Abstract
Rationale Patients with severe asthma are dependent upon treatment with high doses of inhaled corticosteroids (ICS) and often also oral corticosteroids (OCS). The extent of endogenous androgenic anabolic steroid (EAAS) suppression in asthma has not previously been described in detail. The objective of the present study was to measure urinary concentrations of EAAS in relation to exogenous corticosteroid exposure.
Methods Urine collected at baseline in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease outcomes) study of severe adult asthmatics (SA, n=408) was analysed by quantitative mass spectrometry. Data were compared to that of mild-to-moderate asthmatics (MMA, n=70) and healthy subjects (HC, n=98) from the same study.
Measurements and main results The concentrations of urinary endogenous steroid metabolites were substantially lower in SA than in MMA or HC. These differences were more pronounced in SA patients with detectable urinary OCS metabolites. Their dehydroepiandrosterone sulfate (DHEA-S) concentrations were <5% of those in HC, and cortisol concentrations were below the detection limit in 75% of females and 82% of males. The concentrations of EAAS in OCS-positive patients, as well as patients on high-dose ICS only, were more suppressed in females than males (p<0.05). Low levels of DHEA were associated with features of more severe disease and were more prevalent in females (p<0.05). The association between low EAAS and corticosteroid treatment was replicated in 289 of the SA patients at follow-up after 12–18 months.
Conclusion The pronounced suppression of endogenous anabolic androgens in females might contribute to sex differences regarding the prevalence of severe asthma.
Tweetable abstract
Urinary levels of potentially beneficial anabolic androgenic steroids are low in severe asthma patients treated with corticosteroids, especially females. This might be one factor contributing to the increased prevalence of severe asthma in women. https://bit.ly/46kq1R7
Introduction
There is increasing awareness of sex differences in asthma with accumulating evidence that male sex hormones have anti-asthmatic properties. For example, several beneficial effects have been reported for androgens in experimental models [1–3]. Furthermore, a recent study in asthmatics found a positive correlation between blood levels of the androgen dehydroepiandrosterone (DHEA) and lung function [4]. In the same study, higher expression of androgen receptors in bronchial epithelial cells from asthmatics was associated with better lung function, fewer symptoms, and lower exhaled nitric oxide fraction (FENO). In a 6-week placebo-controlled treatment trial in moderate-to-severe asthma, nebulised DHEA provided improvement in asthma control, although lung function did not change [5].
Patients with severe asthma generally require treatment with high doses of inhaled corticosteroids (ICS) and often even supplementation with oral corticosteroids (OCS), either during exacerbations or continuously. Whereas adrenal insufficiency and suppression of cortisol biosynthesis are well known adverse effects of corticosteroid treatment for asthma [6], the concurrent consequences of treatment with OCS or ICS on the levels of endogenous anabolic androgenic steroids (EAAS) remain relatively unexplored. Currently available data are limited to a few studies where testosterone or other androgens have been measured in blood or urine [4, 7–10].
With this in mind, we set out to determine the urinary levels of endogenous steroids, including androgens, in the pan-European U-BIOPRED study (Unbiased Biomarkers for the Prediction of Respiratory Disease outcomes) [11]. This well-characterised cohort includes >400 patients with severe asthma (SA), and ∼100 patients with mild-to-moderate asthma (MMA) and 100 healthy controls (HC). The WADA (World Anti-Doping Agency) accredited doping control laboratory in Stockholm used mass spectrometry to quantify the main EAAS metabolites, cortisone and cortisol, the main metabolites of prednisone and prednisolone, as well as metabolites of common asthma medications. It was therefore possible to relate the levels of EAAS and other endogenous steroids to both objectively detected markers of OCS treatment and recorded prescriptions of OCS and ICS. The measurement of urinary metabolites is the method of choice for assessment of whole-body steroid metabolism [12].
The measured analytes are displayed in figure 1, which summarises the biosynthesis of the natural steroid hormones from cholesterol in the gonads (testis and ovary) and in the adrenal cortex [13]. Pregnenolone is the precursor of cortisol, which is converted to cortisone in peripheral tissues, both of which appear in the circulation and urine. Pregnenolone is also metabolised to DHEA in the adrenal cortex in a step that is inhibited by synthetic steroids [13].
Overview of steroid metabolism with metabolites measured in the study shown in grey boxes.
In the ovary or testis, further metabolism of DHEA leads to androstenedione or androstenediol via a pathway for biosynthesis of the male sex hormone testosterone, and via further metabolism to the female sex hormones, oestrogens. In fertile women, 70–80% of circulating testosterone is derived from adrenal DHEA, whereas testosterone in males is predominantly of testicular origin [13].
