Treatment of dysphagia

Beoordeeld: 07-02-2024

This module is divided into two submodules with the following clinical questions:

Subquestion 1: What is the effect of non-invasive and invasive treatments for dysphagia in patients with idiopathic inflammatory myopathies (IIM) (comprising anti-synthetase syndrome, dermatomyositis, non-specific or overlap myositis, and immune-mediated necrotizing myopathy) and juvenile dermatomyositis (JDM)?

Wat is het effect van niet-invasieve en invasieve behandelingen voor slikstoornissen bij patiënten met idiopathische inflammatoire myopathieën (IIM) en juveniele dermatomyositis (JDM)?

Subquestion 2: what is the effect of non-invasive and invasive treatments for dysphagia in patients with inclusion body myositis (IBM)?

Wat is het effect van niet-invasieve en invasieve behandelingen voor slikstoornissen bij patiënten met idiopathische inclusion body myositis (IBM)?

Recommendations

Diagnostiek en behandeling van slikstoornissen bij IIM, JDM en IBM

Screen op slikstoornissen door te vragen naar symptomen en mogelijke complicaties van slikproblemen bij diagnose en tijdens follow-up.

Vraag naar symptomen van slikstoornissen door te vragen naar: problemen met kauwen en verplaatsen van voedsel in de mond, verslikken, hoesten tijdens of na de maaltijd, blijven “hangen” van voedsel in de keel, voedsel of drinken wat uit de neus komt, oprispen van voedsel, verlenging van de duur van de maaltijd, aangebrachte aanpassingen in het dieet (pureren, prakken, malen, etc.) of de hapgrootte, wijziging van de stem (borrelig, nat stemgeluid), vaker schrapen van de keel, teveel of te dik slijm of speeksel in de keel, speekselvloed, en het vermijden van sociale situaties vanwege de slikstoornissen.

Vraag naar mogelijke complicaties van slikstoornissen door te vragen naar: actueel gewicht en/of BMI, ongewenst gewichtsverlies en recidiverende lagere luchtweginfecties.

Verwijs patiënten met symptomen en/of aanwijzingen voor complicaties van slikstoornissen voor nadere diagnostiek en behandeladvies naar een logopedist en diëtist in de 2e of 3e lijn, bij voorkeur met expertise op het gebied van neuromusculaire aandoeningen (NMA).

Overweeg verwijzing voor psychosociale ondersteuning bij aanwezigheid van stemmingsklachten en/of verwerkingsproblematiek als gevolg van slikstoornissen, verminderde sociale participatie, of verlies van orale intake.

Verricht, bij indicatie voor instrumenteel onderzoek, in overleg met patiënt en afgestemd op zijn/haar mogelijkheden, endoscopische- (FEES – fiberoptic endoscopic evaluation of swallowing) en/of radiologische slikvideo beiden volgens een gestandaardiseerd protocol met minimaal drie consistenties. Idealiter worden zowel een FEES als een radiologische slikvideo verricht.

Verantwoording

Autorisatiedatum en geldigheid

Laatst beoordeeld : 07-02-2024

Laatst geautoriseerd : 07-02-2024

Geplande herbeoordeling : 01-12-2025

Initiatief en autorisatie

Initiatief:

Nederlandse Vereniging voor Neurologie

Geautoriseerd door:

Nederlandse Internisten Vereniging
Nederlandse Vereniging van Artsen voor Longziekten en Tuberculose
Nederlandse Vereniging van Revalidatieartsen
Nederlandse Vereniging voor Cardiologie
Nederlandse Vereniging voor Dermatologie en Venereologie
Nederlandse Vereniging voor Keel-Neus-Oorheelkunde en Heelkunde van het Hoofd-Halsgebied
Nederlandse Vereniging voor Kindergeneeskunde
Nederlandse Vereniging voor Neurologie
Nederlandse Vereniging voor Pathologie
Nederlandse Vereniging voor Reumatologie
Vereniging Spierziekten Nederland

Algemene gegevens

The development of this guideline module was supported by the Knowledge Institute of the Federation of Medical Specialists (www.demedischspecialist.nl/ kennisinstituut) and was financed from the Quality Funds for Medical Specialists (SKMS). The financier has had no influence whatsoever on the content of the guideline module.

