Multiple sources provided by the Egyptian Knowledge Bank (EKB) platform were used to identify up-to-date international guidelines. We searched for guidelines covering ED management of anaphylaxis. We included international guidelines regardless of whether they used the GRADE EtD framework (and some guidelines preceded the EtD methodology) or not.

After applying the Appraisal of Guidelines For Research & Evaluation (AGREE II) tool ⁹, we chose two initial guidelines: one developed by medical Chinese societies ¹⁰and the other by the RCUK ¹¹. We decided to choose the RCUK guideline because it was more suitable for applying the GRADE ADOLOPMENT process.

Each committee member chose one or two recommendations and searched for any key studies related to those recommendations published after the date of the RCUK guideline publication. The studies that could potentially influence the recommendation strength or the level of certainty of evidence were shared among the working group.

The GRADE-PRO web-based application was used to create the draft of the evidence-to-decision (EtD) tables and to facilitate the committee members’ voting for each recommendation ¹². The template provided by RCUK guidelines was used to guide the discussion. The EtD tables were then reviewed by the GDG, and a consensus was reached on whether to support the previous recommendation (“adopted”) or indicate a need to update the recommendation (“adapted”). If there was no consensus regarding the strength of the recommendation, the GDG chair led a thorough discussion to achieve a final agreement. The strength for each recommendation was assigned as either strong or weak (see Annex 1).⁶

➡️Summary of the Evidence

The certainty of evidence for each recommendation was determined as High, Moderate, Low, or Very Low (Table 1), according to the available evidence in RCUK guidelines in addition to the updated literature review conducted by the committee members.

Table 1 – Certainty of evidence ⁴

➡️Contextual Factors Considerations

Although evidence regarding the performance, efficacy, and safety of interventions is crucial for all guidelines, it's important to consider contextual factors of the EtD framework when formulating recommendations. These considerations include the feasibility and acceptability of an intervention in each setting, its cost-effectiveness, and the potential impact on reducing or increasing inequities. Patients' values and preferences should also be considered. All these contextual factors were discussed by the GDG, considering the Egyptian context.