[7] There are fixed-dose combination drugs, such as ACE inhibitor and thiazide combinations. Despite thiazides being cheap and effective, they are not prescribed as often as some newer drugs. This is because they have been associated with increased risk of new-onset diabetes and as such are recommended for use in patients over 65 where the risk of new-onset diabetes is outweighed by the benefits of controlling systolic blood pressure.[8] Another theory is that they are off-patent and thus rarely promoted by the drug industry.[9]
Calcium channel blockers[edit]
Calcium channel blockers block the entry of calcium into muscle cells in artery walls.
- dihydropyridines:
- non-dihydropyridines:
JNC8[who?] recommends calcium channel blockers to be a first-line treatment either as monotherapy or in combination with thiazide-type diuretics, ACE inhibitors, or angiotensin II receptor antagonists for all patients regardless of age or race.[7]
The ratio of CCBs' anti-proteinuria effect, non-dihydropyridine to dihydropyridine was 30 to -2.[10]
ACE inhibitors[edit]
Captopril, the prototypical ACE inhibitor
ACE inhibitors inhibit the activity of angiotensin-converting enzyme (ACE), an enzyme responsible for the conversion of angiotensin I into angiotensin II, a potent vasoconstrictor.
A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as a first line of defense.[11] The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of kidney function compared to calcium channel blockers and beta blockers.[12] As such, ACE inhibitors should be the drug treatment of choice for patients with chronic kidney disease regardless of race or diabetic status.[7]
However, ACE inhibitors (and angiotensin II receptor antagonists) should not be a first-line treatment for black hypertensives without chronic kidney disease.[7] Results from the ALLHAT trial showed that thiazide-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup.[13] Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker.[14] There are fixed-dose combination drugs, such as ACE inhibitor and thiazide combinations.
Notable side effects of ACE inhibitors include dry cough, hyperkalemia, fatigue, dizziness, headaches, loss of taste and a risk for angioedema.[15]
Angiotensin II receptor antagonists[edit]
Valsartan, an angiotensin II receptor antagonist
Angiotensin II receptor antagonists work by antagonizing the activation of angiotensin receptors.
In 2004, an article in the BMJ examined the evidence for and against the suggestion that angiotensin receptor blockers may increase the risk of myocardial infarction (heart attack).[16] The matter was debated in 2006 in the medical journal of the American Heart Association.[17][18] To date[when?], there is no consensus on whether ARBs have a tendency to increase MI, but there is also no substantive evidence to indicate that ARBs are able to reduce MI.
In the VALUE trial, the angiotensin II receptor blocker valsartan produced a statistically significant 19% (p=0.02) relative increase in the prespecified secondary end point of myocardial infarction (fatal and non-fatal) compared with amlodipine.[19]
The CHARM-alternative trial showed a significant +52% (p=0.025) increase in myocardial infarction with candesartan (versus placebo) despite a reduction in blood pressure.[20]
Indeed, as a consequence of AT1 blockade, ARBs increase Angiotensin II levels several-fold above baseline by uncoupling a negative-feedback loop. Increased levels of circulating Angiotensin II result in unopposed stimulation of the AT2 receptors, which are, in addition upregulated. Unfortunately, recent data suggest that AT2 receptor stimulation may be less beneficial than previously proposed and may even be harmful under certain circumstances through mediation of growth promotion, fibrosis, and hypertrophy, as well as proatherogenic and proinflammatory effects.[21][22][23]
ARBs happens to be the favorable alternative to ACE inhibitors if the hypertensive patients with the heart failure type of reduced ejection fraction treated with ACEs was intolerant of cough, angioedema other than hyperkalemia or renal insufficiency[24][25].
Adrenergic receptor antagonists[edit]
Propranolol, the first beta-blocker to be successfully developed
- Beta blockers
- Alpha blockers:
- Mixed Alpha + Beta blockers:
Although beta blockers lower blood pressure, they do not have a positive benefit on endpoints as some other antihypertensives.[26] In particular, beta-blockers are no longer recommended as first-line treatment due to relative adverse risk of stroke and new-onset of type 2 diabetes when compared to other medications,[3] while certain specific beta-blockers such as atenolol appear to be less useful in overall treatment of hypertension than several other agents.[27] A systematic review of 63 trials with over 35,000 participants indicated β-blockers increased the risk of mortality, compared to other antihypertensive therapies.[11] They do, however, have an important role in the prevention of heart attacks in people who have already had a heart attack.[28] In the United Kingdom, the June 2006 'Hypertension: Management of Hypertension in Adults in Primary Care'[29] guideline of the National Institute for Health and Clinical Excellence, downgraded the role of beta-blockers due to their risk of provoking type 2 diabetes.[30]
Despite lowering blood pressure, alpha blockers have significantly poorer endpoint outcomes than other antihypertensives, and are no longer recommended as a first-line choice in the treatment of hypertension.[31]However, they may be useful for some men with symptoms of prostate disease.
