Introduction: risk management in asthma and allergic diseases

The recent advances in therapy for allergic diseases, including allergic rhinitis, asthma, and urticaria, have posed new challenges to physicians who must carefully assess the risks and benefits to the patient of new treatment. Appreciation of the drug interaction between certain second-generation antihistamines, including terfenadine and astemizole, with selective macrolide antibiotics and imidazole antifungal agents leading to QTc interval prolongation, and the potential for fatal cardiac arrhythmias is an example of the need to assess risks of therapy. Risk management in allergic disease includes minimizing disease morbidity by emphasizing allergen avoidance in asthma and by minimizing the therapeutic morbidity and mortality that can occur when allergen immunotherapy is administered either improperly, such as in an unsupervised setting, or inappropriately, such as to unstable asthmatics. Physicians must carefully weigh the benefits of therapies designed to decrease costs, including regimens combining second- and first-generation antihistamines, considering both the potential risk ensued related to sedation and impaired cognitive performance when using first-generation antihistamines and the unproven efficacy of such regimens. Clearly, risk management in asthma and allergic disease will become more complex with greater understanding of mechanisms of allergic disease, of provocative factors exacerbating allergic disease, of the potential adverse consequences of therapy, and of the potential interaction among therapeutic modalities. It is essential that physicians treating the nearly 20% of Americans who have allergic disease thoroughly appreciate the risks and benefits of their therapeutic decisions.