Samenstelling werkgroep

A multidisciplinary working group was set up in 2020 for the development of the guideline module, consisting of representatives of all relevant specialisms and patient organisations (see the Composition of the working group) involved in the care of patients with IIM/myositis.

Working group

Dr. A.J. van der Kooi, neurologist, Amsterdam UMC, location AMC. Nederlandse Vereniging voor Neurologie (chair)
Dr. U.A. Badrising, neurologist, LUMC. Nederlandse Vereniging voor Neurologie
Dr. C.G.J. Saris, neurologist, Radboudumc. Nederlandse Vereniging voor Neurologie
Dr. S. Lassche, neurologist, Zuyderland MC. Nederlandse Vereniging voor Neurologie
Dr. J. Raaphorst, neurologist, Amsterdam UMC, locatie AMC. Nederlandse Vereniging voor Neurologie
Dr. J.E. Hoogendijk, neurologist, UMC Utrecht. Nederlandse Vereniging voor Neurologie
Drs. T.B.G. Olde Dubbelink, neurologist, Rijnstate, Nederlandse Vereniging voor Neurologie
Dr. I.L. Meek, rheumatologist, Radboudumc. Nederlandse Vereniging voor Reumatologie
Dr. R.C. Padmos, rheumatologist, Erasmus MC. Nederlandse Vereniging voor Reumatologie
Prof. dr. E.M.G.J. de Jong, dermatologist, werkzaam in het Radboudumc. Nederlandse Vereniging voor Dermatologie en Venereologie
Drs. W.R. Veldkamp, dermatologist, Ziekenhuis Gelderse Vallei. Nederlandse Vereniging voor Dermatologie en Venereologie
Dr. J.M. van den Berg, pediatrician, Amsterdam UMC, locatie AMC. Nederlandse Vereniging voor Kindergeneeskunde
Dr. M.H.A. Jansen, pediatrician, UMC Utrecht. Nederlandse Vereniging voor Kindergeneeskunde
Dr. A.C. van Groenestijn, rehabilitation physician, Amsterdam UMC, locatie AMC. Nederlandse Vereniging van Revalidatieartsen
Dr. B. Küsters, pathologist, Radboudumc. Nederlandse Vereniging voor Pathologie
Dr. V.A.S.H. Dalm, internist, Erasmus MC. Nederlandse Internisten Vereniging
Drs. J.R. Miedema, pulmonologist, Erasmus MC. Nederlandse Vereniging van Artsen voor Longziekten en Tuberculose
I. de Groot, patient representatieve. Spierziekten Nederland

Advisory board

Prof. dr. E. Aronica, pathologist, Amsterdam UMC, locatie AMC. External expert.
Prof. dr. D. Hamann, Laboratory specialist medical immunology, UMC Utrecht. External expert.
Drs. R.N.P.M. Rinkel, ENT physician, Amsterdam UMC, locatie VUmc. Vereniging voor Keel-Neus-Oorheelkunde en Heelkunde van het Hoofd-Halsgebied
dr. A.S. Amin, cardiologist, werkzaam in werkzaam in het Amsterdam UMC, locatie AMC. Nederlandse Vereniging voor Cardiologie
dr. A. van Royen-Kerkhof, pediatrician, UMC Utrecht. External expert.
dr. L.W.J. Baijens, ENT physician, Maastricht UMC+. External expert.
Em. Prof. Dr. M. de Visser, neurologist, Amsterdam UMC. External expert.

Methodological support

Drs. T. Lamberts, senior advisor, Knowledge institute of the Federation of Medical Specialists
Drs. M. Griekspoor, advisor, Knowledge institute of the Federation of Medical Specialists
Dr. M. M. J. van Rooijen, advisor, Knowledge institute of the Federation of Medical Specialists

Belangenverklaringen

The ‘Code ter voorkoming van oneigenlijke beïnvloeding door belangenverstrengeling’ has been followed. All working group members have declared in writing whether they have had direct financial interests (attribution with a commercial company, personal financial interests, research funding) or indirect interests (personal relationships, reputation management) in the past three years. During the development or revision of a module, changes in interests are communicated to the chairperson. The declaration of interest is reconfirmed during the comment phase.

