TableĀ 2

Situations for which currently available low-quality evidence is associated with strong recommendations that could change as new high-quality evidence emerges*

(1) When low-quality evidence suggests benefit in a life-threatening situation (evidence regarding harms can be low or high)Fresh frozen plasma or vitamin K in a patient receiving warfarin with elevated INR and an intracranial bleed. Only low-quality evidence supports the benefits of limiting the extent of the bleeding
(2) When low-quality evidence suggests benefit and high-quality evidence suggests harm or a very high costHead-to-toe CT/MRI screening for cancer. Low-quality evidence of benefit of early detection but high-quality evidence of possible harm and/or high cost (strong recommendation against this strategy)
(3) When low-quality evidence suggests benefit equivalence of two alternatives, but high-quality evidence of less harm for one of the competing alternativesHelicobacter pylori eradication in patients with early stage gastric MALT lymphoma with H pylori positive. Low-quality evidence suggests that initial H pylori eradication results in similar rates of complete response in comparison with the alternatives of radiation therapy or gastrectomy; high-quality evidence suggests less harm/morbidity from H pylori eradication
(4) When high-quality evidence suggests benefit equivalence of two alternatives and low-quality evidence suggests harm in one alternativeHypertension in women planning conception and in pregnancy. Strong recommendations for labetalol and nifedipine and strong recommendations against ACE inhibitors and angiotensin receptor blockers (ARB). All agents have high-quality evidence of equivalent beneficial outcomes, with low-quality evidence for greater adverse effects with ACE inhibitors and ARBs
(5) When high-quality evidence suggests modest benefits and low/very low-quality evidence suggests possibility of catastrophic harmTestosterone in males with or at risk of prostate cancer. High-quality evidence for moderate benefits of testosterone treatment in men with symptomatic androgen deficiency to improve bone mineral density and muscle strength. Low-quality evidence for harm in patients with or at high risk of prostate cancer
  • *Adapted from reference 42.

  • INR, international normalised ratio; MALT, mucosa-associated lymphoid tissue.