Cortisol is secreted from the adrenal glands in response to adrenocorticotropic hormone and other regulatory hormones produced by the hypothalamic–pituitary–adrenal (HPA) axis. The secretion of sex hormones (both androgens and oestrogens) is similarly regulated by the hypothalamic–pituitary–gonadal (HPG) axis along with the conversion of androgens into oestrogens by aromatase in adipose tissue. The inhibitory effects of exogenous, synthetic steroids on the biosynthesis of endogenous steroids are executed by feedback-inhibition of the HPA and HPG axes [13, 14].
Steroid hormones are excreted in the urine as glucuronated (G) or sulphated (S) conjugates, and metabolites are therefore given the suffix G or S. The urinary metabolites reflect the integrated systemic biosynthesis of steroid hormones over time [12–14]. Previous studies on endogenous steroids in relation to asthma treatment have measured a limited number of analytes, mostly in the blood using immunoassays [4, 8, 10].
Methods
Study information
The U-BIOPRED adult study is a multicentre observational investigation recruiting asthmatics and healthy nonsmoking controls from 16 clinical centres in 11 European countries between January 2011 and December 2013 [11]. The study (ClinicalTrials.gov NCT01976767) was approved by the ethics committees at the clinical sites, and participants provided written informed consent. This report includes the 576 participants with complete data for urinary steroid metabolites: 302 nonsmoking and 106 smoking or ex-smoking SA patients, 70 MMA patients and 98 HC. Their baseline characteristics are displayed in table 1.
Baseline characteristics of the participants in the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes study of urinary steroid metabolites
The diagnosis of severe asthma followed European Respiratory Society/American Thoracic Society guidelines [15]. The SA group was required to use ≥1000 μg fluticasone propionate per day or equivalent dose of other corticosteroids, and MMA <500 μg daily. Patients in the SA group were allowed regular use of systemic corticosteroids. Most severe asthmatics were nonsmoking, defined as no smoking in the past year, and a lifetime history of ≤5 pack-years. Patients with severe asthma who had smoked during the past 12 months or had a history of >5 pack-years were assigned to a group including current smokers and ex-smokers [11].
Participants meeting the inclusion criteria during a screening visit then attended a baseline visit where clinical end-points were examined and biosamples collected. In addition, subjects with SA were invited to a follow-up visit after 12–18 months, where study procedures were repeated [11].
Urine collection and analysis
One spot urine sample was split into five 8-mL tubes (Sarstedt, Nümbrecht, Germany), placed into −20°C freezers at the study sites and kept at −80°C following shipment to the central analysis site in Stockholm. Under such conditions, steroid conjugates have been documented to be intact for ≥10 years, and they are also stable during several thaw–freeze cycles [16].
The quantification of endogenous and exogenous steroids was performed by ultra high-performance liquid chromatography high-resolution mass spectrometry as described previously [17]. Metabolites of prednisone are highest during the first 24–36 h after oral intake [18], but may be found up to a week after the last dose with the high-sensitivity method used (limit of detection (LOD) 1 ng·mL−1 for all analytes) [18].
Data analysis
The urinary levels of steroids followed a non-normal distribution. Due to the exploratory nature of this study, unadjusted p-values were used and p-values <0.05 were considered significant using the Kruskal–Wallis, Mann–Whitney U or Wilcoxon matched-pairs signed-rank tests. For comparison of proportions, Chi-squared analysis was performed. The number of values below LOD for analytes in the panel are indicated for reported datasets (tables 2 and 3). For the statistical analysis, such data points were imputed as 0.5 ng·mL−1. Clinical outcomes and biomarker results for the participants were retrieved from the U-BIOPRED TranSMART data handling system [19]. Statistical evaluation was performed using GraphPad Prism (v9).
Comparison of concentrations of endogenous steroids between the sexes for the three main study groups
Comparison of concentrations of endogenous steroids between the sexes for severe asthma high-dose inhaled corticosteroid (ICS)/oral corticosteroid (OCS)-negative and high-dose ICS/OCS-positive
The presence of urinary prednisone metabolites was used to stratify the patients into two groups regarding OCS detection: yes or no. Relations between the urinary concentrations of DHEA-S and clinical outcomes were evaluated using an extreme group analysis, where asthmatic subjects were stratified into high (>75th percentile) or low (<25th percentile) DHEA-S groups.
