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 cost | Head-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 alternatives | Helicobacter 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 alternative | Hypertension 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 harm | Testosterone 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.