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Disease modifying therapy in vasculitides
  1. Paul A Bacon

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    The target readership for this slim book on the treatment of vasculitis is identified from the outset. Only one chapter is on standard regimens based on cyclophosphamide and steroids. There is widespread recognition of the potential toxicity of standard treatment, especially with prolonged usage. Thus two more chapters deal with alternative approaches to conventional immunosuppressive drugs, discussing methotrexate—which is in widespread use—and the newer agents, mycophenolate mofetil and desoxyspergualin. Five subsequent chapters deal with more experimental treatments, ranging from tumour necrosis factor blockade through intravenous immunoglobulin to various forms of anti-T cell treatment.

    This is thus mainly an update for those specialists already familiar with the standard treatment for vasculitis and all its problems. Minor but important aspects of disease control, such as control of blood pressure, renal function, and even psychological support, are not considered as the editors are dealing only with disease modifying approaches. As such, this is a timely review of knowledge in a rapidly advancing field which will also provide good reading for those who see vasculitis less frequently. It should convince them that there are alternative approaches for relapsing or resistant cases, even if they have received full courses of standard treatment. Referral of cases to specialist centres may even be encouraged, which is probably the only way to obtain a sufficient pool of patients to conduct the necessary studies that will advance knowledge in these rare but serious disorders.

    The chapters have been written by those at the forefront of their fields who have largely discussed the benefits and the risks of the treatments they describe. This will help clinicians faced with difficult treatment choices to make decisions relevant to their individual patients. The idea of a single treatment for a diverse set of diseases that can affect any organ is no longer appropriate. Different stages of disease require different approaches. In the future, treatment may be further individualised according to pathogenesis, as suggested by the chapters on the virus related systemic vasculitis and the prevention of relapse in ANCA related small vessel vasculitis. The last is particularly relevant, both because ANCA associated vasculitides form a major part of the systemic vasculitis seen in Europe/America and because relapse is one of the major problems now that initial remission can be induced in at least 90% of patients. Movement in this field in the past 10 years has occurred and the reader is given clear indications of the current excitement in this steadily progressing area.

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