Results
Urinary excretion of metabolites of endogenous steroids in the recruited study groups
Males had higher urinary concentrations of androgens, and data for endogenous steroids were therefore separated by sex (tables 2 and 3). Furthermore, there were few differences with respect to steroid concentrations between ex-smoking (n=65) and nonsmoking (n=302) SA participants and the current smokers were too few (24 female, 17 male) to enable sufficiently powered analyses of these subgroups (supplementary table S1). Therefore, the data for SA are merged irrespective of smoking history, providing one group of 253 females and another comprised of 155 males.
The concentrations of cortisol and cortisone were the same in males and females (table 2). In both sexes, the concentrations of all urinary steroid metabolites were substantially lower in SA than in MMA or HC (figure 2a–d, table 2). The only exception to this apparent suppression of endogenous steroids in SA was urinary testosterone in males, which was similar in all three study groups, presumably reflecting its gonadal origin in men (figure 2d, table 2). In contrast, the urinary concentrations of most steroid metabolites were similar in both sexes for MMA and HC (figure 2, table 2). Supplementary table S2 summarises the statistical comparisons for all analytes between the study groups.
Levels of endogenous steroids in the urine of female and male study participants. a) Cortisol; b) dehydroepiandrosterone sulfate (DHEA-S); c) androsterone-glucuronate (G); d) testosterone-G. Data are presented as median (interquartile range). The Mann–Whitney U-test was used to compare two groups and the Kruskal–Wallis test to compare three groups. All graphs have a logarithmic y-axis scale, although statistical analyses were performed on arithmetic data. The box plots for the three severe asthma (SA) groups in a) (cortisol) are elongated due to the large number of imputed values (0.5 ng·mL−1) where levels were below limit of detection (LOD) (see also tables 2 and 3). HC: healthy controls; MMA: mild-to-moderate asthma; SA: all patients with severe asthma; SA ICS: severe asthma subgroup with no detectable metabolites of oral corticosteroids in the urine (OCS-neg); SA OCS-pos: severe asthma subgroup with detectable metabolites of oral corticosteroids in the urine.
As the median age of the SA group was greater than HC and MMA (table 1), data were compared between subjects who were older or younger than 45 years (supplementary table S3), also providing an arbitrary stratification of females as pre- and post-menopausal. Although the older patients of both sexes had lower concentrations of cortisol and androgens, the differences in steroid concentrations between the three study groups remained irrespective of age. Furthermore, as the SA group had a higher body mass index (BMI), the steroid metabolites were compared between participants with a BMI below or above 30 kg·m−2 (supplementary table S4). With the exception of androsterone-S, which was lower in both sexes among participants with SA and high BMI, there were no BMI-related differences in EAAS metabolites.
Relationship of endogenous anabolic androgenic steroids to treatment with corticosteroids
We then tested the obvious hypothesis that the differences between the study groups with respect to endogenous steroids were related to the intensity of corticosteroid treatment. According to recorded medical history, 162 (40%) individuals in the SA group reported OCS use at least once a week. In this group, OCS metabolites were detected in the urine of 92 (57%) participants (figure 3, supplementary tables S5 and S6), suggesting that 70 (43%) participants had not taken OCS during the few days before the study visit. For females as well as males, the concentrations of cortisol, cortisone and androgen metabolites were significantly lower in OCS-positive SA patients than OCS-negative SA patients (figure 2, table 3, supplementary table S2). In fact, between 65% and 80% of the patients in the OCS-positive SA groups had signs of adrenal insufficiency with undetectable levels of cortisol and cortisone (table 3).
Reported oral corticosteroid (OCS) use and presence of urinary prednisone metabolites (OCS detected) in patients with severe asthma in the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes study at baseline (n=403) and longitudinal follow-up 12–18 months later (n=289).
For both sexes, the concentrations of DHEA-S and most other EAAS metabolites were lower in the OCS-positive SA groups, compared with the OCS-negative SA patients (figure 2, table 3, supplementary table S2). The only exceptions were testosterone-G (figure 2d) and dihydrotestosterone-G, which among males were essentially unaffected in the OCS-positive SA group (table 3, supplementary table S2). Moreover, the concentrations of all EAAS metabolites were lower in OCS-positive females with SA compared to males (table 3, supplementary table S2). For the two most abundant androgen metabolites, androsterone-G and etiocholanolone-G, the ratio between levels in males and females in the OCS-positive SA group were 7.7 and 5.0, respectively, as compared to 1.8 and 1.4, respectively, in the HC group (table 3).