An overview of the interests of working group members and the opinion on how to deal with any interests can be found in the table below. The signed declarations of interest can be requested from the secretariat of the Knowledge Institute of the Federation of Medical Specialists.

Werkgroeplid	Functie	Nevenfuncties	Gemelde belangen	Ondernomen actie
van der Kooi	Neuroloog, Amsterdam UMC	Voorzitter Spierziektencentrum Nederland (betaald) Eenmalige deelname advisory board ArgenX om het starten van trial in myositis (met efgartigimod). AMC zou als onderzoekslocatie deel kunnen nemen.	Immediate studie (investigator initiated, IVIg behandeling bij therapie naive patienten). --> Financiering via Behring. Studie januari 2019 afgerond	Geen restricties (middel bij advisory board is geen onderdeel van rcihtlijn)
Miedema	Longarts, Erasmus MC	Geen.	Fee voor deelname advisory board 2020: nintedanib voor progressieve longfibrose (Boehringer Ingelheim), niet meer actueel. Fee voor enkele voordrachten Intersitiele longziekten, niet gerelateerd aan het onderwerp van de werkgroep myositis (Boehringer Ingelheim, Roche) Patent behandeling sarcoidose met JAK remmer, in bezit van Erasmus MC, niet gerelateerd aan het onderwerp myositis	Geen restricties
Meek	Afdelingshoofd a.i. afdeling reumatische ziekten, Radboudumc	Commissaris kwaliteit bestuur Nederlandse Vereniging voor Reumatologie (onkostenvergoeding)	Medisch adviseur myositis werkgroep spierziekten Nederland	Geen restricties
Veldkamp	AIOS dermatologie Radboudumc Nijmegen	Lid van Wereld Psoriasus Dag Commissie binnen de NVDV (vacatiegelden) Secretaris van de domeingroep Inflammatoire dermatosen binnen de NVDV (vacatiegelden)	Geen.	Geen restricties
Padmos	Reumatoloog, Erasmus MC	Docent Breederode Hogeschool (afdeling reumatologie EMC wordt hiervoor betaald)	Geen.	Geen restricties
Dalm	Internist-klinisch immunoloog Erasmus MC	Geen.	Geen.	Geen restricties
Olde Dubbelink	Neuroloog in opleiding Canisius-Wilhelmina Ziekenhuis, Nijmegen	Promotie onderzoek naar diagnostiek en outcome van het carpaletunnelsyndroom (onbetaald)	Geen.	Geen restricties
van Groenestijn	Revalidatiearts AmsterdamUMC, locatie AMC	Geen.	Lokale onderzoeker voor de I'M FINE studie (multicentre, leiding door afdeling Revalidatie Amsterdam UMC, samen met UMC Utrecht, Sint Maartenskliniek, Klimmendaal en Merem. Evaluatie van geïndividualiseerd beweegprogramma o.b.v. combinatie van aerobe training en coaching bij mensen met neuromusculaire aandoeningen, NMA). Activiteiten: screening NMA-patiënten die willen participeren aan deze studie. Subsidie van het Prinses Beatrix Spierfonds.	Geen restricties
Lassche	Neuroloog, Zuyderland Medisch Centrum, Heerlen en Sittard-Geleen	Geen.	Geen.	Geen restricties
de Jong	Dermatoloog, afdelingshoofd Dermatologie Radboudumc Nijmegen	Geen.	Has received research grants for the independent research fund of the department of dermatology of the Radboud university medical centre Nijmegen, the Netherlands from AbbVie, Novartis, Janssen Pharmaceutica and Leo Pharma. Has acted as consultant and/or paid speaker for and/or participated in research sponsored by companies that manufacture drugs used for the treatment of psoriasis including AbbVie, Janssen Pharmaceutica, Novartis, Lily, Celgene, Leo Pharma, UCB and Almirall All funding is not personal but goes to the independent research fund of the department of dermatology of Radboud university medical centre Nijmegen, the Netherlands	Geen restricties
Hoogendijk	Neuroloog Universitair Medisch Centrum Utrecht (0,4) Neuroloog Sionsberg, Dokkum (0,6)	Plaatsvervangend voorzitter Commissie Buitenlands Gediplomeerden Volksgezondheid (CBGV), ministerie van VWS, en lid CBGV, commissie artsen beide onbetaald	Geen.	Geen restricties
Badrising	Neuroloog Leids Universitair Medisch Centrum	(U.A.Badrising Neuroloog b.v.: hoofdbestuurder; betreft een vrijwel slapende b.v. als overblijfsel van mijn eerdere praktijk in de maatschap neurologie Dirksland, Het van Weel-Bethesda Ziekenhuis)	Medisch adviseur myositis werkgroep spierziekten Nederland	Geen restricties
van den Berg	Kinderarts-reumatoloog/-immunoloog Emma kinderziekenhuis/ Amsterdam UMC	Geen.	Geen.	Geen restricties
de Groot	Patiënt vertegenwoordiger/ ervaringsdeskundige: voorzitter diagnosewerkgroep myositis bij Spierziekten Nederland in deze commissie patiënt(vertegenwoordiger)	Als patiënt (vertegenwoordiger) betrokken bij diverse, onbetaalde projecten op gebied van myositis, reumatische ziekten in het algemeen (EULAR en OMERACT ReumaZorg Nederland, Reuma Nederland) en spierziekten (Spierziekten Nederland, Myositis Netwerk Nederland). Voor Prinses Beatrix Spierfonds lid van Gebruikers Commissie: vacatiegeld	Geen	Geen restricties
Küsters	Patholoog, Radboud UMC	Geen.	Geen.	Geen restricties
Saris	Neuroloog/ klinisch neurofysioloog, Radboudumc	Geen.	Geen.	Geen restricties
Raaphorst	Neuroloog, Amsterdam UMC	Geen.	Subsidie Sanquin Plasma Products voor het uitvoeren van een fase-2 RCT naar het effect van Ivlg-add on Immediate studie (investigator initiated, IVIg behandeling bij therapie naive patienten). --> Financiering via Behring. Studie januari 2019 afgerond.	Restricties m.b.t. opstellen aanbevelingen IvIg behandeling.
Jansen	Kinderarts-immunoloog-reumatoloog, WKZ UMC Utrecht	Docent bij Mijs-instituut (betaald)	Onderzoek biomakers in juveniele dermatomyositis. Geen belang bij uitkomst richtlijn.	Geen restricties