Vasodilators[edit]
Vasodilators act directly on the smooth muscle of arteries to relax their walls so blood can move more easily through them; they are only used in hypertensive emergencies or when other drugs have failed, and even so are rarely given alone.
Sodium nitroprusside, a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as malignant hypertension or aortic dissection).[32][33]Hydralazine and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies.[33] They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in gestational hypertension.[32]
Five Classes Of Drugs
Renin Inhibitors[edit]
Renin comes one level higher than angiotensin converting enzyme (ACE) in the renin–angiotensin system. Inhibitors of renin can therefore effectively reduce hyptertension. Aliskiren (developed by Novartis) is a renin inhibitor which has been approved by the U.S. FDA for the treatment of hypertension.[34]
Aldosterone receptor antagonists[edit]
Aldosterone receptor antagonists:
Aldosterone receptor antagonists are not recommended as first-line agents for blood pressure,[35] but spironolactone and eplerenone are both used in the treatment of heart failure and resistant hypertension.
Alpha-2 adrenergic receptor agonists[edit]
Central alpha agonists lower blood pressure by stimulating alpha-receptors in the brain which open peripheral arteries easing blood flow. These alpha 2 receptors are known as autoreceptors which provide a negative feedback in neurotransmission (in this case, the vasoconstriction effects of adrenaline). Central alpha agonists, such as clonidine, are usually prescribed when all other anti-hypertensive medications have failed. For treating hypertension, these drugs are usually administered in combination with a diuretic.
Adverse effects of this class of drugs include sedation, drying of the nasal mucosa and rebound hypertension.
Some indirect anti-adrenergics are rarely used in treatment-resistant hypertension:
- guanethidine - replaces norepinephrine in vesicles, decreasing its tonic release
- mecamylamine - antinicotinic and ganglion blocker
- reserpine - indirect via irreversible VMAT inhibition
For the most resistant and severe disease, oral minoxidil (Loniten) in combination with diuretic and β-blocker or other sympathetic nervous system suppressant may be used.
Endothelium receptor blockers[edit]
Bosentan belongs to a new class of drug and works by blocking the receptors of the hormoneendothelium. It is specifically indicated only for the treatment of pulmonary artery hypertension in patients with moderate to severe heart failure.
Choice of initial medication[edit]
For mild blood pressure elevation, consensus guidelines call for medically supervised lifestyle changes and observation before recommending initiation of drug therapy. However, according to the American Hypertension Association, evidence of sustained damage to the body may be present even prior to observed elevation of blood pressure. Therefore, the use of hypertensive medications may be started in individuals with apparent normal blood pressures but who show evidence of hypertension-related nephropathy, proteinuria, atherosclerotic vascular disease, as well as other evidence of hypertension-related organ damage.
If lifestyle changes are ineffective, then drug therapy is initiated, often requiring more than one agent to effectively lower hypertension.Which type of many medications should be used initially for hypertension has been the subject of several large studies and various national guidelines. Considerations include factors such as age, race, and other medical conditions.[35] In the United States, JNC8 (2014) recommends any drug from one of the four following classes to be a good choice as either initial therapy or as an add-on treatment: thiazide-type diuretics, calcium channel blockers, ACE inhibitors, or angiotensin II receptor antagonists.[7]
The first large study to show a mortality benefit from antihypertensive treatment was the VA-NHLBI study, which found that chlorthalidone was effective.[36] The largest study, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in 2002, concluded that chlorthalidone, (a thiazide diuretic) was as effective as lisinopril (an angiotensin converting enzyme inhibitor) or amlodipine (a calcium channel blocker).[13] (ALLHAT showed that doxazosin, an alpha-adrenergic receptor blocker, had a higher incidence of heart failure events, and the doxazosin arm of the study was stopped.)
