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D G Grahame-Smith, J K Aronson
656 pp Price £60 (h/b); £29.50 (p/b) ISBN 0-19-850944-8;
0-19-263234-5. Oxford: Oxford University Press, 2002 .
In the medical press there has been much debate about the lack of clinical pharmacology and therapeutics teaching in medical schools—with a suggestion that this might be a factor in the excessive number of prescribing errors in hospitals. With the 3rd edition of their textbook, Grahame-Smith and Aronson aim to provide medical students and junior doctors with a very practical guide to good prescribing. The text comes in four sections, the first of which deals with pharmacokinetics and pharmacodynamics. The principles are well explained, with good examples. Subsequent chapters in this section offer advice on how to take a good drug history, what factors to consider when a patient responds poorly to treatment, and special precautions for prescribing in the young, the old, the pregnant and the patient with renal failure. One of the best chapters explains the process of drug discovery from laboratory to clinic. It discusses the roles of the Committee on Safety of Medicines and NICE, and what is required of a drug for licensing purposes. Then follows a chapter on how to look at the design of clinical studies on new drugs. These two chapters deal with an area that tends to be neglected at medical school, yet has to be understood by anyone who wishes to evaluate a new agent on the market. My only criticism of this whole section is that it lacks an account of the role of the clinical pharmacologist in both laboratory and hospital medicine. What sort of patients should be referred to a clinical pharmacologist?
The second section, entitled ‘Practical prescribing’, begins with the thought-processes one should go through before deciding which drugs to prescribe for a patient; and readers are then told exactly how to write a prescription for a hospital patient or in general practice. The third section adopts a systems-based format to discuss the pharmacological treatments of common medical and surgical conditions. Although these recommendations are well explained and easy to read, I would have welcomed more information on the quality of the evidence. For example, a treatment with an excellent evidence base could have been given two stars, a treatment with moderate evidence one star and a treatment with no evidence no star. The last group tend to survive because of ‘tradition’. In long-case exams and on ward rounds we are often asked ‘how good is the evidence’—for thrombolysis, for example. These parts of the text might usefully have been referenced. I was disappointed by the chapter on immunological therapies. It provides a basic explanation of the four types of hypersensitivity reaction but no account of the inflammatory mediators involved—essential information for an understanding of immunomodulatory anti-inflammatory agents and the cytokine-antibody therapies now being used in rheumatoid arthritis and Crohn's disease. The last section is a pharmacopoeia—in effect, short notes on all the commonly prescribed drugs. This will be useful for fast information and last-minute revision before exams.
The first two sections of this textbook will be of particular value to junior doctors who wish to sharpen their prescribing skills; they cover practical matters that are little discussed in other texts. The information in the third and fourth sections can be found in any good book on pharmacology, but the presentation focuses much more on practical issues for clinicians. Any clinical medical student or junior doctor will find this work enjoyable and useful.