Book Review

Asthma: Critical Debates

N Engl J Med 2003; 348:479-480January 30, 2003

Article

Asthma: Critical Debates
Edited by Sebastian L. Johnston and Stephen T. Holgate. 395 pp., illustrated. Oxford, England, Blackwell Science, 2002. $139.95. ISBN: 0-632-05721-1

The rising tide of asthma in the Western world invites many questions. Why is the incidence of asthma increasing? Does avoidance of allergens help? When should treatment be started, and what are the therapeutic options? Anyone faced with these and related questions will find Asthma: Critical Debates invaluable. This book, a compact review of many topical issues in asthma by internationally renowned experts, is divided into four sections covering epidemiology, pathophysiology, treatment, and delivery of care. The title of each chapter is a commonly asked question. The book addresses not only the causes, pathogenesis, and treatment of asthma but also the effects of psychosocial problems on its control.

“Why Is the Incidence of Asthma Increasing?” leads the reader into the first section of the book, which deals with possible causes of atopy and allergic asthma. Chapters on air pollution, nutrition, exposure to allergens, hygiene, and infection suggest that atopy and allergy are the costs of industrialization. The environmental changes that followed German reunification after the fall of the Berlin wall are an example of rapid industrialization. Von Mutius's review of the increase in atopy but not asthma in some areas of East Germany after reunification leads us to the question posed in the next chapter: “How Much Asthma Can Be Attributed to Atopic Sensitization?” The thoughtful answer given by Richard Beasley and colleagues will inspire readers to continue.

Some chapters are easier to read than others. “Is Air Pollution Important in Asthma?” would have benefited from presentation of the clinical data in tables. “Genetics of Asthma: What's New?” is a concise summary of the chromosomal regions and candidate genes implicated in asthma and atopy, and it introduces the reader to pharmacogenetics. For the uninitiated, it will almost certainly require a second reading.

Custovic and Woodcock discuss avoidance of allergens and present the results of numerous clinical studies in tables, providing a detailed yet highly readable chapter. Their views are clear: “There is strong evidence that sensitization and exposure to indoor allergens is a primary cause of asthma.” Clinicians providing care for patients with allergic asthma who refuse to get rid of the family pet will find this chapter informative and practical. “What New Therapies Are Being Developed for Asthma and Will They Offer Something Better Than Steroids?” — another well-written chapter — presents an easy-to-understand discussion of several new and exciting approaches to treatment that arose from studies of interleukin-12, anti–interleukin-4 antibody, anti–interleukin-5 antibody, and anti-IgE antibody. From new therapies, the focus shifts to current therapies and one of the most controversial issues in the management of asthma in recent years: the use of long-acting b₂ agonists. Sears summarizes the debate and discusses the mechanism of action of long-acting b₂ agonists, concerns about safety, and indications for their use. There is also a discussion of the use of leukotriene modifiers, which have clear benefits and a favorable safety profile for the treatment of aspirin-sensitive asthma, exercise-induced asthma, and allergen-associated asthma. Nominating leukotriene modifiers as “an excellent choice for first-line asthma therapy in mild persistent asthmatics,” Wechsler and Drazen are likely to stimulate even further debate. A joint perspective that recognized the obvious transatlantic differences of opinion about the place of leukotriene modifiers in the treatment of asthma would have made for a more critical debate.

Many questions about the care of asthma remain. There is no evidence, for example, of the benefit or cost effectiveness of asthma clinics. In reviewing patient education, however, Partridge concludes that “the teaching of asthma self-management behaviour and the issuing of self-treatment plans is associated with a significant improvement in outcomes.” In the chapter on the role of psychosocial factors, Harrison and Mildenhall provide evidence that deaths from asthma, brittle asthma, emergency room visits, and poor compliance are associated with denial, depression, deprivation, smoking, and alcohol and drug abuse. The authors describe their own experiences and the establishment of an innovative clinic run by a chest physician and a psychiatrist. Their results are thought-provoking, and their recommendations for the care of high-risk patients will be valuable to all clinicians who manage asthma.

Robert Ian Ketchell, M.D.
Guy's and St. Thomas's Hospital National Health Service Trust, London SE1 9RT, United Kingdom
ian.ketchell@kcl.ac.uk