A subsequent smaller study (ANBP2) did not show the slight advantages in thiazide diuretic outcomes observed in the ALLHAT study, and actually showed slightly better outcomes for ACE-inhibitors in older white male patients.[37]
Thiazide diuretics are effective, recommended as the best first-line drug for hypertension by many experts,[citation needed] and are much more affordable than other therapies, yet they are not prescribed as often as some newer drugs. Chlorthalidone is the thiazide drug that is most strongly supported by the evidence as providing a mortality benefit, although in the ALLHAT study, a chlorthalidone dose of only 10 mg/day was used; clinicians in the US commonly prescribe chlorthalidone at a dose of 12.5 mg (half of a 25 mg tablet), as no 10 mg formulation of chlorthalidone is currently available in the US. Chlorthalidone has repeatedly been found to have a stronger effect on lowering blood pressure than hydrochlorothiazide, and hydrochlorothiazide and chlorthalidone have a similar risk of hypokalemia and other adverse effects at the usual doses prescribed in routine clinical practice.[38] Patients with an exaggerated hypokalemic response to a low dose of a thiazide diuretic should be suspected to have Hyperaldosteronism, a common cause of secondary hypertension.
Other drugs have a role in treating hypertension. Adverse effects of thiazide diuretics include hypercholesterolemia, and impaired glucose tolerance with increased risk of developing Diabetes mellitus type 2. The thiazide diuretics also deplete circulating potassium unless combined with a potassium-sparing diuretic or supplemental potassium. Some authors have challenged thiazides as first line treatment.[39][40][41] However, as the Merck Manual of Geriatrics notes, 'thiazide-type diuretics are especially safe and effective in the elderly.'[42]
Current UK guidelines suggest starting patients over the age of 55 years and all those of African/Afrocaribbean ethnicity firstly on calcium channel blockers or thiazide diuretics, whilst younger patients of other ethnic groups should be started on ACE-inhibitors. Subsequently, if dual therapy is required to use ACE-inhibitor in combination with either a calcium channel blocker or a (thiazide) diuretic. Triple therapy is then of all three groups and should the need arise then to add in a fourth agent, to consider either a further diuretic (e.g. spironolactone or furosemide), an alpha-blocker or a beta-blocker.[43] Prior to the demotion of beta-blockers as first line agents, the UK sequence of combination therapy used the first letter of the drug classes and was known as the 'ABCD rule'.[43][44]
Patient factors[edit]
The choice between the drugs is to a large degree determined by the characteristics of the patient being prescribed for, the drugs' side-effects, and cost. Most drugs have other uses; sometimes the presence of other symptoms can warrant the use of one particular antihypertensive. Examples include:
- Age can affect the choice of medications. Current UK guidelines suggest starting patients over the age of 55 years first on calcium channel blockers or thiazide diuretics.
- Anxiety may be improved with the use of beta blockers.
- Asthmatics have been reported to have worsening symptoms when using beta blockers.
- Benign prostatic hyperplasia may be improved with the use of an alpha blocker.
- Chronic kidney disease. ACE inhibitors or ARBs should be included in the treatment plan to improve kidney outcomes regardless of race or diabetic status.[7][12]
- Diabetes mellitus. The ACE inhibitors and angiotensin receptor blockers have been shown to prevent the kidney and retinal complications of diabetes mellitus.
- Gout may be worsened by thiazide diuretics, while losartan reduces serum urate.[45]
- Kidney stones may be improved with the use of thiazide-type diuretics [46]
- Heart block. β-blockers and nondihydropyridine calcium channel blockers should not be used in patients with heart block greater than first degree. JNC8 does not recommend β-blockers as initial therapy for hypertension [47]
- Heart failure may be worsened with nondihydropyridine calcium channel blockers, the alpha blocker doxazosin, and the alpha-2 agonists moxonidine and clonidine. On the other hand, β-blockers, diuretics, ACE inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists have been shown to improve outcome.[48]
- Pregnancy. Although α-methyldopa is generally regarded as a first-line agent, labetalol and metoprolol are also acceptable. Atenolol has been associated with intrauterine growth retardation, as well as decreased placental growth and weight when prescribed during pregnancy. ACE inhibitors and angiotensin II receptor blockers (ARBs) are contraindicated in women who are or who intend to become pregnant.[35]
- Periodontal disease could mitigate the efficacy of antihypertensive drugs.[49]
- Race. JNC8 guidelines particularly point out that when used as monotherapy, thiazide diuretics, and calcium channel blockers have been found to be more effective in reducing blood pressure in black hypertensives than β-blockers, ACE inhibitors, or ARBs.[7]
- Tremor may warrant the use of beta blockers.
