ARIA-EAACI 2024-2025 Guidelines on Intranasal Treatments: Where do Substantiation and Recommendations Still need to Align?
Contributors
Researcher (4):
Rights holder:
- 1. Division Of Allergy And Immunology, Department Of Paediatrics, University Of California San Diego / Rady Children's Hospital,USA
- 2. North Carolina Clinical Research, Raleigh, NC, United states
- 3. Departments of Paediatrics and Immunology, University of Pretoria, Pretoria, South africa
- 4. Department of Respiratory Medicine, North Western Medical University, Saint Petersburg, Russia
- 5. Consultant ENT Surgeon, HBT Medical College, Mumbai, India
Description
The ARIA-EAACI 2024-2025 Guidelines on intranasal treatments for allergic rhinitis recommend azelastine–fluticasone (AF) over olopatadine-mometasone (OM) for adult patients. This editorial examines whether the available evidence sufficiently supports this preferential recommendation. Particular focus is placed on interpretation of network meta-analysis (NMA) findings, internal consistency of effect estimates, heterogeneity and incoherence within the evidence network, application of the GRADE framework, and incorporation of patient-reported and long-term clinical data.
The NMA underpinning the recommendation reports posterior probabilities of 23% for non-trivial improvement in nasal symptoms and 56% for ocular symptoms and quality-of-life outcomes in favour of AF. These estimates indicate substantial uncertainty and proximity to equipoise rather than convincing superiority. Internal analyses reveal inconsistent direction of effect, with treatment differences frequently crossing zero and sensitivity analyses favouring neutrality or OM. The evidence base further demonstrates substantial heterogeneity (I² > 50%) and statistically significant incoherence, limiting confidence in treatment ranking and indirect comparisons.
Despite these limitations, the certainty of evidence was graded as “moderate,” a designation that appears difficult to reconcile with established GRADE principles for indirect, heterogeneous, and incoherent evidence. Additional reliance on app-based patient-reported outcomes is constrained by marked sample imbalance and potential selection bias. Furthermore, long-term randomised evidence supporting OM in perennial allergic rhinitis remains underrepresented in the guideline narrative.
Collectively, the current evidence does not substantiate a clear directional preference between AF and OM. Reconsideration of certainty grading and adoption of a conditional, no-preference recommendation may more accurately reflect the available data and support balanced clinical decision-making.