Severe Asthma. Pathogenesis and Clinical Management

Book reviews Severe Asthma. Pathogenesis and Clinical Management Edited by S. J. Szefler and D. Y. M. Leung. Marcel Dekker, Inc., New York, 1996. 614 pages. Hard cover $195.00 Physiologic impact, frequency and severity of symptoms, extent of inflammation, and impact on function and quality of life can define the severity of asthma. Depending on the definition and the population studied, investigators have concluded 4.9% to 31% of patients with asthma may have severe asthma. Much of the economic cost of asthma has been due to severe asthma. The total cost of asthma in the United States in 1990 was an estimated $6.4 billion. The risk of fatal asthma is much less than 1% of the general population in countries from which reliable data are available. Although rates of death from asthma in the United States increased from 1977 through 1988, much of the increase may have been due to increases in prevalence. Admissions to hospitals for asthma as a percentage of prevalence have decreased. Since 1988 there has been stabilization of the previously increasing mortality rates, although at a rate nearly double that of 1977 after adjustment for revision of the International Classification of Diseases that took effect in 1979. Accordingly, a review of pathogenesis and management of severe asthma, always timely, is especially appropriate now. This volume 86 of the series, “Lung Biology in Health and Disease,” is a comprehensive, current textbook on almost every aspect of the most-difficultto-manage asthmatic patient, the patient with severe asthma. After the introductory chapter explains the epidemiology and socioeconomic impact of severe asthma, other internationally recognized experts review in more detail than available in most textbooks risk factors for morbidity and mortality; pathology; pulmonary physiology; evidence and mechanisms of inflammation; pharmacologic

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management with emphasis on adrenal corticosteroids, including mechanisms of action and steroid resistance; alternative anti-inflammatory and immunomodulatory therapy; and diagnosis and management, including psychosocial aspects and compliance with recommended therapy. A major strength of this book is the very detailed review of mechanisms and response to glucocorticoid therapy, as one might expect of a text edited by physician-pharmacologists recognized internationally for expertise in these areas. The two informative case studies of difficult-to-control asthmatic patients left me wanting to hear about more but wondering how accessible the sophisticated corticosteroid studies described would be for most clinicians. Detailed analysis of anti-inflammatory and immunomodulatory therapeutic alternatives to corticosteroids place these alternatives in proper perspective as experimental and of uncertain usefulness. The impact of rhinitis on asthma merits more than a half page in a book of this length, but the chief omission is a critical review of immunotherapy. The chapter on allergen-specific therapy is devoted largely to avoidance with only one page on immunotherapy including only three literature citations, two of which describe systemic reactions. A suggestion that immunotherapy “might be appropriate in the child. . .who lives on a farm, where avoidance of [aeroallergens] is not realistic” disregards the ubiquity of aeroallergens and numerous studies indicating beneficial effects in patients with allergic rhinitis and asthma. Although immunotherapy may be less beneficial in most patients with severe asthma than in those with mild or moderate asthma, not even the studies suggesting this are reviewed. The reader is left with the impression that methotrexate or cyclosporine is a more rea-

sonable therapeutic option than immunotherapy! Photomicrographs of airways of an asthmatic patient are of limited usefulness because of publication in black and white. It is time for publishers of both books and journals to recognize the need for color for such illustrations, the added cost notwithstanding. The text is well edited in general although there is some duplication of discussion of therapeutic alternatives to corticosteroids in different chapters. Indexes not only to subjects but also to authors of references cited facilitate location of passages of immediate interest. This important textbook should be essential in the library if not on the desk of every clinician who treats patients with asthma and every investigator who studies pathophysiology or pharmacology of asthma. Selected chapters may also be of interest to sophisticated asthmatic patients. I hope the editors and authors will revise it frequently to keep future editions as current in this rapidly advancing body of knowledge. R MICHAEL SLY, MD Children’s National Medical Center Washington, DC Monograph on Insect Allergy, Third Edition. Edited by Macy I. Levine, MD and Richard F. Lockey, MD. American Academy of Allergy and Immunology, 1995. 145 pages, $20.00. This book is an indispensable resource for allergists. Authored by national and international experts in the field, the monograph is concise, yet thorough and up-to-date. The chapters are well-organized and well-referenced, beginning with a historical perspective on Hymenoptera allergy that takes us from the earliest known reference up to today’s still un-

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