Inbreng patiëntenperspectief

Attention was paid to the patient's perspective by offering the Vereniging Spierziekten Nederland to take part in the working group. Vereniging Spierziekten Nederland has made use of this offer, the Dutch Artritis Society has waived it. In addition, an invitational conference was held to which the Vereniging Spierziekten Nederland, the Dutch Artritis Society nd Patiëntenfederatie Nederland were invited and the patient's perspective was discussed. The report of this meeting was discussed in the working group. The input obtained was included in the formulation of the clinical questions, the choice of outcome measures and the considerations. The draft guideline was also submitted for comment to the Vereniging Spierziekten Nederland, the Dutch Artritis Society and Patiëntenfederatie Nederland, and any comments submitted were reviewed and processed.

Qualitative estimate of possible financial consequences in the context of the Wkkgz

In accordance with the Healthcare Quality, Complaints and Disputes Act (Wet Kwaliteit, klachten en geschillen Zorg, Wkkgz), a qualitative estimate has been made for the guideline as to whether the recommendations may lead to substantial financial consequences. In conducting this assessment, guideline modules were tested in various domains (see the flowchart on the Guideline Database).

The qualitative estimate shows that there are probably no substantial financial consequences, see table below.

Module	Estimate	Explanation
Module diagnostische waarde ziekteverschijnselen	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Optimale strategie aanvullende diagnostiek myositis	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Autoantibody testing in myositis	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Screening op maligniteiten	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Screening op comorbiditeiten	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Immunosuppressie en -modulatie bij IBM	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Treatment with Physical training	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Treatment of dysphagia in myositis	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Treatment of dysphagia in IBM	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Topical therapy	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Treatment of calcinosis	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.
Module Organization of care	No substantial financial consequences	Outcome 1 No financial consequences. The recommendations are not widely applicable (<5,000 patients) and are therefore not expected to have any substantial financial consequences on collective expenditures.

Werkwijze

Methods

AGREE

This guideline module has been drawn up in accordance with the requirements stated in the Medisch Specialistische Richtlijnen 2.0 report of the Advisory Committee on Guidelines of the Quality Council. This report is based on the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II; Brouwers, 2010).

