BACKGROUND AND OBJECTIVE: The Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-ADOLOPMENT methodology has been widely used to adopt, adapt, or de novo develop recommendations from existing or new guideline and evidence synthesis efforts. The objective of this guidance is to refine the operationalization for applying GRADE-ADOLOPMENT. METHODS: Through iterative discussions, online meetings, and email communications, the GRADE-ADOLOPMENT project group drafted the updated guidance. We then conducted a review of handbooks of guideline-producing organizations, and a scoping review of published and planned adolopment guideline projects. The lead authors refined the existing approach based on the scoping review findings and feedback from members of the GRADE working group. We presented the revised approach to the group in November 2022 (approximately 115 people), in May 2023 (approximately 100 people), and twice in September 2023 (approximately 60 and 90 people) for approval. RESULTS: This GRADE guidance shows how to effectively and efficiently contextualize recommendations using the GRADE-ADOLOPMENT approach by doing the following: (1) showcasing alternative pathways for starting an adolopment effort; (2) elaborating on the different essential steps of this approach, such as building on existing evidence-to-decision (EtDs), when available or developing new EtDs, if necessary; and (3) providing examples from adolopment case studies to facilitate the application of the approach. We demonstrate how to use contextual evidence to make judgments about EtD criteria, and highlight the importance of making the resulting EtDs available to facilitate adolopment efforts by others. CONCLUSION: This updated GRADE guidance further operationalizes the application of GRADE-ADOLOPMENT based on over 6 years of experience. It serves to support uptake and application by end users interested in contextualizing recommendations to a local setting or specific reality in a short period of time or with limited resources.

Agency for Clinical Practice Guideline Korean Academy of Medical Sciences Seoul South Korea; Division of Lifespan and Population Health The University of Nottingham Nottingham UK

Center for Evidence based Medicine Medicinski fakultet Sveucilista u Splitu University of Split School of Medicine Split Croatia

Centre for Evidence based Health Care Division of Epidemiology and Biostatistics Department of Global Health Stellenbosch Univeristy Cape Town South Africa

Chair of Epidemiology and Preventive Medicine Jagiellonian University Medical College Krakow Poland; Krakow GRADE Centre Krakow Poland

Clinical Epidemiology and Research Center Humanitas University and Humanitas Research Hospital Via Rita Levi Montalcini 4 20090 Pieve Emanuele Milano Italy; Physiotherapy Unit Humanitas Clinical and Research Center IRCCS Rozzano Milan Italy

Cochrane Czech Republic Czech CEBHC JBI Centre of Excellence Czech GRADE Network Institute of Health Information and Statistics of the Czech Republic Prague Czech Republic

Cochrane Czech Republic Czech CEBHC JBI Centre of Excellence Czech GRADE Network Institute of Health Information and Statistics of the Czech Republic Prague Czech Republic; Center of Evidence based Education and Arts Therapies A JBI Affiliated Group Faculty of Education Palacký University Olomouc Prague Czech Republic

Cochrane Czech Republic Czech CEBHC JBI Centre of Excellence Czech GRADE Network Institute of Health Information and Statistics of the Czech Republic Prague Czech Republic; Department of Health Sciences Faculty of Medicine Masaryk University Brno Czech Republic

Cochrane Czech Republic Czech CEBHC JBI Centre of Excellence Czech GRADE Network Institute of Health Information and Statistics of the Czech Republic Prague Czech Republic; Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic

College of Medicine Nursing and Health Sciences University Galway Galway Ireland; Evidence Synthesis Ireland and Cochrane Ireland University of Galway Galway Ireland

Department of Clinical Epidemiology and Public Health The Sant Pau Biomedical Research Institute Barcelona Spain

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada; Clinical Epidemiology and Research Center Humanitas University and Humanitas Research Hospital Via Rita Levi Montalcini 4 20090 Pieve Emanuele Milano Italy; Nottingham Ningbo GRADE Centre School of Economics The University of Nottingham Ningbo China Ningbo China; China European Research Executive Agency European Commission Brussels Belgium

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada; Department of Anesthesia Faculty of Health Sciences McMaster University Hamilton Ontario Canada

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada; Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada; Division of Nephrology and Hypertension University of Kansas Medical Center Kansas City MO USA

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada; School of Medicine Case Western Reserve University Cleveland OH USA

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada; School of Medicine Universidad San Sebastian Santiago Chile

Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon

Department of Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada

Department of Medicine Massachusetts General Brigham Salem Hospital Boston MA USA

Department of Medicine McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada

Department of Pediatrics Baylor College of Medicine Houston TX USA

Department of Physical Medicine and Rehabilitation Christian Medical College Vellore India

Department of Preventive Medicine and Public Health School of Medicine Ajou University Suwon South Korea

Department of Primary Care Faculty of Medicine Université Libre de Bruxelles Brussels Belgium; Working group Development of Primary Care Guidelines Antwerpen Belgium

Department of Public Health Universidade Federal de Ciências da Saúde de Porto Alegre Porto Alegre Brazil

Departments of Family Medicine and Epidemiology and Biostatistics Western University London Ontario Canada

Division of Country Health Policies and Systems World Health Organization Regional Office for Europe Copenhagen Denmark

Division of Gastroenterology Hepatology and Nutrition University of Minnesota Minneapolis MN USA

Division of Immunology Immunity to Infection and Respiratory Medicine School of Biological Sciences The University of Manchester Manchester UK; North West Lung Centre Wythenshawe Hospital Manchester University NHS Foundation Trust Manchester Academic Health Science Centre Manchester UK

European Research Executive Agency European Commission Brussels Belgium

Faculty of Health Sciences Brandenburg Brandenburg Medical School Rüdersdorf Germany

Health Evidence Synthesis Recommendations and Impact School of Public Health The University of Adelaide Adelaide South Australia Australia

Iberoamerican Cochrane Centre Biomedical Research Institute Sant Pau Barcelona Spain

Institute for Evidence in Medicine Medical Center University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany

Medical Critical Pharmacy Division King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia; College of Medicine and Pharmacy Alfaisal University Riyadh Saudi Arabia

Pediatrics Department Quality Management Department King Saud University Medical City Research Chair for Evidence Based Healthcare and Knowledge Translation King Saud University Riyadh Saudi Arabia; Department of Internal Medicine Ribeirão Preto Medical School University of São Paulo Ribeirão Preto São Paulo Brazil

Research and Development National Health Care Institute Zorginstituut The Netherlands

Sigma Health Consulting LLC McLean VA USA

Thailand Center for Evidence Based Health Care Faculty of Nursing Chiang Mai University Chiang Mai Thailand

World Health Organization Collaborating Center for Infectious Diseases Research Methods and Recommendations Michael G DeGroote Cochrane Canada and McMaster GRADE Centres McMaster University Hamilton Ontario Canada; Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton L8S 4L8 Ontario Canada