Abstract
Objective: To review GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methods and discuss the clinical application of conditional recommendations in clinical guidelines, specifically in the context of anaphylaxis. Data Sources: Articles that described GRADE, evidence synthesis, evidence to recommendation frameworks, and shared decision making were used to discuss conditional recommendations of the 2020 Anaphylaxis GRADE guideline. Study Selections: A narrative review detailing concepts of GRADE and approaches to translate conditional recommendations to individualized and contextualized patient care. Results: GRADE methods encourage a nuanced relationship between certainty of evidence and strength of recommendations. Strength of recommendation must incorporate key factors, including the balance between benefits and harms, patient values and preferences, and resource allocation (costs), with equity, feasibility, and acceptability also often included as considerations. GRADE guidelines provide recommendations that are characterized by directionality (for or against) and strength (strong or conditional). A conditional recommendation is tailored to context and primarily applied through a lens of patient preferences related to the likelihood of outcomes of importance and a shared decision-making approach. Although the 2020 Anaphylaxis GRADE guideline better informs the practice of anaphylaxis prevention through (1) identification and mitigation of risk factors for biphasic anaphylaxis and (2) evaluation of the use of glucocorticoid and/or antihistamine pretreatment, all GRADE recommendations, although directional, are conditional and as such should not be universally applied to every circumstance. Conclusion: Clinical guidelines provide an important opportunity to critically appraise evidence and translate evidence to practice. Patients, practitioners, and policy makers should appreciate the strength of recommendation and certainty of evidence and understand how this affects guideline applicability and implementation.
Original language | English |
---|---|
Pages (from-to) | 526-535.e2 |
Journal | Annals of Allergy, Asthma and Immunology |
Volume | 124 |
Issue number | 6 |
DOIs | |
State | Published - Jun 2020 |
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In: Annals of Allergy, Asthma and Immunology, Vol. 124, No. 6, 06.2020, p. 526-535.e2.
Research output: Contribution to journal › Review article › peer-review
TY - JOUR
T1 - Making the GRADE in anaphylaxis management
T2 - Toward recommendations integrating values, preferences, context, and shared decision making
AU - Joint Task Force for Allergy Practice Parameters
AU - Contributors
AU - Shaker, Marcus S.
AU - Oppenheimer, John
AU - Wallace, Dana V.
AU - Golden, David B.K.
AU - Lang, David M.
AU - Lang, Eddy S.
AU - Bernstein, Jonathan A.
AU - Campbell, Ronna L.
AU - Chu, Derek
AU - Dinakar, Chitra
AU - Ellis, Anne K.
AU - Greenhawt, Matthew
AU - Horner, Caroline
AU - Lieberman, Jay A.
AU - Rank, Matthew A.
AU - Stukus, David R.
AU - Wang, Julie
N1 - Funding Information: Disclosures: The Joint Task Force for Allergy Practice Parameters (JTFPP) members and work group members’ conflict of interest disclosure forms can be found at www.allergyparameters.org. Jonathan Bernstein has received financial support from Sanofi Regeneron, AstraZeneca, Merck, Optinose, Takeda, CSL Behring, Biocryst, Pharming, the National Institutes of Health, and Taylor Francis; he is the editor in chief of the Journal of Asthma, INEOS medical immunosurveillance director, vice chair and lectureship chair of the American Academy of Allergy, Asthma, and Immunology (AAAAI) Foundation, chairman of AFI, American College of Asthma, Allergy, and Immunology (ACAAI) asthma chair, scientific chair, and Young Investigator Award chair and serves on the board of directors and Scientific Committee of Interasma. Ronna Campbell has served as a peer reviewer for EB Medicine and an author for UpToDate. Derek Chu has served as a member of the GRADE Working Group; is supported by Canadian Allergy, Asthma, and Immunology Foundation, Canadian Society of Allergy and Clinical Immunology, and AllerGen; and has received an Emerging Clinician Scientist Award. Chitra Dinakar has received