Furthermore, the OCS-negative SA group on high-dose ICS also showed markedly lower concentrations of most measured endogenous steroids when compared to MMA or HC (figure 2, tables 2 and 3, supplementary table S2). In this group, females consistently displayed lower levels of EAAS than males (table 3).
The patients with MMA had higher concentrations of endogenous steroids than the two SA groups, although there were no significant differences between MMA and HC (tables 2 and 3, supplementary table S2). Seven patients in the MMA group had detectable prednisone metabolites in their urine and were excluded from further analysis (supplementary table S6).
Data stability at longitudinal follow-up visit
Consent for a follow-up visit after 12–18 months was obtained from 289 (71%) of the 408 patients with severe asthma. The clinical outcomes and the observed suppression of EAAS metabolites were replicated and stable (table 4). Cortisol concentrations were slightly higher at the longitudinal visit; however, somewhat fewer participants used OCS at the longitudinal visit, both according to self-reported intake and detection of urinary OCS metabolites (figure 3, supplementary table S5).
Comparison between baseline and longitudinal data for the patients in the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes study with severe asthma attending both visits (n=289)
Relationships between endogenous androgens and clinical outcomes
Clinical or biomarker outcomes were related to concentrations of the key androgen intermediate DHEA-S (figure 4, table 5). The odds for SA patients taking OCS to be in the quartile of samples with the lowest concentrations of DHEA-S were 2.3-fold higher (Chi-squared test) than those not taking OCS (table 5). OCS-positive SA patients also had lower blood eosinophils, higher blood neutrophils and higher serum matrix metalloproteinase (MMP)-3 (supplementary table S7), all of which are objective markers of corticosteroid exposure.
Clinical and biomarker variables for the lowest (25th percentile; n=119) and highest (75th percentile; n=118) quartiles of asthmatic patients stratified for urinary concentrations of dehydroepiandrosterone sulfate (DHEA-S). Data are presented as median (interquartile range) for a) forced expiratory volume in 1 s (FEV1; % predicted), b) Asthma Control Questionnaire (ACQ)-5, c) exacerbations in past year, d) Asthma Quality-of-Life Questionnaire (AQLQ), e) Hospital Anxiety and Depression Scale (HADS) total score, f) high-sensitivity C-reactive protein (hCRP) and g) S-matrix metalloproteinase (MMP)-3 (low and high groups were compared by Mann–Whitney U-test); and h) the number of subjects with detectable urinary oral corticosteroid (OCS) metabolites (significance calculated according to the Chi-squared test).
Extreme group comparison of endogenous steroid profiles, clinical outcomes and selected biomarkers in relation to urinary dehydroepiandrosterone (DHEA) concentration at the baseline visit for all asthmatics (mild-to-moderate asthma (MMA); severe asthma (SA)) in the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes study
In this extreme group comparison, low concentrations of DHEA-S were associated with multiple clinical outcomes indicating more severe disease, such as lower asthma-specific quality of life, higher HADS score, lower forced expiratory volume in 1 s (FEV1), more frequent exacerbations, lower asthma control and a higher proportion of subjects with detectable OCS metabolites (figure 4, table 5). The concentrations of bronchoconstrictive prostaglandin and cysteinyl-leukotriene metabolites in the urine, as well as serum C-reactive protein (CRP) and MMP-3, were highest in the lowest quartile (table 5). Regarding lung function, there was a weak but significant correlation with urinary DHEA-S in both sexes (r2 0.07 for females and 0.14 for males; p>0.001).
There were more females in the low DHEA-S group (85 versus 34 males), and all EAAS metabolites were lower in this group (table 5). Moreover, the low DHEA group included only patients with SA, whereas one-third of patients in the high DHEA group had MMA (table 5).
Detection of metabolites of bronchodilators
Approximately one-third of asthma patients had detectable levels of short-acting β-agonists with no differences between disease severity groups or sexes (supplementary table S6).
Discussion
We quantified the levels of urinary metabolites of endogenous steroids by mass spectrometry in a clinical cohort of 478 well-characterised patients with asthma of differing severity and a control group of 98 healthy subjects. Simultaneous measurement of the urinary metabolites of prednisone and prednisolone provided an objective assessment of exposure to OCS.
