Page 79 - 80 guidelines for the treatment of malaria_opt

ANNEX 1. The Guidelines development process

IDENTIFICATION OF ArEAS OF UNCErTAINTy A1
A1
The first meeting of the Malaria Treatment Guidelines Panel identified areas where
updates were being considered. On this basis, a sub-group of the panel, the GRADE sub-
committee worked together in preparing appropriate, up-to-date systematic reviews and
GRADE profiles. The sub-committee, thereafter, met to decide on the recommendations
arising from the evidence and other explicitly stated considerations. The following areas
were identified:
• consider adding dihydroartemisinin plus piperaquine to the recommended list of ACTs
for uncomplicated malaria;
• consider removing amodiaquine plus sulfadoxine-pyrimethamine from the list of
recommended antimalarial drugs for uncomplicated malaria;
• reconsider the recommendation of artesunate plus mefloquine in Africa, with specific
concerns regarding toxicity/vomiting in children;
• assess the role of ACTs in P. vivax malaria in areas without chloroquine resistant
P. vivax;
• assess the role of ACTs in P. vivax malaria in areas with chloroquine resistant
P. vivax;
• consider the best treatment for radical cure of P. vivax malaria; and
• consider the relative effectiveness of IV artesunate instead of quinine for severe
malaria.

ASSESSINg QUALITy OF EVIDENCE
The GRADE approach starts with a baseline quality for each outcome. Evidence considered
by the panel for the purpose of this annex was derived solely from randomized-controlled
trials, for which the baseline quality using the GRADE approach is defined as high.
Cochrane reviews were carried out using standard methods. All head-to-head comparisons
of ACTs were reviewed. Outcomes for the review, which are reflected in the GRADE
assessments, were agreed upon by the Malaria Technical Guidelines Group.
The panel assessed the four GRADE quality components described below across each
outcome for each profile and made judgements as to whether each component had: no
serious limitations (do not downgrade); serious limitations (downgrade by 1 level); or
very serious limitations (downgrade by 2 levels). For each judgement, the justification for
the panel’s decision is referenced in a footnote below each profile under the appropriate
quality component. Specific decision rules were developed over time that seemed
appropriate to forming GRADE profiles within this health problem.

65