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The layout of the book is interesting and practical. The authors start out with a review of the 6 CYP systems as separate chapters. They start out with the most well characterized systems. They look at enzyme locations, metabolic activity, polymorphisms, inducers and inhibitors. They also provide vignettes of typical problems at the end of each chapter. A good example of the level of analysis in this book is contained in the brief vignette at the end of the 2C9 chapter. They describe a case of phenytoin toxicity that occurs when fluoxetine is added to phenytoin maintenance therapy. Their comment is: "Phenytoin is metabolized by 2C9, 2C19, and phase II conjugation systems. Although not a potent inhibitor of 2C9 and 2C19, fluoxetine does inhibit these enzymes and most certainly was the cause of this woman's increase in phenytoin levels". Comparison with other methods of checking these interaction usually does not provide this level of detail. Commonly used drug interaction programs may attribute the accumulation of phenytoin to "decreased metabolism" and point out that other compounds also have this effect. Drug interaction cards or charts might count on you being able to see both phenytoin and fluoxetine in two different columns and making the connection. The authors' analysis pulls all the relevant facts together in one place.
Chapters specific to Gynecology, Internal Medicine, Infectious Diseases, Neurology, Oncology and Surgery follow the initial chapters on CYP enzymes. Specific clinical examples of relevant drug- drug interactions are given in each chapter. As an example, the Gynecology chapter discusses the issue of contraceptive failure due to enzyme induction. Specific prescription drugs and a potential problem with St. John's wort are discussed. These chapters are all clinically relevant and well referenced.
The book concludes with two appendices - one about how to search the literature and very well written Appendix A. Guidelines for Prescribing in a Polypharmacy Environment. Polypharmacy has become the rule rather than the exception these days as more therapeutic agents are added to treat multiple illnesses in the same patient. In fact, in some situations multiple agents from the same therapeutic class are being used to treat refractory problems. The authors suggest five principles for physicians to use that decrease the likelihood of drug-drug interactions. These guidelines are adaptable to individual practices and allow the clinician to choose a profile of medications with the greatest level of safety. The book also contains a pocket guide called "P450 Tables" that summarizes the interactions listed on specific chapters.
My particular bias as a practicing physician is that I need to know the information in this book. After attending seminars on the topic, reading journal articles and pharmacology texts, and using several computer programs on drug interactions the information presented in this book is comprehensive and unique. As a paperback book it is also inexpensive. It is a book that should be read by psychiatrists and other physicians who prescribe medications to patients using other prescription or over the counter medications.
George Dawson, MD
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Frederick Douglass was one of the most articulate voices opposed to slavery among free blacks. A natural writer, he describes his life in slavery and how dehumanizing it was. The time he spent in slavery was a microcosm of most of the contradictions of slavery. Taken from his mother at a young age, he knew nothing about his white father. A slave was property to their owner, somewhat on a par with a horse or cattle. And yet, many slaveholders fathered children with their female slaves. Many slaves were severely beaten or killed for disobedience. Chivalrous gentleman who would not tolerate a man beating a horse would speak approval of similar actions being performed on a defenseless slave. Douglass was beaten many times, even to the point of possible permanent injury, for actions that were simply human. Finally, there was the bizarre spectacle of slaves and free blacks living in the same areas, sometimes even being relatives by blood or marriage. The woman who eventually became his wife was a free woman while he was a slave, joining him after he escaped to freedom.
It does us all good to be reminded how destructive slavery was to the structure of American society. Douglass lived on both sides of the issue and his story of the slave years are a powerful tale of human destruction. Written for older children, this book should be required reading for graduation from high school.