Results showed that individuals with SA had very low concentrations of endogenous androgens and cortisol in comparison to MMA and HC. The low concentrations of cortisol were expected, because systemic corticosteroids are known to cause suppression of the HPA axis [6, 20], but the extent was greater than anticipated. The majority (75% of females and 82% of males) of patients with SA with detectable prednisone metabolites had undetectable concentrations of cortisol (table 3). The associated, and uniformly low, levels of the EAAS metabolites in the WADA panel among OCS users or patients on high-dose ICS treatment has not been reported previously.
Moreover, the concentrations of EAAS metabolites among females with SA were more depressed than those observed in males with SA (figure 2, table 2), both in the OCS-positive and the OCS-negative groups (table 3). Although men with SA also displayed low concentrations of DHEA-S and the other EAAS metabolites compared with HC (table 2), men retained high levels of testosterone that were unaffected by corticosteroid treatment (tables 2 and 3, figure 2D). Accordingly, in the extreme group comparison, all subjects in the low DHEA-S group had severe asthma; 71% were female; and this group was characterised by worse asthma outcomes (figure 4, table 5).
In contrast to the many reports on the influence of corticosteroid treatment on levels of cortisone or cortisol in plasma or urine [6, 8, 20], the effects of corticosteroids on endogenous androgens have received less attention. A small study addressing the risk of osteoporosis in men with asthma [10] found a 33% reduction in circulating testosterone levels in 12 patients on OCS, but no significant effects in 23 patients on low or high doses of inhaled beclomethasone. In an early study of 15 females with asthma who had been on oral glucocorticoid therapy for 3–7 years, the levels of DHEA in plasma and urine were found to be lower than in 10 matched controls despite the asthmatics using only bronchodilators at the time of the investigation [7]. However, they also had low cortisol levels, suggesting persisting adrenal insufficiency. Priftis et al. [9] followed 25 children of both sexes with asthma during treatment with beclomethasone and documented suppressed urinary cortisol compared with 23 steroid-naïve children, but there were no differences between the groups with respect to the excretion of the androgens androsterone and etiocholanolone.
Using much larger cohorts, the United States National Heart, Lung, and Blood Institute-funded Severe Asthma Research Programme (SARP) consortium reported a positive correlation between blood DHEA levels and lung function in both sexes, as well as more symptoms and higher FENO in subjects with low blood DHEA [4]. The relationship between blood levels of DHEA and lung function has also been observed in adolescents [21]. Interestingly, the beneficial role of androgens is supported by a registry study where subjects with the rare disease androgen insensitivity syndrome (AIS) had an increased risk of asthma [22]. The syndrome is caused by hereditary loss of androgen receptor function, and the risk of asthma was less in those with AIS being treated with testosterone.
The U-BIOPRED data confirm and extend the observation of a relationship between DHEA and lung function, as we also found a correlation between urinary DHEA and FEV1 (% predicted). Although the correlation is relatively weak (r2 0.07 and 0.16 for females and males, respectively), it is similar in magnitude to that reported for blood DHEA in the SARP study (0.15–0.16) [4]. Moreover, our study of 478 patients with asthma further extends the association between more severe asthma and androgen levels by showing higher scores in the low DHEA group with respect to patient-reported outcomes, as well as biomarkers such as CRP, MMP-3 and the lipid mediators leukotriene E4 and tetranor PGDM (table 5). The objective markers of poor asthma control are also associated with low levels of other key EAAS metabolites (table 5).
In line with previous publications [6], our data support dose-dependent effects of corticosteroid treatment on endogenous steroids. In both sexes, those on high-dose ICS treatment with detectable OCS metabolites showed the most profound suppression of EAAS and cortisol, whereas those treated only with high-dose ICS showed less pronounced depressions in EAAS. Nevertheless, the concentrations of cortisol and EAAS in the OCS-negative SA group treated with high-dose ICS were consistently substantially lower than in the MMA group; in general, ≥50% lower than the EAAS metabolites in HC (figure 2, tables 2 and 3).
Also consistent with most other reports (see [6] and [20] for reviews), we found no significant difference in endogenous steroids between MMA and HC (supplementary table S2). However, a recent nonquantitative metabolomic screen of large epidemiological asthma cohorts found that regular treatment of asthma with low-dose ICS was associated with suppressed plasma levels of 15 steroid hormones, including some androgens and cortisol [23].
