DRACMA one year after: Which changes have occurred in diagnosis and treatment of CMA in Italy?

Challenges with the guideline development process include difficulties in synthesizing evidence on diagnostic tests and therapeutic indications, reconciliation of information obtained through different statistical methods, transparency in evaluation of diagnostic and therapeutic tools, adherence to the clinical questions to which a physician is confronted in real-life [6].In order to meet these needs, two panels were constituted in DRACMA: a clinical panel and a methodological GRADE revision panel [7]. Three systematic reviews addressing the clinical questions were developed by the GRADE revision panel: 1-diagnosis, 2-use of substitute formulas and 3-immunotherapy for CMA. The GRADE evidence profiles for the clinical questions were developed on these systematic reviews. Summaries of evidence were reviewed by the panel members whose suggestions were incorporated. The quality of the evidence was classified as "high", "moderate", "low " or "very low" [6,8-12]. Finally, the DRACMA guideline panel reviewed the evidence summaries and formulated "strong" or "conditional and/or weak" recommendations. The statements on the underlying values, preferences and remarks are integral parts of the recommendations, and serve to facilitate their accurate interpretation.DRACMA was first introduced at the 2009 Buenos Aires World Allergy Congress and in a dedicated Meeting in Milan in February 2010 [13]. After the first publication in WAO Journal in April 2010, DRACMA was replicated in an indexed journal [14]. The worldwide situation in diagnosis and treatment of CMA before DRACMA was described in a round table at the Milan Meeting [15]. The subsequently published NIAID guidelines [16] widely referred to DRACMA, now cited by dozens. Of note, the method used has been indicated as an example of transparency in the development of guidelines and it has become a cornerstone for GRADE methodology [7,8,17-19]. A DRACMA implementation committee has been appointed at WAO in order to favour the d