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Allergic Rhinitis and Its Impact on Asthma (ARIA)‐EAACI Guidelines—2024–2025 Revision: Part II—Guidelines on Oral and Ocular Treatments

ARIA/EAACI · 2026 · Europe

Source and licence

Authors
Rafael José Vieira, Bernardo Sousa‐Pinto, Jean Bousquet et al.
Title
Allergic Rhinitis and Its Impact on Asthma (ARIA)‐EAACI Guidelines—2024–2025 Revision: Part II—Guidelines on Oral and Ocular Treatments
Journal
Allergy, 2026
DOI
10.1111/all.70305
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13256267

Licence statement of the original publication

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Should any specific OAH vs. other OAH be used for the treatment of AR?

  • In patients with AR, we suggest that the choice of specific OAH over others should be based on patients' preferences on efficacy and safety and on availability and affordability.Conditional recommendation|Very Low CoE

Should an OAH + LTRA vs. OAH be used for the treatment of AR?

  • In patients with AR, we suggest using OAH over OAH + LTRA.Conditional recommendation|Moderate CoE

Should OcAH vs. OAH be used for the treatment of ocular symptoms in patients with AR?

  • In patients with AR, we suggest against using OcAH over OAH, except for very fast relief of ocular symptomsConditional recommendation|Very Low CoE

Should OcAH vs. ocular mast cell stabilisers be used for the treatment of ocular symptoms in patients with AR?

  • In patients with AR, we suggest using OcAH over mast cell stabilisersConditional recommendation|Very Low CoE

Should OAH versus LTRA be used for the treatment of AR?

  • In patients with AR, we recommend using OAH over LTRA.Strong recommendation|Moderate CoE

Should INCS versus OAH be used for the treatment of AR?

  • In patients with AR, we recommend using INCS over OAH.Strong recommendation|Moderate CoE

Should LTRA vs. no treatment be used for the treatment of AR?

  • In patients with AR under no treatment, we suggest against using LTRA.Conditional recommendation|Moderate CoE

Should OcAH versus no treatment be used for the treatment of ocular symptoms in patients with AR?

  • In patients with seasonal AR, we suggest against using OcAH over no treatment, except for few days (7 or less) or as‐needed for very fast symptom relief (Conditional recommendation|Low CoE). In patients with perennial AR, we suggest using OcAH over no treatmentConditional recommendation|Very Low CoE

Should OAH versus no treatment be used for the treatment of AR?

  • In patients with AR, we recommend using OAH over no treatment.Strong recommendation|Moderate CoE

Should second‐generation OAH versus first‐generation OAH be used for the treatment of AR?

  • In patients with AR, we recommend using second‐generation OAH over first‐generation OAH.Strong recommendation|Very low CoE

Should INAH versus OAHs be used for the treatment of AR?

  • In patients with AR, we suggest either using INAH or OAHConditional recommendation|Moderate CoE