We were initially surprised to find that <50% of patients reporting current OCS use at the baseline visit, or at the follow-up after 12–18 months, had detectable prednisone metabolites in their urine (figure 3). The observation could suggest adherence issues [24], or simply a longer time since last OCS dose, as steroid use was recorded as treatment during the past week and most data suggest that prednisone metabolites are undetectable after a few days [18]. Presumably, those with detectable prednisone metabolites belonged to the most severe, steroid-dependent subset of SA patients. Accordingly, this group displayed evidence of recent exposure to corticosteroids such as higher blood neutrophils, lower eosinophils and higher serum MMP-3 [25] (supplementary table S7). Higher exposure to systemic steroids would also explain why steroid-sensitive type-2 markers such as FENO, periostin and blood eosinophils were not elevated in the more severe group with detected OCS exposure (table 5). It is noteworthy that 15% of patients reporting no OCS prescription still displayed detectable prednisolone metabolites in their urine, as well as a handful of patients in the MMA group (figure 3, supplementary table S6). The latter findings are probably explained by widespread access to OCS as a self-medication among patients with asthma. Taken together, our data on urinary OCS metabolites highlights the inadequacy of evaluating corticosteroid exposure from prescription records only.
One limitation of the U-BIOPRED study is that we have no information regarding the ratio between androgens and female sex hormones as the WADA doping panel is designed to measure EAAS. Likewise, data concerning female reproductive physiology (e.g. menstrual cycle phase, use of contraceptives or hormone replacement) was not collected. Concerning the potential influence of the menstrual cycle, the clinical and biomarker outcomes in the extreme group comparison were assessed in relation to DHEA-S, which is a long-lived metabolite not altered significantly during the menstrual cycle [26]. It has also been established using the same analytical platform that the levels of EAAS metabolites change very little during a normal menstrual cycle [27]. In our study, the greatest effects on androgens were observed in SA where only 27% of participants were aged <45 years (supplementary table S2). This makes it unlikely that the use of hormonal contraceptives is a major confounder. Conversely, use of hormone replacement therapy (HRT) might be an issue. We have not found data on the prevalence of HRT in severe asthma, but a large prospective study in a primary care database in the United Kingdom (UK) estimated that 16% of women aged 46–70 years used HRT [28]. As the U-BIOPRED study is pan-European, there may be variability between countries reflecting cultural and regional differences in the use of HRT. Assuming the UK prevalence, there is nevertheless no reason to believe that this subgroup should have been driving the differences in the levels of androgen metabolites between men and women with severe asthma. Given that the women with asthma in our cohort also demonstrate the same clear dose–response relationships for suppression of adrenal androgens as the men in the study (low-dose ICS<high-dose ICS<high-dose ICS+OCS; tables 2 and 3), we conclude that the possible bias due to HRT is likely to have been small and evenly distributed among women with different severities of asthma.
Another limitation of the current study is that we were unable to assess the potential influence of smoking on steroid hormone levels because too few active smokers were included. However, our report does have many strengths, being the first to assess the relationship between corticosteroid treatment and a broad panel of endogenous steroids in a comprehensively characterised cohort of close to 500 individuals with asthma, and providing new findings concerning associations between steroid levels and many clinical and biomarker outcomes. Moreover, we used a validated quantitative method used by international sports authorities to disqualify athletes due to doping, namely, the measurement of urinary metabolites reflecting whole-body metabolism. A further strength of our study is that clinical data, biomarker profiles, and concentrations of urinary metabolites of steroid hormones observed in SA patients at baseline were replicated at follow-up, 12–18 months later (table 4).
In conclusion, the comprehensive measurements of endogenous and exogenous steroid metabolites in the U-BIOPRED study demonstrate that severe asthma is associated with substantial suppression of EAAS levels in addition to cortisol. The data clearly reveal that the level of treatment with exogenous corticosteroids is the main cause of this adrenal suppression, as previously observed in a small study of healthy subjects [29]. Given the indications that androgens have beneficial anti-asthmatic properties [4, 30], our findings suggest that sex differences in asthma severity and prevalence [31, 32] may in part relate to a disproportionally greater relative deficiency in androgen levels during steroid treatment in females compared to males. Our study also supports the clinical goal of reducing the adverse effects of corticosteroids by reducing high-dose ICS therapy, and particularly by tapering of OCS [33]. In addition, we highlight the importance of assessing adrenal function and androgens in patients with severe asthma exposed to high doses of corticosteroids. Future studies will reveal whether new biologic therapies facilitate steroid-sparing treatment associated with less suppression of endogenous androgens.
Supplementary material
Supplementary Material
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Supplementary material 00269-2023.SUPPLEMENT
Acknowledgement
We thank the whole U-BIOPRED team for dedicated contributions.
Footnotes
Provenance: Submitted article, peer reviewed.
