Allergic Rhinitis and its Impact on Asthma - ARIA

ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA GUIDELINES ● 2010 – V. 9/8/2010
preferences of those for whom the recommendations are intended. For most recommendations
resource utilization (cost) was also taken into account (44). Recommendations were classified as
'strong' or 'weak' as recommended by the GRADE working group (4). Statements about the
underlying values <strong>and</strong> preferences as well as the remarks are integral parts of the recommendations
<strong>and</strong> serve to facilitate accurate interpretation. They should not be omitted when citing or translating
recommendations in the ARIA guidelines. In this document, the expression ―values <strong>and</strong> preferences‖
refers to the relative worth or importance of a health state or the consequences of a decision to
follow a particular course of action (i.e. a relative weight one attributes to particular benef<strong>its</strong>, harms,
burdens, <strong>and</strong> costs to determine their balance). Individuals usually assign less value to <strong>and</strong> have less
preference for more impaired health states (e.g. death or impaired social functioning <strong>and</strong> work
productivity due to severe rhinitis symptoms) compared to other health states (e.g. full health or
having very mild symptoms that do not interfere with daily life). We used the decision framework
described previously to determine the strength of recommendations (33, 45).
Little information about costs of prevention or treatment of allergic rhinitis was available to the
panel <strong>and</strong> it is very likely that it varies considerably across geographical areas <strong>and</strong> jurisdictions.
Cost, therefore, plays a limited role in these recommendations. However, whenever we considered
cost <strong>and</strong> resource expenditure we used health system perspective (46). For individual patients cost
may not be an issue if the medication is provided at reduced price or free of charge. Clinicians <strong>and</strong>
patients should consider their local resource implications when interpreting these recommendations.
Following the GRADE approach, in these guidelines we classified recommendations as either
strong or conditional (weak). The strength of recommendations depends on a balance between all
desirable <strong>and</strong> all undesirable effects of an intervention (i.e. net clinical benefit), quality of available
evidence, values <strong>and</strong> preferences, <strong>and</strong> cost (resource utilization) (45). In general, the higher the
quality of the supporting evidence, the more likely it is for the recommendation to be strong.
Conversely, if the quality is low or very low a conditional recommendation is more likely. Strong
recommendations based on low or very low quality evidence are rare, but possible (25).
An alternative, acceptable term for conditional recommendation is weak. For strong
recommendations we used words “we recommend” <strong>and</strong> for conditional recommendations –
“we suggest”. We offer the suggested interpretation of strong <strong>and</strong> conditional (weak)
recommendations in the Table (33). Underst<strong>and</strong>ing the interpretation of these two grades – either
strong or conditional – of the strength of recommendations is essential for sagacious clinical
decision making.
Consultation
We asked 80 clinicians involved in the management of patients <strong>and</strong>/or research of AR from a
variety of countries <strong>and</strong> 3 members of patient organizations to review the guidelines. As a result we
performed additional searches for most recent studies <strong>and</strong> reassessed the evidence for several
questions.
We think that the natural order of clinical reasoning starts from defining the patients (population)
<strong>and</strong> the clinical problem <strong>and</strong> subsequently choosing one the available management options
(interventions). Thus, when formulating the recommendations for ARIA guidelines, we followed
PICO (population, intervention, comparison, outcomes) format (35).
PAGE 26 OF 153