Making the GRADE in Anaphylaxis Management: Towards Recommendations Integrating Values, Preferences, Context, and Shared Decision-Making.

Abstract Objective To review GRADE methodology and discuss the clinical application of conditional recommendations in clinical guidelines, specifically in the context of anaphylaxis. Data Sources Articles describing 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 methodology encourages a nuanced relationship between certainty of evidence and strength of recommendations. Strengthof recommendation must incorporate key factors including the balance between benefits/harms, patient values /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. While the 2020 Anaphylaxis GRADE guideline better informs the practice of anaphylaxis prevention through (i) identification and mitigation of risk factors for biphasic anaphylaxis and (ii) evaluation of the use of glucocorticoid and/or antihistamine pretreatment, all GRADE recommendations, while 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, clinicians, and policy makers should appreciate the strength of recommendation and certainty of evidence, and understand how this impacts guideline applicability and implementation.