Paradigmatic situation | Brief explanation | Recommendation | Example situationsa |
---|---|---|---|
Life-threatening (or catastrophical) situation | When low quality evidence suggests benefit in a life-threatening situation (evidence regarding harms can be low or high) | Strong recommendation in favour | Indirect evidence from seasonal influenza suggests that patients with avian influenza may benefit from the use of oseltamivir (low confidence in effect estimates). Given the high mortality of the disease and the absence of effective alternatives, the WHO made a strong recommendation in favour of the use of Oseltamivir rather than no treatment in patients with avian influenza |
Potential equivalence, one option clearly less risky or costly | When low quality evidence suggests equivalence of two alternatives, but high-quality evidence of less harm for one of the competing alternatives | Strong recommendation for less harmful/less expensive | H. pylori eradication in patients with early stage Extranodal marginal zone B cell (MALT) lymphoma with H. pylori positive. Low quality evidence suggests that initial H pylori eradication results in similar rates of complete response in comparison to the alternatives of radiation therapy or gastrectomy but with high confidence of less harm/morbidity/cost. Consequently, UpToDate made a strong in favour of H. pylori eradication rather than radiotherapy in patients with MALT lymphoma |
Uncertain benefit, certain harm | When very low/ low quality evidence suggests modest benefits and moderate/high quality evidence suggests possibility of harm | Strong recommendation against (or in favour of the less harmful/less expensive alternative when two are compared) | In patients with idiopathic pulmonary fibrosis, treatment with azathioprine plus prednisone offers a possible but uncertain benefit in comparison with no treatment. The intervention, however, is associated with a substantial established harm. An international guideline made a recommendation against the combination of corticosteroids plus Azathioprine in patients with idiopathic pulmonary fibrosis |
High certainty in similar benefits, one option potentially more risky or costly | When high quality evidence suggests equivalence of two alternatives and low-quality evidence suggests harm in one alternative | Strong recommendation against the intervention with possible greater harm | In women requiring anticoagulation and planning conception or in pregnancy, high confidence estimates suggests similar effects of different anticoagulants. However, indirect evidence (low confidence in effect estimates) suggests potential harm to the unborn infant with oral direct thrombin (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban). The AT9 guidelines recommended against the use of such anticoagulants in women planning conception or in pregnancy |
Potential catastrophic harm | When low to high quality evidence suggests modest benefits and low/ very low-quality evidence suggests possibility of catastrophic harm | Strong recommendation against the intervention (or in favour of the less harmful/less expensive alternative when two are compared) | In males with androgen deficiency, testosterone supplementation likely improves quality of life. Low confidence evidence suggests that testosterone increases cancer spread in patients with prostate cancer. The Endocrine Society (USA) made a recommendation against testosterone supplementation in patients with prostate cancer |