• Marcus S Shaker, John Oppenheimer, Dana V Wallace, GoldenDavid B KDBKDivision of Allergy-Clinical Immunology, Johns Hopkins University, Baltimore, Maryland., David M Lang, Joint Task Force for Allergy Practice Parameters, Contributors, Eddy S Lang, Jonathan A Bernstein, Ronna L Campbell, Derek Chu, Chitra Dinakar, Anne K Ellis, Matthew Greenhawt, Caroline Horner, Jay A Lieberman, Matthew A Rank, David R Stukus, and Julie Wang.
• Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire. Electronic address: Marcus.shaker@dartmouth.edu.
• Ann. Allergy Asthma Immunol. 2020 Jun 1; 124 (6): 526-535.e2.

ObjectiveTo 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 SourcesArticles 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 SelectionsA narrative review detailing concepts of GRADE and approaches to translate conditional recommendations to individualized and contextualized patient care.ResultsGRADE 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.ConclusionClinical 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.Copyright © 2020 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

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