financial support from Propeller Health, DBV Technologies, ACAAI (stipend for editorial board of AllergyWatch), the American Association of Allergists of Indian Origin; serves on the board of directors of the AAAAI and on the medical advisory board of Food Equity Initiative; and is assistant editor of AllergyWatch. Anne Ellis has received financial support from ALK-Abello, AstraZeneca, Green Cross, Merck, Novartis, Nuvo, Pediapharm, Pfizer, Kaleo, Sanofi, and Regeneron and serves on the board of directors of the Canadian Allergy Society of Allergy and Clinical Immunology. David Golden has received financial support from Aquestive, Sandoz, ALK-Abello, Sandoz, Genentech, Stallergenes-Greer, and UpToDate. Matthew Greenhawt has received financial support from Aquestive, Merck, Allergenis, Allergy Therapeutics, Sanofi Genzyme, Genentech, Aravax, Prota, Before Brands, the Institute for Clinical and Economic Review, ACAAI, DBV, and Intrommune and is supported by the Agency of Healthcare Research and Quality; has served on the advisory board of International FPIES Association, the Asthma and Allergy Foundation of America, and the National Peanut Board; and is associate editor of the Annals of Allergy, Asthma & Immunology. Caroline Horner has served as committee chair for the AAAAI Asthma Diagnosis and Treatment Interest Section, Interest Section Coordinating Committee, and In-Training Exam Coordinating Committee. Eddy Lang received an honorarium from the JTFPP for GRADE methods support. Jay Lieberman has received financial support from the ACAAI, Aquestive, Aimmune, DBV, Biotest Pharma, and Regeneron; is associate editor of the Annals of Allergy, Asthma & Immunology, vice chair for the ACAAI Food Allergy Committee, and medical director for Food Allergy Alliance of the MidSouth. John Oppenheimer has received financial support from DBV, TEVA, GlaxoSmithKline adjudication/data safety monitoring board, AstraZeneca, Novartis, and Sanofi; he is associate editor of the Annals of Allergy, Asthma & Immunology and AllergyWatch, an American Board of Internal Medicine (ABIM) council member, and American Board of Allergy and Immunology liaison to the ABIM (∗r Oppenheimer had no role in designing CME learning objectives or CME questions), UpToDate reviewer, ACCP Cough Guideline committee member, and WebMD editor. Matthew Rank has received financial support from the ACAAI, National Institutes of Health, and Levin Family Foundation; has served as chair of the AAAAI HEDQ Interest Section, and is research director of the Phoenix Children's Hospital Breathmobile. Marcus Shaker has received financial support from the Eastern Allergy Conference and has a family member who is the chief executive officer of Altrix Medical. David Stukus has received financial support from Aimmune, Before Brands, Abbott Nutrition, the American Academy of Pediatrics, ACAAI and has served as committee chair for the AAAAI and ACAAI. Dana Wallace has received financial support from Mylan, Kaleo, Optinose, ALK, Bryan, and Sanofi; is Education Council chair and Rhinitis/Sinusitis/Ocular Committee chair for the ACAAI; she is website content editor and ESP/WATS committee chair for the World Allergy Organization. Julie Wang has received financial support from ALK Abello, Regeneron, DBV, and Aimmune; is an UpToDate author; serves on the Executive Committee of the American Academy of Pediatrics Section on Allergy and Immunology; and serves as vice chair of the AAAAI Anaphylaxis, Dermatitis, Drug Allergy Interest Section. Funding Information: Disclosures: The Joint Task Force for Allergy Practice Parameters (JTFPP) members and work group members’ conflict of interest disclosure forms can be found at www.allergyparameters.org . Jonathan Bernstein has received financial support from Sanofi Regeneron , AstraZeneca , Merck , Optinose, Takeda , CSL Behring , Biocryst, Pharming, the National Institutes of Health , and Taylor Francis; he is the editor in chief of the Journal of Asthma, INEOS medical immunosurveillance director, vice chair and lectureship chair of the American Academy of Allergy, Asthma, and Immunology ( AAAAI ) Foundation, chairman of AFI, American College of Asthma, Allergy, and Immunology (ACAAI) asthma chair, scientific chair, and Young Investigator Award