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Monographs in Clinical Pharmacology, 5. Drug Treatment of Respiratory Disease
Br.j’.
Dis.
Chest
(1983) 77, 315
BOOK REVIEWS Monographs in Clinical Pharmacology, ment of Respiratory Disease
R. B. Cole Edinburgh: Churchill x + 334. Price E19.00
Livingstone.
5. Drug
Treat-
1982. Pp.
Drug Treatment of Respiratory Disease is a book in a series of monographs in clinical pharmacology. The series originates in the United States, and is designed to some extent for an American audience, though the author, Dr Cole, writes from his experience in Britain. This can be slightly unsettling, though in certain areas it introduces a broader perspective than would be seen in a book produced for local consumption only. Books on clinical pharmacology tend to divide into three types; the reference book, the practical guide on management of medical problems and the up date review of areas of growth and controversy. This monograph falls mainly into the practical guide category. The book starts with a fairly standard background of pharmacodynamics and pharmacokinetics. General points are illustrated by specific, often non-respiratory, examples which may in fact require considerable pharmacological knowledge to follow fully. This is classical textbook pharmacology, the principles of which will be reasonably well known by the majority of readers, even if the examples are not. The book goes some way to being a reference book in that it contains quite a lot of detail of doses and drug interactions, but it is not comprehensive enough, nor well organized enough to replace more standard textbooks. For example, some of the chapters are drug orientated, e.g. antibiotics; others disease orientated, e.g. respiratory failure. Each chapter contains a large number of useful references, although in some areas these do not reflect the balance of studies that have been carried out. For example, the authors quote one study showing that intravenous salbutamol is preferable to inhaled salbutamol in severe asthma and none of the several studies showing nebulization to be at least as effective as the intravenous route with fewer side-effects. As a practical guide on drug treatment in respiratory disease the book contains a lot of
well-balanced and sensible advice. Antibiotics are well covered with a lot of useful information, and a nice simple guide to the cephalosporins for those feeling overwhelmed by the proclivity of these drugs. Dr Cole’s conclusion that cephalasporins have little place in the routine management of chronic respiratory disease could be useful ammunition for the next crusading drug representative. I was surprised to find co-trimoxazole described as a second-line drug for exacerbations of chronic bronchitis. Much of the advice given by Dr Cole is unexceptional, but there is some which I would question. For example - that doxepram should only be used in patients considered unfit for mechanical ventilation; that eye testing should be carried out on all patients prior to ethambutol treatment; that heparin should be given for 7 days for a deep vein thrombosis; that sodium cromoglycate controls symptoms in 65-70% of adult patients with severe asthma; and that streptomycin is still indicated for large tuberculous cavities with current drug regimens. The maintenance dose of iv. aminophylline recommended by Dr Cole from the work by Mitenko and Ogilvie (0,9mg/kg/hour), is probably too high in the light ofmore recent work. Hendeles et al. (Am. Rev. resp. Dis. 1978,118,97) suggests that a dose of 0.5mg/kg/hour provides a safer balance between therapeutic efficacy and toxic side-effects, particularly ifblood levels cannot be measured. The suggestion that arterial Pco, should be monitored half hourly for the first 2 hours of oxygen therapy in respiratory failure seems a little impractical. Clearer statements about the danger of giving iv. aminophylline to patients receiving oral theophylline, and ephedrine to patients on monoamine oxidase inhibitors, and a caution about using ethambutol for the elderly or those with impaired vision, would be useful. This book may disappoint people with an interest in respiratory pharmacology since it does not address current areas of controversy and research interest. The action oftheophylline is stated as being due to phosphodiesterase inhibition with no mention of the arguments against this hypothesis, nor mention of other possible mechanisms of action. Dr Cole tends to present
316
Book Reviews
the findings from the large number ofstudies he quotes at face value. I would have preferred a more critical analysis of the evidence, particularly where results are obviously conflicting. Overall, a book which contains a lot of good advice, but also some that appears to be slightly dated. Those with an interest in clinical pharmacology may find it a little bland. A. E. Tattersfield
&zical
Strategies
in Adult
Asthma
Charles H. Scoggin and Thomas L. Petty Philadelphia: Lea and Febiger. 1st edition. 1982. Pp. 149. Price $9.75 (paper) This paperback describes the approach to asthma management in Denver, Colorado, and is aimed at the ‘practising physician’. The major part of the book is divided into chapters on acute asthma, acute intermittent asthma and chronic persistent asthma, each chapter being written by one of the authors. This is a useful, practical approach but the authors vary in their emphasis on mechanism and diagnosis or on treatment and this leads to some lack of balance. Most paragraphs are headed by questions, a technique often found in American textbooks, which may help the reader to refer quickly to a topic. There are a number of case histories illustrating specific points. The few illustrations used are ofgood quality. An early chapter on recognition and assessment of asthma is well written and useful, although there are some misprints and mistakes, particularly in descriptions offlow-volume loops and forced expiratory ratios. There are valuable sections on pregnancy and asthma, surgery and asthma and bronchoscoping asthmatic patients. Readers on this side of the Atlantic will find the drug treatment ofasthma least satisfactory. The range of drugs available in the USA is limited and few British chest physicians would consider oral theophylline preparations to be the first line of treatment. Inhaled corticosteroids are also used late in the recommended approach to treatment. Overall it is an interesting look at an individual approach to the rational treatment of asthma but it cannot be recommended as a guide to management ofasthma in this country. P. J. Rees
Current Diseases
Topics
in
the Management
of
Edited by J. S. Brody & G. L. Snider Edinburgh: Churchill Livingstone. x + 182. Price E10.50