Clinical questions

During the preparatory phase, the working group inventoried the bottlenecks in the care of patients with IIM. Bottlenecks were also put forward by the parties involved via an invitational conference. A report of this is included under related products.

Based on the results of the bottleneck analysis, the working group drew up and finalized draft basic questions.

Outcome measures

After formulating the search question associated with the clinical question, the working group inventoried which outcome measures are relevant to the patient, looking at both desired and undesired effects. A maximum of eight outcome measures were used. The working group rated these outcome measures according to their relative importance in decision-making regarding recommendations, as critical (critical to decision-making), important (but not critical), and unimportant. The working group also defined at least for the crucial outcome measures which differences they considered clinically (patient) relevant.

Methods used in the literature analyses

A detailed description of the literature search and selection strategy and the assessment of the risk-of-bias of the individual studies can be found under 'Search and selection' under Substantiation. The assessment of the strength of the scientific evidence is explained below.

Assessment of the level of scientific evidence

The strength of the scientific evidence was determined according to the GRADE method. GRADE stands for Grading Recommendations Assessment, Development and Evaluation (see http://www.gradeworkinggroup.org/). The basic principles of the GRADE methodology are: naming and prioritizing the clinically (patient) relevant outcome measures, a systematic review per outcome measure, and an assessment of the strength of evidence per outcome measure based on the eight GRADE domains (downgrading domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias; domains for upgrading: dose-effect relationship, large effect, and residual plausible confounding).

GRADE distinguishes four grades for the quality of scientific evidence: high, fair, low and very low. These degrees refer to the degree of certainty that exists about the literature conclusion, in particular the degree of certainty that the literature conclusion adequately supports the recommendation (Schünemann, 2013; Hultcrantz, 2017).

GRADE	Definitie
High	there is high confidence that the true effect of treatment is close to the estimated effect of treatment; it is very unlikely that the literature conclusion will change clinically relevant when results of new large-scale research are added to the literature analysis.
Moderate	there is reasonable assurance that the true effect of treatment is close to the estimated effect of treatment; it is possible that the conclusion changes clinically relevant when results of new large-scale studies are added to the literature analysis.
Low	there is low certainty that the true effect of treatment is close to the estimated effect of treatment; there is a real chance that the conclusion will change clinically relevant when results of new large-scale research are added to the literature analysis.
Very low	Very low there is very low certainty that the true effect of treatment is close to the estimated effect of treatment; the literature conclusion is very uncertain.

When assessing (grading) the strength of the scientific evidence in guidelines according to the GRADE methodology, limits for clinical decision-making play an important role (Hultcrantz, 2017). These are the limits that, if exceeded, would lead to an adjustment of the recommendation. To set limits for clinical decision-making, all relevant outcome measures and considerations should be considered. The boundaries for clinical decision-making are therefore not directly comparable with the minimal clinically important difference (MCID). Particularly in situations where an intervention has no significant drawbacks and the costs are relatively low, the threshold for clinical decision-making regarding the effectiveness of the intervention may lie at a lower value (closer to zero effect) than the MCID (Hultcrantz, 2017).

Considerations

In addition to (the quality of) the scientific evidence, other aspects are also important in arriving at a recommendation and are taken into account, such as additional arguments from, for example, biomechanics or physiology, values and preferences of patients, costs (resource requirements), acceptability, feasibility and implementation. These aspects are systematically listed and assessed (weighted) under the heading 'Considerations' and may be (partly) based on expert opinion. A structured format based on the evidence-to-decision framework of the international GRADE Working Group was used (Alonso-Coello, 2016a; Alonso-Coello 2016b). This evidence-to-decision framework is an integral part of the GRADE methodology.

Formulation of conclusions

The recommendations answer the clinical question and are based on the available scientific evidence, the most important considerations, and a weighting of the favorable and unfavorable effects of the relevant interventions. The strength of the scientific evidence and the weight assigned to the considerations by the working group together determine the strength of the recommendation. In accordance with the GRADE method, a low evidential value of conclusions in the systematic literature analysis does not preclude a strong recommendation a priori, and weak recommendations are also possible with a high evidential value (Agoritsas, 2017; Neumann, 2016). The strength of the recommendation is always determined by weighing all relevant arguments together. The working group has included with each recommendation how they arrived at the direction and strength of the recommendation.