chair and serves on the board of directors and Scientific Committee of Interasma. Ronna Campbell has served as a peer reviewer for EB Medicine and an author for UpToDate. Derek Chu has served as a member of the GRADE Working Group; is supported by Canadian Allergy, Asthma, and Immunology Foundation, Canadian Society of Allergy and Clinical Immunology, and AllerGen; and has received an Emerging Clinician Scientist Award. Chitra Dinakar has received financial support from Propeller Health, DBV Technologies, ACAAI (stipend for editorial board of AllergyWatch), the American Association of Allergists of Indian Origin; serves on the board of directors of the AAAAI and on the medical advisory board of Food Equity Initiative; and is assistant editor of AllergyWatch. Anne Ellis has received financial support from ALK-Abello, AstraZeneca , Green Cross, Merck , Novartis , Nuvo, Pediapharm, Pfizer , Kaleo, Sanofi , and Regeneron and serves on the board of directors of the Canadian Allergy Society of Allergy and Clinical Immunology. David Golden has received financial support from Aquestive, Sandoz , ALK-Abello, Sandoz , Genentech , Stallergenes-Greer, and UpToDate. Matthew Greenhawt has received financial support from Aquestive, Merck , Allergenis, Allergy Therapeutics, Sanofi Genzyme , Genentech , Aravax, Prota, Before Brands, the Institute for Clinical and Economic Review, ACAAI, DBV , and Intrommune and is supported by the Agency of Healthcare Research and Quality; has served on the advisory board of International FPIES Association, the Asthma and Allergy Foundation of America , and the National Peanut Board; and is associate editor of the Annals of Allergy, Asthma & Immunology. Caroline Horner has served as committee chair for the AAAAI Asthma Diagnosis and Treatment Interest Section, Interest Section Coordinating Committee, and In-Training Exam Coordinating Committee. Eddy Lang received an honorarium from the JTFPP for GRADE methods support. Jay Lieberman has received financial support from the ACAAI, Aquestive, Aimmune, DBV , Biotest Pharma, and Regeneron; is associate editor of the Annals of Allergy, Asthma & Immunology, vice chair for the ACAAI Food Allergy Committee, and medical director for Food Allergy Alliance of the MidSouth. John Oppenheimer has received financial support from DBV , TEVA, GlaxoSmithKline adjudication/data safety monitoring board, AstraZeneca , Novartis , and Sanofi; he is associate editor of the Annals of Allergy, Asthma & Immunology and AllergyWatch, an American Board of Internal Medicine (ABIM) council member, and American Board of Allergy and Immunology liaison to the ABIM (∗r Oppenheimer had no role in designing CME learning objectives or CME questions), UpToDate reviewer, ACCP Cough Guideline committee member, and WebMD editor. Matthew Rank has received financial support from the ACAAI, National Institutes of Health , and Levin Family Foundation; has served as chair of the AAAAI HEDQ Interest Section, and is research director of the Phoenix Children’s Hospital Breathmobile. Marcus Shaker has received financial support from the Eastern Allergy Conference and has a family member who is the chief executive officer of Altrix Medical. David Stukus has received financial support from Aimmune, Before Brands, Abbott Nutrition , the American Academy of Pediatrics , ACAAI and has served as committee chair for the AAAAI and ACAAI. Dana Wallace has received financial support from Mylan, Kaleo, Optinose, ALK, Bryan, and Sanofi; is Education Council chair and Rhinitis/Sinusitis/Ocular Committee chair for the ACAAI; she is website content editor and ESP /WATS committee chair for the World Allergy Organization. Julie Wang has received financial support from ALK Abello, Regeneron , DBV , and Aimmune; is an UpToDate author; serves on the Executive Committee of the American Academy of Pediatrics Section on Allergy and Immunology; and serves as vice chair of the AAAAI Anaphylaxis, Dermatitis, Drug Allergy Interest Section. Publisher Copyright: © 2020 American College of Allergy, Asthma & Immunology
PY - 2020/6
Y1 - 2020/6