Respiratory
1981. Pp.
This book has been written jointly by the Senior Staff in the Pulmonary Division of the Boston University School of Medicine. It is a highly readable book which aims to provide a concise guide to the management of respiratory diseases for physicians, medical students and ‘allied health personnel’. Each section of the book is prefaced by an account of the rationale behind the management practised by the authors. For instance, the chapter on bronchomotor tone introduces the treatment ofsevere asthma and of chronic airways obstruction. However, it contains only three paragraphs on airways physiology, the first of which contains the surprising statement that Poiseuille’s law concerns turbulent, as well as laminar flow. The authors admit that there are considerable species differences in the neural control of airways smooth muscle, but they devote space to describing the results of animal experiments, while giving few references to the human studies and failing to mention either the controversies concerning the effect ofanticholinergic agents on induced bronchospasm, the results of radioligand binding studies on human lung adrenoreceptors, the evidence concerning pz-adrenergic function in normal and asthmatic bronchi, or the role of different types of histamine receptors in human bronchi. The chapters on the treatment ofasthma and the prevention of tuberculosis include much that is controversial, but the references have been carefully selected to support the authors’ viewpoint. A wide literature concerning, among other topics, p2-adrenergic agonists and the protective effect of BCG is completely ignored. Predictably a strong preference is expressed for intravenous aminophylline in the treatment of severe asthma. However, I think that the authors’ preferred method ofstaging and the use of this staging in the management of severe asthma is potentially dangerous. An asthmatic with an FEV, of 1.3-2.0 litres, unrelated to predicted values and a Pao, of less than 80 mmHg is regarded as having only moderate airways obstruction, which can be managed safely without steroids on an outpatient basis. The criteria for admission to hospital appear to be an
Dis.
Chest
(1983) 77, 315
BOOK REVIEWS Monographs in Clinical Pharmacology, ment of Respiratory Disease
R. B. Cole Edinburgh: Churchill x + 334. Price E19.00
Livingstone.
5. Drug
Treat-
1982. Pp.
Drug Treatment of Respiratory Disease is a book in a series of monographs in clinical pharmacology. The series originates in the United States, and is designed to some extent for an American audience, though the author, Dr Cole, writes from his experience in Britain. This can be slightly unsettling, though in certain areas it introduces a broader perspective than would be seen in a book produced for local consumption only. Books on clinical pharmacology tend to divide into three types; the reference book, the practical guide on management of medical problems and the up date review of areas of growth and controversy. This monograph falls mainly into the practical guide category. The book starts with a fairly standard background of pharmacodynamics and pharmacokinetics. General points are illustrated by specific, often non-respiratory, examples which may in fact require considerable pharmacological knowledge to follow fully. This is classical textbook pharmacology, the principles of which will be reasonably well known by the majority of readers, even if the examples are not. The book goes some way to being a reference book in that it contains quite a lot of detail of doses and drug interactions, but it is not comprehensive enough, nor well organized enough to replace more standard textbooks. For example, some of the chapters are drug orientated, e.g. antibiotics; others disease orientated, e.g. respiratory failure. Each chapter contains a large number of useful references, although in some areas these do not reflect the balance of studies that have been carried out. For example, the authors quote one study showing that intravenous salbutamol is preferable to inhaled salbutamol in severe asthma and none of the several studies showing nebulization to be at least as effective as the intravenous route with fewer side-effects. As a practical guide on drug treatment in respiratory disease the book contains a lot of
well-balanced and sensible advice. Antibiotics are well covered with a lot of useful information, and a nice simple guide to the cephalosporins for those feeling overwhelmed by the proclivity of these drugs. Dr Cole’s conclusion that cephalasporins have little place in the routine management of chronic respiratory disease could be useful ammunition for the next crusading drug representative. I was surprised to find co-trimoxazole described as a second-line drug for exacerbations of chronic bronchitis. Much of the advice given by Dr Cole is unexceptional, but there is some which I would question. For example - that doxepram should only be used in patients considered unfit for mechanical ventilation; that eye testing should be carried out on all patients prior to ethambutol treatment; that heparin should be given for 7 days for a deep vein thrombosis; that sodium cromoglycate controls symptoms in 65-70% of adult patients with severe asthma; and that streptomycin is still indicated for large tuberculous cavities with current drug regimens. The maintenance dose of iv. aminophylline recommended by Dr Cole from the work by Mitenko and Ogilvie (0,9mg/kg/hour), is