Preferred therapy recommendation for adult asthmatic Step 4 to 5 transition


A provider who prescribes a non-preferred Step 5 treatment for an adult (age 12+ years) asthmatic patient on Step 4 preferred therapy receives a recommendation to prescribe a medium-dose inhaled corticosteroid -- long-acting beta agonist combo inhaler [ICS-LABA] + a long-acting muscarinic antagonist inhaler [LAMA] + an as-needed short-acting beta agonist inhaler [SABA] as the preferred Step 5 therapy.  In addition, the provider is advised to verify patient adherence to treatment and proper use of inhalers, recommend use of a spacer or chamber inhaler device, and recommend referral to an asthma care specialist if the patient has not had one within the prior 6 months.  A pre-checked order for a LAMA is proposed, and selectable orders for a medium-dose ICS-LABA, a SABA, and a referral to an asthma care specialist are provided.  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


This artifact was developed by Elimu Informatics, Inc. in collaboration with representatives from:

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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 asthma patient who is uncontrolled on (preferred Step 4 therapy of) medium-dose ICS-formoterol SMART therapy should be treated with (Step 5 therapy of) medium-high dose ICS-LABA + LAMA + prn SABA, which is preferred over (alternative Step 5 therapies of) an increased ICS dose (above medium-dose) without LAMA.


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 uncontrolled persistent asthma, the Expert Panel conditionally recommends adding LAMA to ICS-LABA compared to continuing the same dose of ICS-LABA.

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. 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.

3. Expert Panel members advised that, for an asthmatic on an ICS inhaler (preferred Step 2 therapy or higher), one may presume the use of a SABA inhaler; i.e., rule logic does not need to explicitly check for an active SABA inhaler medication.

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.


Patient is age 12 years or older with a condition of asthma treated with the preferred Step 4 therapy (medium-dose ICS-formoterol SMART inhaler), and is newly prescribed a non-preferred Step 5 treatment in the NHLBI Stepwise Approach For Asthma Management diagram.


Patient is on any treatment recommended in Step 5 of the Step Care diagram.

Interventions and Actions
  • Recommend a medium-high dose inhaled corticosteroid in combination with a long-acting beta agonist (medium-dose ICS-LABA combo inhaler), along with a daily long acting muscarinic antagonist and an as-needed short-acting beta agonist, as the preferred Step 5 therapy for moderate-to-severe persistent asthma.  Verify patient adherence to treatment and proper use of inhalers, including use of a spacer or chamber inhaler device.  Recommend consultation with an asthma care specialist if the patient has had none in the prior 6 months;
  • Offer a pre-checked order for 60 ACTUAT tiotropium 0.00125 MG/ACTUAT Inhalation Spray with instructions to take 2 inhalations by mouth daily;
  • Offer a non-prechecked order for 120 ACTUAT fluticasone propionate 0.115 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler with instructions to take 2 inhalation by mouth BID;
  • Offer a non-prechecked order for  200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler to take 1 - 2 inhalations by mouth every 4 to 6 hours prn asthma symptoms; 
  • Offer an order for a spacer or holding chamber device without mask for use with MDI/HFA inhalers;
  • If patient had no encounter with an asthma care specialist within the prior 6 months and none is scheduled for the following 3 months, then offer an order for consultation with an asthma care specialist as mutually-exclusive non-prechecked orders for referral to a pulmonologist or to a clinical allergist;  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