Ethics statement: The U-BIOPRED observational study of severe asthma was approved by the ethics committees at all the clinical sites in eleven countries, and participants provided written informed consent.
U-BIOPRED Study Group: H. Ahmed, C. Auffray, A.T. Bansal, F. Baribaud, E.H. Bel, J. Bigler, B. Billing, H. Bisgaard, M.J. Boedigheimer, K. Bønnelykke, J. Brandsma, P. Brinkman, E. Bucchioni, D. Burg, A. Bush, D. Campagna, A. Chaiboonchoe, R. Chalekis, T. Cheka, C.H. Compton, J. Corfield, D. Cunoosamy, A. D'Amico, B. De Meulder, R. Emma, V.J. Erpenbeck, D. Erzen, K. Fichtner, N. Fitch, L.J. Fleming, R. Formaggio, U. Frey, M. Gahlemann, V. Goss, Y. Guo, S. Hashimoto, J. Haughney, G. Hedlin, P.W. Hekking, T. Higenbottam, J.M. Hohlfeld, A.J. Knox, J. Konradson, N. Lazarinis, D. Lefaudeux, C-X. Li, M.J. Loza, R. Lutter, A. Manta, S. Masefield, J.G. Matthews, A. Mazein, A. Meiser, R.J.M. Middelveld, M. Miralpeix, N. Mores, C.S. Murray, J. Musial, D. Myles, B. Nordlund, H. Olsson, J. Östling, L. Pahus, S. Pavlidis, A. Postle, P. Powel, G. Praticò, M. Puig Valls, R. Rao, S. Reinke, A. Roberts, G. Roberts, A. Rowe, T. Sandström, J.P.R. Schofield, W. Seibold, A. Selby, R. Sigmund, F. Singer, P.J. Skipp, M. Smicker, M. Ström, K. Sun, B. Thornton, M. Uddin, W.M. van Aalderen, M. van Geest, J. Vestbo, N.H. Vissing, A.H. Wagener, S.S. Wagers, Z. Weiszhart, Å. Wheelock and S.J. Wilson.
Author contributions: M. Ericsson, J.H. Riley, S. Bates, P.S. Bakke, M. Caruso, P. Chanez, S.J. Fowler, T. Geiser, P.H. Howarth, I. Horváth, N. Krug, P. Montuschi, M. Sanak, D.E. Shaw, R.G. Knowles, B. Dahlén, A-H. Maitland-van der Zee, P.J. Sterk, R. Djukanovic, I.M. Adcock, K.F. Chung, C.E. Wheelock and S-E. Dahlén designed the studies. A.R. Sousa, J.H. Riley, S. Bates, P.S. Bakke, M. Caruso, P. Chanez, S.J. Fowler, T. Geiser, P.H. Howarth, I. Horváth, N. Krug, P. Montuschi, M. Sanak, A. Behndig, D.E. Shaw, B. Dahlén, P.J. Sterk, R. Djukanovic and K.F. Chung executed the clinical studies. V. Yasinska, C. Gómez, J. Kolmert, M. Ericsson, A. Pohanka, A. James, L.I. Andersson, M. Sparreman-Mikus, I.M. Adcock, C.E. Wheelock, S-E. Dahlén and E. Wikström Jonsson acquired and analysed the data. V. Yasinska, C. Gómez, J. Kolmert, M. Ericsson, A. Pohanka, A. James, L.I. Andersson, M. Sparreman-Mikus, S.J. Fowler, M. Sanak, A-H. Maitland-van der Zee, P.J. Sterk, I.M. Adcock, K.F. Chung, C.E. Wheelock, S-E. Dahlén and E. Wikström Jonsson interpreted the data. V. Yasinska, C. Gómez, J. Kolmert, A. James, L.I. Andersson, I.M. Adcock, K.F. Chung, C.E. Wheelock, S-E. Dahlén and E. Wikström Jonsson wrote the manuscript draft, which was reviewed and revised by all authors. All authors attest to the accuracy of the work submitted.
Conflict of interest: V. Yasinska reports participation in advisory boards for AZ and GSK, and lecture honoraria from Sanofi and GSK.
Conflict of interest: C. Gómez has nothing to disclose.
Conflict of interest: J. Kolmert has nothing to disclose.
Conflict of interest: M. Ericsson has nothing to disclose.
Conflict of interest: A. Pohanka has nothing to disclose.
Conflict of interest: A. James reports personal grant from Swedish Heart-Lung Foundation.
Conflict of interest: L.I. Andersson has nothing to disclose.