Recommendations and Summary of Findings

  • 1Should any specific individual second‐generation oral H 1 ‐antihistamines vs. other individual oral H 1 ‐antihistamines be used for the treatment of allergic rhinitis?
  • RecommendationIn patients with AR, we suggest that the choice of specific second‐generation OAHs over others should be based on patients' preferences on efficacy and safety and on availability and affordabilityconditional recommendation based on mostly very low certainty of evidence
  • Considerations in children, adolescents and pregnant women: In preschool‐ and school‐age children, evidence was not sufficient to support recommending a specific second‐generation OAH. In pregnant women, existing studies do not suggest a teratogenic effect of OAH and the Food and Drug Administration (FDA) considers loratadine and cetirizine generally safe in pregnancy [21].
  • Implementation considerations: When selecting a second‐generation OAH, several factors should be considered, including efficacy, safety (e.g., sedative potential), affordability and specific patient characteristics. Patients often value efficacy over safety; however, the sedative effects of some OAH can influence adherence and daily functioning, making the balance between efficacy and safety clinically relevant. Moreover, in some professions, workers cannot have medications with sedative effect. Table 3 displays a summary of implementation and safety aspects. Some highlights include: ○ Cetirizine consistently ranks high in terms of efficacy and patient satisfaction. It is affordable in most countries and included in the World Health Organisation (WHO) List of Essential Medicines. Nonetheless, it has a relatively higher sedative potential compared to other second‐generation OAH and may be better suited for evening use. In addition, the FDA has warned that cetirizine (and levocetirizine) can rarely result in severe itching after discontinuation. ○ Loratadine offers good efficacy, is non‐sedating, widely affordable, and also included in the WHO List of Essential Medicines. ○ Fexofenadine, also in the WHO List of Essential Medicines, is considered non‐sedating but appears to be less efficacious than other OAH. ○ Bilastine, ebastine and rupatadine are among the most efficacious second‐generation OAHs and are generally well‐accepted by patients. Rupatadine has a rapid onset of action. However, the affordability of these medications can vary depending on the setting, potentially limiting their use in low‐ and middle‐income countries. ○ In terms of renal or hepatic impairment, bilastine and fexofenadine are preferred due to the absence of required dose adjustments. However, fexofenadine and bilastine blood levels (as well as those of rupatadine) may be reduced because of interactions with grapefruit and some other fruit juices [22], so they should be taken with water (Table 3) [23]. ○ In low‐ and middle‐income countries, the choice of OAH is often shaped by local availability and cost. ○ Planetary health concerns may also play a role, encouraging the selection of locally manufactured generics to minimise environmental impact.
  • Cetirizine consistently ranks high in terms of efficacy and patient satisfaction. It is affordable in most countries and included in the World Health Organisation (WHO) List of Essential Medicines. Nonetheless, it has a relatively higher sedative potential compared to other second‐generation OAH and may be better suited for evening use. In addition, the FDA has warned that cetirizine (and levocetirizine) can rarely result in severe itching after discontinuation.
  • Loratadine offers good efficacy, is non‐sedating, widely affordable, and also included in the WHO List of Essential Medicines.
  • Fexofenadine, also in the WHO List of Essential Medicines, is considered non‐sedating but appears to be less efficacious than other OAH.
  • Bilastine, ebastine and rupatadine are among the most efficacious second‐generation OAHs and are generally well‐accepted by patients. Rupatadine has a rapid onset of action. However, the affordability of these medications can vary depending on the setting, potentially limiting their use in low‐ and middle‐income countries.
  • In terms of renal or hepatic impairment, bilastine and fexofenadine are preferred due to the absence of required dose adjustments. However, fexofenadine and bilastine blood levels (as well as those of rupatadine) may be reduced because of interactions with grapefruit and some other fruit juices [22], so they should be taken with water (Table 3) [23].
  • In low‐ and middle‐income countries, the choice of OAH is often shaped by local availability and cost.
  • Planetary health concerns may also play a role, encouraging the selection of locally manufactured generics to minimise environmental impact.
  • 2Should a combination of a leukotriene receptor antagonist and an oral H1 ‐antihistamine vs. an oral H1 ‐antihistamine alone be used for the treatment of allergic rhinitis?
  • RecommendationIn patients with AR, we suggest using OAH alone over combinations of OAH and LTRAconditional recommendation based on moderate certainty of evidence
  • Considerations in children and adolescents: The recommendation is applicable to preschool and school‐aged children
  • Implementation considerations: In low‐ and middle‐income countries (LMIC), OAH in the WHO List of Essential Medicines and/or locally produced generics may be preferred.
  • 3Should ocular H1 ‐antihistamines vs. oral H1 ‐antihistamines be used for the treatment of ocular symptoms in patients with allergic rhinitis?
  • Implementation considerations: In LMIC, OAH in the WHO List of Essential Medicines and/or locally produced generics may be preferred.
  • 4Should ocular H1 ‐antihistamines vs. ocular mast cell stabilisers be used for the treatment of ocular symptoms in patients with allergic rhinitis?
  • RecommendationIn patients with AR, we suggest using OcAH over ocular mast cell stabilisersconditional recommendation based on very low certainty of evidence
  • Implementation considerations: None
  • 5Should oral H1 ‐antihistamines vs. leukotriene receptor antagonists be used for the treatment of allergic rhinitis?
  • 6Should intranasal corticosteroids vs. oral H1 ‐antihistamines be used for the treatment of allergic rhinitis?
  • Considerations in children, adolescents and pregnant women: The recommendation is applicable to preschool‐aged, school‐aged children and pregnant women. However, for pregnant women, there are concerns that one INCS, triamcinolone, may have teratogenic effects.
  • Implementation considerations: In LMIC, INCS in the WHO List of Essential Medicines and/or locally produced generics may be preferred.
  • 7Should leukotriene receptor antagonists vs. no treatment be used for the treatment of allergic rhinitis?
  • Considerations in children and adolescents: The recommendation is applicable to children and adolescents.
  • Implementation considerations: LTRA may be considered in patients who are not well‐controlled with other medications and have a strong preference for oral treatments (particularly if they have asthma). In patients who are not using any treatment, the ARIA guideline panel suggests against using LTRA as the starting medication.
  • 8Should ocular H1 ‐antihistamines vs. no treatment be used for the treatment of ocular symptoms in patients with allergic rhinitis?
  • RecommendationIn patients with SAR under no ocular treatment, we suggest against starting OcAH (conditional recommendation based on low certainty of evidence) except for few days (7 or less) or as‐needed for very fast symptom relief. In patients with PAR under no treatment, we suggest using OcAH (conditional recommendation based on very low certainty of evidence). This recommendation is not focused on adding OcAH to a previous treatment.
  • Implementation considerations: None specific
  • 9Should oral H1 ‐antihistamines vs. no treatment be used for the treatment of allergic rhinitis?
  • 10Should second‐generation oral H1 ‐antihistamines vs. first‐generation oral H1 ‐antihistamines be used for the treatment of allergic rhinitis?
  • Considerations in children, adolescents and older adults: The recommendation is applicable to preschool‐aged, school‐aged children and older adults.
  • Implementation considerations: See the implementation considerations for question number 1.
  • 11Should intranasal H1 ‐antihistamines vs. oral H1 ‐antihistamines be used for the treatment of allergic rhinitis?