N2 - Objective: To review GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methods and discuss the clinical application of conditional recommendations in clinical guidelines, specifically in the context of anaphylaxis. Data Sources: Articles that described GRADE, evidence synthesis, evidence to recommendation frameworks, and shared decision making were used to discuss conditional recommendations of the 2020 Anaphylaxis GRADE guideline. Study Selections: A narrative review detailing concepts of GRADE and approaches to translate conditional recommendations to individualized and contextualized patient care. Results: GRADE methods encourage a nuanced relationship between certainty of evidence and strength of recommendations. Strength of recommendation must incorporate key factors, including the balance between benefits and harms, patient values and preferences, and resource allocation (costs), with equity, feasibility, and acceptability also often included as considerations. GRADE guidelines provide recommendations that are characterized by directionality (for or against) and strength (strong or conditional). A conditional recommendation is tailored to context and primarily applied through a lens of patient preferences related to the likelihood of outcomes of importance and a shared decision-making approach. Although the 2020 Anaphylaxis GRADE guideline better informs the practice of anaphylaxis prevention through (1) identification and mitigation of risk factors for biphasic anaphylaxis and (2) evaluation of the use of glucocorticoid and/or antihistamine pretreatment, all GRADE recommendations, although directional, are conditional and as such should not be universally applied to every circumstance. Conclusion: Clinical guidelines provide an important opportunity to critically appraise evidence and translate evidence to practice. Patients, practitioners, and policy makers should appreciate the strength of recommendation and certainty of evidence and understand how this affects guideline applicability and implementation.
AB - Objective: To review GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methods and discuss the clinical application of conditional recommendations in clinical guidelines, specifically in the context of anaphylaxis. Data Sources: Articles that described GRADE, evidence synthesis, evidence to recommendation frameworks, and shared decision making were used to discuss conditional recommendations of the 2020 Anaphylaxis GRADE guideline. Study Selections: A narrative review detailing concepts of GRADE and approaches to translate conditional recommendations to individualized and contextualized patient care. Results: GRADE methods encourage a nuanced relationship between certainty of evidence and strength of recommendations. Strength of recommendation must incorporate key factors, including the balance between benefits and harms, patient values and preferences, and resource allocation (costs), with equity, feasibility, and acceptability also often included as considerations. GRADE guidelines provide recommendations that are characterized by directionality (for or against) and strength (strong or conditional). A conditional recommendation is tailored to context and primarily applied through a lens of patient preferences related to the likelihood of outcomes of importance and a shared decision-making approach. Although the 2020 Anaphylaxis GRADE guideline better informs the practice of anaphylaxis prevention through (1) identification and mitigation of risk factors for biphasic anaphylaxis and (2) evaluation of the use of glucocorticoid and/or antihistamine pretreatment, all GRADE recommendations, although directional, are conditional and as such should not be universally applied to every circumstance. Conclusion: Clinical guidelines provide an important opportunity to critically appraise evidence and translate evidence to practice. Patients, practitioners, and policy makers should appreciate the strength of recommendation and certainty of evidence and understand how this affects guideline applicability and implementation.
UR - http://www.scopus.com/inward/record.url?scp=85083392925&partnerID=8YFLogxK
U2 - 10.1016/j.anai.2020.03.009
DO - 10.1016/j.anai.2020.03.009
M3 - Review article
C2 - 32199979
AN - SCOPUS:85083392925
SN - 1081-1206
VL - 124
SP - 526-535.e2
JO - Annals of Allergy, Asthma and Immunology
JF - Annals of Allergy, Asthma and Immunology
IS - 6
ER -