The GRADE methodology distinguishes between strong and weak (or conditional) recommendations. The strength of a recommendation refers to the degree of certainty that the benefits of the intervention outweigh the harms (or vice versa) across the spectrum of patients targeted by the recommendation. The strength of a recommendation has clear implications for patients, practitioners and policy makers (see table below). A recommendation is not a dictate, even a strong recommendation based on high quality evidence (GRADE grading HIGH) will not always apply, under all possible circumstances and for each individual patient.

Implications of strong and weak recommendations for guideline users

	Strong recommendation	Weak recommendations
For patients	Most patients would choose the recommended intervention or approach and only a small number would not.	A significant proportion of patients would choose the recommended intervention or approach, but many patients would not.
For practitioners	Most patients should receive the recommended intervention or approach.	There are several suitable interventions or approaches. The patient should be supported in choosing the intervention or approach that best reflects his or her values and preferences.
For policy makers	The recommended intervention or approach can be seen as standard policy.	Policy-making requires extensive discussion involving many stakeholders. There is a greater likelihood of local policy differences.

Organization of care

In the bottleneck analysis and in the development of the guideline module, explicit attention was paid to the organization of care: all aspects that are preconditions for providing care (such as coordination, communication, (financial) resources, manpower and infrastructure). Preconditions that are relevant for answering this specific initial question are mentioned in the considerations. More general, overarching or additional aspects of the organization of care are dealt with in the module Organization of care.

Commentary and authtorisation phase

The draft guideline module was submitted to the involved (scientific) associations and (patient) organizations for comment. The comments were collected and discussed with the working group. In response to the comments, the draft guideline module was modified and finalized by the working group. The final guideline module was submitted to the participating (scientific) associations and (patient) organizations for authorization and authorized or approved by them.

References

Agoritsas T, Merglen A, Heen AF, Kristiansen A, Neumann I, Brito JP, Brignardello-Petersen R, Alexander PE, Rind DM, Vandvik PO, Guyatt GH. UpToDate adherence to GRADE criteria for strong recommendations: an analytical survey. BMJ Open. 2017 Nov 16;7(11):e018593. doi: 10.1136/bmjopen-2017-018593. PubMed PMID: 29150475; PubMed Central PMCID: PMC5701989.

Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ. 2016 Jun 28;353:i2016. doi: 10.1136/bmj.i2016. PubMed PMID: 27353417.

Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schünemann HJ; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ. 2016 Jun 30;353:i2089. doi: 10.1136/bmj.i2089. PubMed PMID: 27365494.

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42. doi: 10.1503/cmaj.090449. Epub 2010 Jul 5. Review. PubMed PMID: 20603348; PubMed Central PMCID: PMC3001530.

Hultcrantz M, Rind D, Akl EA, Treweek S, Mustafa RA, Iorio A, Alper BS, Meerpohl JJ, Murad MH, Ansari MT, Katikireddi SV, Östlund P, Tranæus S, Christensen R, Gartlehner G, Brozek J, Izcovich A, Schünemann H, Guyatt G. The GRADE Working Group clarifies the construct of certainty of evidence. J Clin Epidemiol. 2017 Jul;87:4-13. doi: 10.1016/j.jclinepi.2017.05.006. Epub 2017 May 18. PubMed PMID: 28529184; PubMed Central PMCID: PMC6542664.

Medisch Specialistische Richtlijnen 2.0 (2012). Adviescommissie Richtlijnen van de Raad Kwaliteit. http://richtlijnendatabase.nl/over_deze_site/over_richtlijnontwikkeling.html

Neumann I, Santesso N, Akl EA, Rind DM, Vandvik PO, Alonso-Coello P, Agoritsas T, Mustafa RA, Alexander PE, Schünemann H, Guyatt GH. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016 Apr;72:45-55. doi: 10.1016/j.jclinepi.2015.11.017. Epub 2016 Jan 6. Review. PubMed PMID: 26772609.

Schünemann H, Brożek J, Guyatt G, . GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from http://gdt.guidelinedevelopment.org/central_prod/_design/client/handbook/handbook.html.

Richtlijnendatabase

Myositis