probably too high in the light ofmore recent work. Hendeles et al. (Am. Rev. resp. Dis. 1978,118,97) suggests that a dose of 0.5mg/kg/hour provides a safer balance between therapeutic efficacy and toxic side-effects, particularly ifblood levels cannot be measured. The suggestion that arterial Pco, should be monitored half hourly for the first 2 hours of oxygen therapy in respiratory failure seems a little impractical. Clearer statements about the danger of giving iv. aminophylline to patients receiving oral theophylline, and ephedrine to patients on monoamine oxidase inhibitors, and a caution about using ethambutol for the elderly or those with impaired vision, would be useful. This book may disappoint people with an interest in respiratory pharmacology since it does not address current areas of controversy and research interest. The action oftheophylline is stated as being due to phosphodiesterase inhibition with no mention of the arguments against this hypothesis, nor mention of other possible mechanisms of action. Dr Cole tends to present
316
Book Reviews
the findings from the large number ofstudies he quotes at face value. I would have preferred a more critical analysis of the evidence, particularly where results are obviously conflicting. Overall, a book which contains a lot of good advice, but also some that appears to be slightly dated. Those with an interest in clinical pharmacology may find it a little bland. A. E. Tattersfield
&zical
Strategies
in Adult
Asthma
Charles H. Scoggin and Thomas L. Petty Philadelphia: Lea and Febiger. 1st edition. 1982. Pp. 149. Price $9.75 (paper) This paperback describes the approach to asthma management in Denver, Colorado, and is aimed at the ‘practising physician’. The major part of the book is divided into chapters on acute asthma, acute intermittent asthma and chronic persistent asthma, each chapter being written by one of the authors. This is a useful, practical approach but the authors vary in their emphasis on mechanism and diagnosis or on treatment and this leads to some lack of balance. Most paragraphs are headed by questions, a technique often found in American textbooks, which may help the reader to refer quickly to a topic. There are a number of case histories illustrating specific points. The few illustrations used are ofgood quality. An early chapter on recognition and assessment of asthma is well written and useful, although there are some misprints and mistakes, particularly in descriptions offlow-volume loops and forced expiratory ratios. There are valuable sections on pregnancy and asthma, surgery and asthma and bronchoscoping asthmatic patients. Readers on this side of the Atlantic will find the drug treatment ofasthma least satisfactory. The range of drugs available in the USA is limited and few British chest physicians would consider oral theophylline preparations to be the first line of treatment. Inhaled corticosteroids are also used late in the recommended approach to treatment. Overall it is an interesting look at an individual approach to the rational treatment of asthma but it cannot be recommended as a guide to management ofasthma in this country. P. J. Rees
Current Diseases
Topics
in
the Management
of
Edited by J. S. Brody & G. L. Snider Edinburgh: Churchill Livingstone. x + 182. Price E10.50
Respiratory
1981. Pp.
This book has been written jointly by the Senior Staff in the Pulmonary Division of the Boston University School of Medicine. It is a highly readable book which aims to provide a concise guide to the management of respiratory diseases for physicians, medical students and ‘allied health personnel’. Each section of the book is prefaced by an account of the rationale behind the management practised by the authors. For instance, the chapter on bronchomotor tone introduces the treatment ofsevere asthma and of chronic airways obstruction. However, it contains only three paragraphs on airways physiology, the first of which contains the surprising statement that Poiseuille’s law concerns turbulent, as well as laminar flow. The authors admit that there are considerable species differences in the neural control of airways smooth muscle, but they devote space to describing the results of animal experiments, while giving few references to the human studies and failing to mention either the controversies concerning the effect ofanticholinergic agents on induced bronchospasm, the results of radioligand binding studies on human lung adrenoreceptors, the evidence concerning pz-adrenergic function in normal and asthmatic bronchi, or the role of different types of histamine receptors in human bronchi. The chapters on the treatment ofasthma and the prevention of tuberculosis include much that is controversial, but the references have been carefully selected to support the authors’ viewpoint. A wide literature concerning, among other topics, p2-adrenergic agonists and the protective effect of BCG is completely ignored. Predictably a strong preference is expressed for intravenous aminophylline in the treatment of severe asthma. However, I think that the authors’ preferred method ofstaging and the use of this staging in the management of severe asthma is potentially dangerous. An asthmatic with an FEV, of 1.3-2.0 litres, unrelated to predicted values and a Pao, of less than 80 mmHg is regarded as having only moderate airways obstruction, which can be managed safely without steroids on an outpatient basis. The criteria for admission to hospital appear to be an