From The New England Journal of Medicine, May 18, 2000
"Medicines," wrote Leonardo da Vinci, "will be well used when the doctor understands their nature, what man is, what life is, and what constitution and health are. Know these well and you will know their opposites; you will then know well how to devise a remedy." As the coauthor of a textbook on clinical pharmacology and drug therapy for medical students, in which this principle is espoused, I applaud any attempt by others to do likewise. That is indeed the basis for this textbook on drug therapy for clinical pharmacists.
An introductory section on some of the basic principles of clinical pharmacology is followed by 16 sections on the management of diseases, organized according to systems of the body. In each of the chapters dealing with individual diseases, the authors first discuss the pathophysiologic principles and then outline the methods of drug therapy appropriate to each, firmly grounding the therapy in the context of the pathophysiology. Some of the sections on systems of the body include accounts of the evaluation of the diseases to which the system is prey. In each case, the arguments for using one drug or another are based on the most recent evidence, cited in the bibliography at the end of each chapter, although one of the cornerstones of evidence-based medicine, the number of patients who would need to be treated to produce a given outcome (known as the number needed to treat), is conspicuously absent. The discussions are for the most part excellent, but the chapters that include contributions from physicians have a slight edge over those that do not.
It is strange that such a high-quality text is not accompanied by better diagrams. Although there are several good anatomical diagrams, there are few that illustrate normal physiology or the pathophysiology of disease, and those that are provided do not show the use of drugs and where they act. In contrast, for virtually every condition, there is a flow chart indicating what to do when a test is positive or negative, when a patient has a particular clinical feature that might modify therapy, or when a patient does or does not have a response to treatment. But these diagrams are difficult to use. Moreover, their rigid format does not accommodate an understanding that the enormous variability among the patients one encounters in everyday practice greatly militates against such an approach in all but the simplest stepwise problem, such as the treatment of asthma, which is clearly illustrated by the simplicity of the flow chart for asthma.
The introductory chapters are disappointing. To open with a chapter on the economics of drug therapy surely gives the wrong emphasis, even in an increasingly cost-conscious health care system. The chapter on pharmacokinetics and pharmacodynamics sets a high bar to vault, and other chapters are too short to allow their authors a long enough run up to succeed. An introduction of only 90 pages (less than 4 percent of the text) is not enough, although to be fair, some general aspects of drug therapy are discussed in other chapters (for instance, there is a description of how to alter drug dosages in the section on renal disorders). I found few mistakes in the book and none of importance, except for the curious dose ranges for angiotensin-converting-enzyme inhibitors listed in the chapter on heart failure, with daily doses as high as 400 mg given for drugs such as enalapril.
This book is a good reference for clinical pharmacists who can create their own diagrams. But to get the most out of the text, they will need to know their basics pretty well and be prepared to flesh out certain points by consulting the review literature.
Jeffrey K. Aronson, D.Phil., F.R.C.P.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to an out of print or unavailable edition of this titl
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