Therapy of Systemic Rheumatic Disorders

Presents the latest information on the pharmacotherapy of systemic rheumatic disorders-including polyarthritis, spondyloarthropathies, and connective tissue diseases-highlighting the importance of early diagnosis, disease assessment, and monitoring.

A generation ago, in the 1960s, many exciting developments were taking place in rheumatology. Clinical studies were greatly improving the classification of the systemic rheumatic diseases, basic research was elucidating the immune system and its central involvement in the pathogenesis of many diseases, and controlled clinical trials were beginning to validate the effectiveness of some treatments. During the ensuing two decades there were few important therapeutic advances. Now, rheumatology may be on the threshold of a new era with the emergence of specific biologic agents that target selected cell-surface antigens and proinflammatory cytokines and the development of strategies in which drugs, previously used only in monotherapeutic regimens, are judiciously combined. In addition, there has been a radical philosophical change in decision making by clinicians when prescribing potent disease-modifying drugs. In rheumatoid arthritis, articular damage occurs early, and it is no longer thought appropriate to delay effective therapy until the erosive potential of the disease is established.

Therapy of Systemic Rheumatic Disorders highlights these advances. It opens with a comprehensive review of the pathogenic mechanisms that may provide targets for therapy in rheumatoid arthritis. Issues relating to rheumatoid arthritis occupy more than half the book. Several chapters discuss methods of clinical evaluation, the identification of prognostic markers, methods of designing and interpreting clinical trials, and the process of deciding when to commence and when to discontinue potent therapeutic interventions that may provide clinical benefit but may also have limitations. These discussions will fascinate all practicing and trainee rheumatologists, as well as physicians with a general interest in the evaluation and treatment of chronic inflammatory diseases. Some of the concepts outlined in the opening chapters are still evolving. For example, in the search for more accurate prognostic markers of aggressive disease in the pre-erosive phase, the influence of genetic factors in various populations and the potential of newer imaging techniques may be crucial.

These reviews set the scene for detailed discussions of second-line therapeutic agents, including the conventional compounds, cytotoxic drugs, corticosteroids, and antibiotics. There are excellent reviews of the early experience with biologic therapies, although the second edition of this book is likely to require several additional chapters to consider these developments further. Several authors address combination therapy. There is also a specific chapter on the subject, and each of the chapters dealing with individual second-line agents also discusses the inclusion of these agents in various combination regimens. The excellent chapter on aggressive therapeutic approaches also discusses combination regimens.

There is an unavoidable degree of duplication. Clearly, the chapters were written over a relatively long period, and only one author refers to the important study by O'Dell et al. (New England Journal of Medicine, Vol. 334:(20), pp. 1287-1291) that evaluated the combination of methotrexate, sulfasalazine, and hydroxychloroquine in the treatment of rheumatoid arthritis. In at least one chapter, the most up-to-date reference to a full-length publication is to one published in 1994. The chapter on local therapy for inflammatory arthritis, which includes an evaluation of arthrocentesis, intraarticular corticosteroid preparations, and chemical and radiation synovectomy, is among the best of its kind in the rheumatology literature.

Separate sections discuss therapy of other polyarthritides, both common and rare, and the collagen vascular diseases. Inevitably, in a multiauthored textbook, there are variations in the level of detail and depth of discussion. For example, the chapter on systemic lupus erythematosus, including the discussion of the treatment of renal, neurologic, and other major complications, is about half as long as the chapter on scleroderma, which contains virtually no discussion at all of the treatment of arthritis, which can be severe in this disorder.

The large number of typographic, spelling, and editorial errors throughout is unfortunate. In one example the author is, delightfully, on first-name terms with Desiree et al. in a table but resorts to the more conventional last-name format of van der Heijde et al. in the list of references. Nevertheless, this book has several merits, and it undoubtedly achieves its objective of providing comprehensive discussions of most current therapeutic issues relating to systemic inflammatory rheumatic diseases.

Reviewed by Barry Bresnihan, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.