Ragweed, mold, and lingering warm temperatures are driving this year's fall allergic rhinitis season, and clinicians fielding a fresh wave of nasal symptom complaints now have an updated evidence base to prescribe against.1 The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative, in collaboration with the European Academy of Allergy and Clinical Immunology (EAACI), published its 2024-2025 revision of the ARIA guidelines across 2 manuscripts in the journal Allergy earlier this year, with part 1 on intranasal treatments appearing in April 2026 and part 2 on oral and ocular treatments following in June 2026.2,3

The writing group, led by Bernardo Sousa-Pinto, MD, PhD (University of Porto), and Jean Bousquet, MD, PhD (Institute of Allergology, Charité—Universitätsmedizin Berlin), developed the update using GRADE methodology, marking the first substantive revision to ARIA's pharmacologic recommendations since 2016 and the most significant shift in first-line intranasal therapy since the original 2010 update.4 For clinicians prescribing this season, whether starting fresh or revisiting regimens for patients whose fall symptoms outlast a single-agent spray, the update changes which therapy tops the treatment ladder.

The guideline reflects a broader move toward combination intranasal therapy over monotherapy. It also introduces individual agent-level preferences within drug classes for the first time, rather than stopping at class-level recommendations, and it reverses a prior recommendation on intranasal decongestants, a category patients often reach for on their own as fall congestion sets in.

Frequently Asked Questions

Q: What is new about this guideline compared with ARIA 2010/2016?

A: Four questions were evaluated for the first time in this revision:

1. Should a fixed combination of an intranasal antihistamine and intranasal corticosteroid (INAH+INCS) be used over no treatment at all? (strong recommendation for INAH+INCS)
2. Should a particular intranasal corticosteroid be preferred over others? (conditional recommendation favoring fluticasone furoate/propionate)
3. Should one fixed combination be preferred over another? (conditional recommendation favoring azelastine-fluticasone)
4. Should an intranasal corticosteroid be combined with a decongestant or used alone? (conditional recommendation against adding the decongestant)

Additionally, 3 existing recommendations changed in strength or directionality:

1. INAH vs. no treatment (now a strong recommendation toward INAH)
2. Intranasal decongestant vs. no treatment (flipped from conditional-for to conditional-against for long-term use)
3. INAH+INCS vs. INCS alone (shifted from "either is fine" to conditional preference for the combination)

The key shift: fixed INAH+INCS combinations move from an equal alternative to INCS monotherapy to the preferred option when monotherapy is unlikely to control symptoms.2

Q: What is the key recommendation on combination intranasal therapy?

A: In patients with allergic rhinitis in whom monotherapy is unlikely to lead to significant symptom improvement, the guideline recommends using a fixed INAH+INCS combination over no treatment, a strong recommendation based on moderate certainty of evidence for seasonal allergic rhinitis and very low certainty of evidence for perennial allergic rhinitis.2

Q: Which individual agents does the guideline prefer within each class?

A: For INCS monotherapy, the guideline suggests fluticasone furoate or fluticasone propionate over beclomethasone, budesonide, ciclesonide, mometasone, and triamcinolone, a conditional recommendation based on low to very low certainty of evidence drawn from network meta-analysis.2

For fixed combination therapy, it suggests azelastine-fluticasone over olopatadine-mometasone, a conditional recommendation based on moderate certainty of evidence in seasonal allergic rhinitis. The guideline notes that both combinations share a similar safety profile and that olopatadine-mometasone may be preferred in patients who find azelastine-fluticasone's taste profile intolerable.2

Q: What changed regarding intranasal decongestants?

A: The guideline now recommends against adding an intranasal decongestant to an INCS, a reversal from the 2010/2016 guidelines. The current recommendation is conditional and based on very low certainty of evidence.2

Q: What does part 2 recommend for oral and ocular treatment?

A: The panel now conditionally recommends against adding a leukotriene receptor antagonist (LTRA) to an oral antihistamine.3

For eye symptoms, oral antihistamines are conditionally preferred over ocular antihistamines except when very fast relief is needed. Ocular antihistamines are conditionally preferred over ocular mast cell stabilizers.

On choosing among individual oral antihistamines, the guideline stops short of naming a winner: cetirizine, bilastine, rupatadine, loratadine, and others each have tradeoffs in sedation, onset, and affordability, so the recommendation is to match agent to patient preference rather than default to one drug.

4 changed recommendations:

1. OAH vs. LTRA (changed from conditional to strong recommendation for OAH)
2. Intranasal corticosteroids vs. OAH (upgraded to a strong recommendation for INCS)
3. LTRA vs. no treatment (reversed to a conditional recommendation against LTRA in both seasonal and perennial disease, reflecting rare but serious neuropsychiatric safety signals)
4. OcAH vs. no treatment (now conditional against starting OcAH in seasonal disease (except brief or as-needed use) but conditional for OcAH in perennial disease)

Q: Are there population-specific caveats clinicians should know?

A: Yes. The INCS agent-level preference was not extended to children and adolescents due to insufficient evidence for that population. For the combination-agent comparison, the guideline suggests either azelastine-fluticasone or olopatadine-mometasone in children and adolescents rather than favoring one. The writing group also notes that in low- and middle-income countries, availability and affordability, including WHO Essential Medicines List status for budesonide, may reasonably outweigh the efficacy-based preference for fluticasone formulations.

References

1. Why Are You Getting Allergies in the Fall? Cleveland Clinic. Published September 9, 2026. Accessed September 11, 2026. https://health.clevelandclinic.org/fall-allergies

2. Sousa-Pinto B, Bousquet J, Vieira RJ, et al. Allergic Rhinitis and Its Impact on Asthma (ARIA)-EAACI guidelines-2024-2025 revision: part I-guidelines on intranasal treatments. Allergy. 2026;81(4):954-976. doi:10.1111/all.70131

3. Vieira RJ, Sousa-Pinto B, Bousquet J, et al. Allergic Rhinitis and Its Impact on Asthma (ARIA)-EAACI guidelines-2024-2025 revision: part II-guidelines on oral and ocular treatments. Allergy. 2026;81:1947-1970. doi:10.1111/all.70305

4. Brożek JL, Bousquet J, Agache I, Agarwal A, Bachert C, Bosnic-Anticevich S, Brignardello-Petersen R, Canonica GW, Casale T, Chavannes NH, Correia de Sousa J, Cruz AA, Cuello-Garcia CA, Demoly P, Dykewicz M, Etxeandia-Ikobaltzeta I, Florez ID, Fokkens W, Fonseca J, Hellings PW, Klimek L, Kowalski S, Kuna P, Laisaar KT, Larenas-Linnemann DE, Lødrup Carlsen KC, Manning PJ, Meltzer E, Mullol J, Muraro A, O'Hehir R, Ohta K, Panzner P, Papadopoulos N, Park HS, Passalacqua G, Pawankar R, Price D, Riva JJ, Roldán Y, Ryan D, Sadeghirad B, Samolinski B, Schmid-Grendelmeier P, Sheikh A, Togias A, Valero A, Valiulis A, Valovirta E, Ventresca M, Wallace D, Waserman S, Wickman M, Wiercioch W, Yepes-Nuñez JJ, Zhang L, Zhang Y, Zidarn M, Zuberbier T, Schünemann HJ. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol. 2017 Oct;140(4):950-958. doi: 10.1016/j.jaci.2017.03.050. Epub 2017 Jun 8. PMID: 28602936.