Conclusions

  • In patients with AR and moderate to severe nasal and/or ocular symptoms that are not controlled with other treatments, we suggest a short course of oral corticosteroidsconditional recommendation|very low‐quality evidence
  • In patients with AR, we suggest that clinicians do not administer and patients do not use oral decongestants regularlyconditional recommendation|low‐quality evidence
  • In patients with AR, we suggest clinicians do not administer and patients do not use regularly a combination of oral H1‐antihistamine and an oral decongestant compared with oral H1‐antihistamine aloneconditional recommendation|moderate‐quality evidence

Abstract

Background: Oral and ocular medications are frequently used in the treatment of allergic rhinitis (AR). As part of the update of the Allergic Rhinitis and its Impact on Asthma (ARIA)‐EAACI guidelines, this manuscript presents the ARIA‐EAACI 2024–2025 recommendations for oral and ocular treatments.

Methods: The ARIA‐EAACI 2024–2025 guideline panel issued recommendations following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence‐to‐decision framework. Several sources of evidence were used to inform panel judgements and recommendations, including systematic reviews, mHealth and pharmacovigilance data as well as a survey on costs.

Results: Eight guideline questions concerning oral treatments for AR and three questions concerning ocular treatments were addressed. These questions led to the recommendations. Overall, these questions concern the choice between different classes of medication. They also discuss the role of oral antihistamines (OAH), leukotriene receptor antagonists (LTRA), ocular antihistamines (OcAH) and ocular mast cell stabilisers. Four questions had not been previously evaluated in ARIA guidelines, while, for the other four, there was a change in the strength or directionality of the recommendations. Overall, these guidelines recommend using intranasal corticosteroids over OAH and using OAH over LTRA. Moreover, they suggest using OAH over OcAH and suggest being against adding LTRA to OAH. Finally, considerations for choosing between different individual OAHs are presented.

Conclusion: This ARIA‐EAACI 2024–2025 article supports patients, their caregivers and healthcare professionals in choosing oral and ocular treatments for AR. Decisions on treatment should consider the clinical variability of the disease, patients' values and the affordability of medications.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Questions Addressed by This Guideline
  • Methodology
  • How to Use These Guidelines
  • Recommendations and Summary of Findings
  • Conclusions
  • Supporting information

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