Conflict of interest: M. Sparreman-Mikus has nothing to disclose.
Conflict of interest: A.R. Sousa reports employment and stocks or stock options from GSK.
Conflict of interest: J.H. Riley has nothing to disclose.
Conflict of interest: S. Bates has nothing to disclose.
Conflict of interest: P.S. Bakke reports lecture honoraria from AstraZeneca and Boehringer Ingelheim.
Conflict of interest: N. Zounemat Kermani has nothing to disclose.
Conflict of interest: M. Caruso has nothing to disclose.
Conflict of interest: P. Chanez reports participation in advisory boards, honoraria for consultancy, lectures fees and support for attending and/or travel from ALK, Almirall, AZ, Chiesi, GSK, Menarini, Novartis and Sanofi.
Conflict of interest: S.J. Fowler has nothing to disclose.
Conflict of interest: T. Geiser has nothing to disclose.
Conflict of interest: P.H. Howarth reports employment and stocks or stock options from GSK.
Conflict of interest: I. Horváth reports participation on an advisory board for AZ and Chiesi, honoraria for lectures from Chiesi and Roche, and support for attending and/or travel from Roche.
Conflict of interest: N. Krug has nothing to disclose.
Conflict of interest: P. Montuschi has nothing to disclose.
Conflict of interest: M. Sanak has nothing to disclose.
Conflict of interest: A. Behndig has nothing to disclose.
Conflict of interest: D.E. Shaw has nothing to disclose.
Conflict of interest: R.G. Knowles has nothing to disclose.
Conflict of interest: B. Dahlén reports grant from GSK and Novartis.
Conflict of interest: A-H. Maitland-van der Zee reports grants from BI, Vertex Innovation Award, Dutch Lung Foundation, Stichting Astma Bestrijding, IMI/3TR, EU grant ONELAB and EUROSTARS grant with Respiq, consulting fees from AZ and BI, and lecture honoraria from GSK.
Conflict of interest: P.J. Sterk reports a grant from the Innovative Medicines Initiative.
Conflict of interest: R. Djukanovic reports consulting fees from Synairgen, lecture honoraria from Regeneron, GSK and Kymab, and an advisory board for Synairgen.
Conflict of interest: I.M. Adcock reports grant from EU-IMI, grants from GSK, MRK, EPSRC and Sanofi, consulting fees from GSK, Sanofi, Chiesi and Kinaset, lecture honoraria from AZ, Sanofi and Eurodrug, and payment for an educational event from Sunovion.
Conflict of interest: K.F. Chung reports lectures honoraria from Novartis, AZ and Merck, advisory boards for GSK, AZ, Novartis, Roche, Merck, Rickett-Beckinson, Nocion and Shionogi, the Scientific Advisory Board of the Clean Breathing Institute supported by Haleon, grants from GSK, MRC and EPSRC, and support for travel from AZ.
Conflict of interest: C.E. Wheelock has nothing to disclose.
Conflict of interest: S-E. Dahlén reports research grants, consulting fees or lecture honoraria from AZ, Cayman Chemicals, GSK, Regeneron, Sanofi and Teva.
Conflict of interest: E. Wikström Jonsson reports a research grant and expert assignment by Region Stockholm, and an expert appointment by the Swedish Medical Product Agency.
Support statement: The U-BIOPRED study has received infrastructure and operational funding from the Innovative Medicines Initiative (www.imi.europa.eu) joint undertaking under grant agreement 115010, resources which are composed of financial contributions from the European Union's Seventh Framework Programme (FP7/2007–2013) and the European Federation of Pharmaceutical Industries and Associations. The partners have provided matching funding to enable studies utilising the data and bioresources collected in the study. For this report, funding to Karolinska Institutet from the following sources have been instrumental: the Swedish Heart–Lung Foundation; the Swedish Research Council; the Stockholm Region County Council funds (ALF); CIMED; the Konsul Th.C. Bergh Research Foundation; the ChAMP (Centre for Allergy Research Highlights Asthma Markers of Phenotype) consortium, which is funded by the Swedish Foundation for Strategic Research; the Karolinska Institutet; the AstraZeneca & Science for Life Laboratory Joint Research Collaboration; and the Vårdal Foundation. A. James was supported by the Osher Initiative for Severe Asthma Research. C.E. Wheelock was supported by the Swedish Heart–Lung Foundation (HLF 20210519). Funding information for this article has been deposited with the Crossref Funder Registry.
- Received April 27, 2023.
- Accepted June 21, 2023.
- Copyright ©The authors 2023
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