The JNC8 guidelines indicate reasons to choose one drug over the others for certain individual patients.[7]
History[edit]
The first known instance of an effective antihypertensive treatment was in 1947 using Primaquine, an antimalarial.[50]
Chlorothiazide was discovered in 1957.
Research[edit]
Blood pressure vaccines[edit]
Vaccinations are being trialed and may become a treatment option for high blood pressure in the future. CYT006-AngQb was only moderately successful in studies, but similar vaccines are being investigated.[51]
References[edit]
- ^Antihypertensive+Agents at the US National Library of Medicine Medical Subject Headings (MeSH)
- ^Law M, Wald N, Morris J (2003). 'Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy'(PDF). Health Technol Assess. 7 (31): 1–94. doi:10.3310/hta7310. PMID14604498. Archived from the original(PDF) on 2011-03-04.
- ^ abNelson, Mark. 'Drug treatment of elevated blood pressure'. Australian Prescriber (33): 108–112. Archived from the original on 26 August 2010. Retrieved August 11, 2010.
- ^Nelson MR; McNeil JJ; Peeters A; et al. (Jun 4, 2001). 'PBS/RPBS cost implications of trends and guideline recommendations in the pharmacological management of hypertension in Australia, 1994–1998'. Med J Aust. 174 (11): 565–8. PMID11453328.
- ^Wright JM, Musini VM (April 2018). Wright JM (ed.). 'First-line drugs for hypertension'. Cochrane Database of Systematic Reviews. 4: CD001841. doi:10.1002/14651858.CD001841.pub3. PMID29667175.
- ^'Archived copy'(PDF). Archived(PDF) from the original on 2012-01-07. Retrieved 2012-01-09.CS1 maint: Archived copy as title (link), p19
- ^ abcdefghJames, Paul A.; Oparil, Suzanne; Carter, Barry L.; Cushman, William C.; Dennison-Himmelfarb, Cheryl; Handler, Joel; Lackland, Daniel T.; LeFevre, Michael L.; MacKenzie, Thomas D.; Ogedegbe, Olugbenga; Smith, Sidney C.; Svetkey, Laura P.; Taler, Sandra J.; Townsend, Raymond R.; Wright, Jackson T.; Narva, Andrew S.; Ortiz, Eduardo (18 December 2013). '2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults'. JAMA. 311 (5): 507–20. doi:10.1001/jama.2013.284427. PMID24352797.
- ^Zillich AJ; Garg J; Basu S; et al. (August 2006). 'Thiazide diretics, potassium and the development of diabetes: a quantitative review'. Hypertension. 48 (2): 219–224. doi:10.1161/01.HYP.0000231552.10054.aa. PMID16801488.
- ^Wang TJ, Ausiello JC, Stafford RS (20 April 1999). 'Trends in Antihypertensive Drug Advertising, 1985–1996'. Circulation. 99 (15): 2055–2057. doi:10.1161/01.CIR.99.15.2055. PMID10209012. Archived from the original on 30 December 2005.
- ^Bakris, George L.; Weir, Matthew R.; Secic, Michelle; Campbell, Brett; Weis-McNulty, Annette (2004). 'Differential effects of calcium antagonist subclasses on markers of nephropathy progression'. Kidney International. 65 (6): 1991–2002. doi:10.1111/j.1523-1755.2004.00620.x. ISSN0085-2538. PMID15149313.
- ^ abWu, H.-Y.; Huang, J.-W.; Lin, H.-J.; Liao, W.-C.; Peng, Y.-S.; Hung, K.-Y.; Wu, K.-D.; Tu, Y.-K.; Chien, K.-L. (24 October 2013). 'Comparative effectiveness of renin–angiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and Bayesian network meta-analysis'. BMJ. 347: f6008. doi:10.1136/bmj.f6008. PMC3807847. PMID24157497. Archived from the original on 22 February 2014.
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