Preferred therapy recommendation for adult asthmatic Step 1-to-2 transition


A provider who prescribes a non-preferred Step 2 treatment for an asthmatic adult (age 12+) on Step 1 preferred therapy (short-acting beta agonist [SABA]) receives a recommendation to prescribe daily low-dose inhaled corticosteroid [ICS] treatment and as-needed SABA, or as needed low-dose ICS and SABA used concomitantly, as the preferred Step 2 treatment.  In addition, the provider is advised to verify patient adherence to treatment and proper use of inhalers.  Two mutually exclusive orders for low-dose ICS treatment are proposed: a pre-checked order for prn low-dose ICS concomitant with prn SABA, and a non-pre-checked order for daily low-dose ICS.  If the patient has no active persistent asthma condition on their problem list, then the provider is also offered a pre-checked action to add "Persistent asthma" to the patient's problem list.

Creation Date

Artifact Creation and Usage


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Implementation Details
Engineering Details

The ECA rule conforms to the FHIR R4 PlanDefinition resource and includes a reference to the FHIR Library resource which references the CQL library file.  The CQL library file uses the FHIR R4 data model and uses US Core v3 profiles where applicable.  Valuesets referenced in the CQL library file are published at the Value Set Authority Center.  Rule logic has undergone unit testing; see Test Patients in Purpose and Usage.

Repository Information
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage

Provide CDS for select prioritized recommendations in the NHLBI NAEPP 2020 Focused Updates to the Asthma Management Guidelines.  The ECA rule is one of 8 rules which provide CDS for Recommendations #10, #12, #13, and #16 of the 2020 Focused Updates, and for changes in the preferred treatment recommendation in Steps 2 – 5 of the Stepwise Approach For Management of Asthma in children (age 5 – 11 years) and adults (age 12+ years).

Intended Population

Individuals age 12+ years with persistent asthma


An asthmatic adult (age 12+ years) who is uncontrolled on (Step 1 therapy of) prn SABA should be treated with (Step 2 therapy of) daily low-dose ICS and as needed SABA, or as needed low dose ICS and SABA used concomitantly, which is preferred over (alternative Step 2 therapies of) LTRA/cromolyn/nedocromil/theophylline/zileuton + prn SABA.


Rule logic has been unit-tested but the CDS rule has not been clinically piloted. 

The approach assumes that inhaled corticosteroid (ICS) preparations may be partitioned into mutually exclusive valuesets of low dose, medium-dose, and high-dose ICS preparations for maintenance therapy of adult (age 12+ years) vs child (age 5-11 years) asthmatics.  The utility of this assumption has not been clinically validated.  Use of an ICS preparation for maintenance therapy in an atypical fashion (greater or fewer inhalations per day than is typical or expected) may not align with the partitioning of an ICS preparation into a dose-ranged (low/medium/high) valueset.  The rationale for this approach comes from our observations of inconsistency and lack of usability of structured dosage information for inhaled medications in CDA and FHIR data across vendor systems and implementations.

The rule recommends a medication class and proposes an order for provider convenience, but the suggested medication is only a specific example of the recommended class.   Any of the suggested orders can and should be reviewed and changed to align with local preferences.

Supporting Evidence
Source Description

In individuals aged 12 y and older with mild persistent asthma, the Expert Panel conditionally recommends either daily low-dose ICS and as-needed SABA for quick-relief therapy or as-needed ICS and SABA used concomitantly.

Strength of Recommendation

Conditional (Different choices will be appropriate for individuals consistent with their values and preferences. Use shared decision making. Decision aids may be useful in helping individuals make decisions consistent with their risks, values, and preferences.)

Quality of Evidence

Moderate (Authors of the recommendation are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different).

Artifact Decision Notes

1. Due to observed and acknowledged imprecision in the maintenance of EHR condition lists, Expert Panel members advised that a condition (problem or diagnosis) of "Asthma" (i.e., a condition in the "Asthma" valueset) should satisfy inclusion criteria rather than a condition of "Persistent asthma" (i.e., a condition in the "Persistent asthma" valueset).

2. A patient's perception of asthma symptoms matters in the management of asthma.  An accurate perception of asthma severity enables a patient to make appropriate changes in their activity level, physical environment, and medical treatments in a timely fashion.  However, in some patients there is a discrepancy between perception of asthma symptoms and objective measures of lung function.  A number of tools exist to evaluate symptom perception (e.g., a visual analog scale) but the 2020 Focused Updates to the Asthma Management Guidelines make no recommendation about assessing "perception of asthma symptoms".  Rule logic is not dependent upon any measures of "perception of asthma symptoms", but leaves that judgement to the clinician-consumer of the Rule's recommendations.

3. Assessment of asthma control is important in using the Stepwise Approach For Management of Asthma Therapy.  Clinical studies may use a validated instrument (e.g., ACT or ACQ) to assess asthma control, but the 2020 Focused Updates to the Asthma Management Guidelines make no recommendation about using such a tool in clinical practice.  Rule logic does not depend upon any quantitative assessment of, or (coded) qualitative assertion of, asthma control.

Artifact Representation

A named-event of ‘medication-prescribe’; the exact medications prescribed are passed as a parameter and analyzed in logic to determine compliance with Preferred Therapy recommendations in the NHLBI Stepwise Approach For Asthma Management diagram.


The patient in context is age 12 years or older with a condition of asthma treated with a short-acting beta agonist, and newly prescribed a non-preferred Step 2 asthma treatment or any treatment recommended in Steps 3-5 of the NHLBI Stepwise Approach For Asthma Management diagram.


Patient is on any asthma treatment other than a short-acting beta agonist.

Interventions and Actions
  • Recommend a low-dose inhaled corticosteroid as the preferred Step 2 treatment for mild persistent asthma, used daily with as needed SABA or used as needed concomitantly with SABA.  Verify patient adherence to treatment and proper use of inhalers, including use of a spacer or chamber inhaler device;  
  • Offer mutually exclusive options of:
    • a pre-checked low-dose ICS (beclomethasone dipropionate 0.04 MG/ACTUAT Metered Dose Inhaler) order for prn use concomitantly with prn SABA, and
    • a non-pre-checked low-dose ICS (beclomethasone dipropionate 0.04 MG/ACTUAT Metered Dose Inhaler) for daily use;
  • Offer a spacer or holding chamber device for use with MDI/HFA inhalers; and
  • If the patient does not have a condition of “Persistent asthma” on their problem list, then offer to add “Persistent asthma” to the problem list.
Logic Files
Testing Experience