In this study, a new method will be used to evaluate response to 2 approved biologic therapies, and assess how well each patient responds to each asthma treatment. This study will measure the response to these treatments using genomic and biologic measurements obtained from participants biosamples.

By evaluating response to 2 different biologic therapies, this study has the potential to provide an in-depth understanding of the mechanisms underlying severe asthma that will inform and change treatment decisions, and may ultimately lead to a change in the way that asthma patients are evaluated for potential personalized therapies and maximize the probability that the subject will respond to treatment.

The study design mirrors standard of care for this study population (moderate to severe asthmatics) in that the procedures are drugs and not outside of standard of care and not experimental. The drugs were chosen based on safety, availability, and their use in patient care. The use of the drugs/biologics and other asthma related processes and procedures are not experimental. Eligible participants will have the option of receiving Symbicort as their controller medication, during their involvement in the study.

The study focuses on a series of pre- and post-therapy characterizations or 'evoked phenotypes' that are not studied in traditional randomized clinical trials. Specifically, in a broad spectrum of 120 moderate-severe nonsmoking asthmatics, after evaluating pharmacologic response to systemic corticosteroids, each subject will undergo 'evoked phenotypes' with anti-IL-5R (benralizumab) and anti-IL-4Rα (dupilumab) in a random order along with comprehensive transcriptomic data interrogation prior to and during each therapeutic intervention.

A specific strength of our approach is the longitudinal assessment of within individual response related to therapeutic immunomodulation combined with state-of-the-art computational methods that will further define disease biology.

Current biomarkers are inadequate to distinguish responders and non-responders because they are not sensitive or specific enough for true predictive precision medicine. This study will use novel genomics approaches to assess and predict responses using therapy-induced phenotypes across a spectrum of asthma severity and endotypes.

Inclusion Criteria:

• Stated willingness to comply with all study procedures and availability for the duration of the study.

• Stable asthma medications: No change in asthma medications for the past 2 months:

  1. Use of medium or high dose inhaled corticosteroids (ICS) AND
  2. Use of an additional asthma controller medication.

• Baseline poor or uncontrolled asthma.

• Evidence of asthma demonstrated by either bronchodilator reversibility (either at screening or by historical evidence) or methacholine responsiveness (by historical evidence).

• Agreement to adhere to Lifestyle Considerations throughout study duration.

Exclusion Criteria:

• Current participation in an interventional trial (e.g. drugs, diets, etc.).

• Currently on an asthma biologic or having been on biologic within 3 months of screening.

• Enrollment in a clinical trial where the study medication was administered within the past 60 days or within 5 half-lives (whichever is greater).

• Physician diagnosis of other chronic pulmonary disorders associated with asthma-like symptoms, including, but not limited to, cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, severe scoliosis or chest wall deformities that affect lung function, or congenital disorders of the lungs or airways.

• Receiving one or more immune-modulating therapies for diseases other than asthma. This includes biologics that are also approved for asthma.

• Receiving methotrexate, mycophenolate (CellCept®), or azathioprine (Imuran®).

• Receiving aero allergen immunotherapy and not on at least 3 months of maintenance allergen immunotherapy.

• Underwent a bronchial thermoplasty within the last two years.

• Born before 30 weeks of gestation.

• Uncontrolled hypertension, defined as systolic blood pressure > 160 mm/Hg or diastolic blood pressure > 100 mm/Hg.

• History of malignancy except non-melanoma skin cancer within the last five years.

• History of smoking:

  1. If <45 years old: Smoked for ≥5 pack-years*
  2. If ≥45 years old: Smoked ≥ 10 pack years.

• Active use of any inhalant >1 time per month in the past year.

• Substance abuse within the last year.

• Unwillingness to practice medically acceptable birth control or complete abstinence during the study, current pregnancy, or lactation.

• Requirement for daily systemic corticosteroids at the time of screening.

• Respiratory infection within 1 month of screening.

• Intubation for asthma in the last 12 months.

• Any clinically significant abnormal findings in the history, physical examination, vital signs, electrocardiogram, hematology or clinical chemistry during run-in period, which in the opinion of the site investigator, may put the participant at risk because of his/her participation in the study, or may influence the results of the study, or the participant's ability to complete the entire duration of the study.

• BMI > 38.

• Allergic to any of the drugs, biologics or chemicals used in this study.

This study will be conducted in accordance with the following publication and data sharing policies and regulations:

National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access to the published results of NIH funded research. It requires scientists to submit final peer-reviewed journal manuscripts that arise from NIH funds to the digital archive PubMed Central upon acceptance for publication.

This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. As such, this study will be registered at ClinicalTrials.gov, and results information from this trial will be submitted to ClinicalTrials.gov. In addition, every attempt will be made to publish results in peer-reviewed journals.

Data from this study may be requested from other researchers after the completion of the primary endpoint.

Data from this study may be requested from other by contacting NHLBI's BioLINCC. Industry partners who are providing study agents will be provided with serious adverse events reports that occur when participants are receiving their product.

In addition, this study will comply with the NIH Genomic Data Sharing Policy, which applies to all NIH-funded research that generates large-scale human or non-human genomic data, as well as the use of these data for subsequent research. Large-scale data include genome-wide association studies (GWAS), SNP arrays, and genome sequence, transcriptomic, epigenomic, and gene expression data. Only genetic data contributing directly to prognostic testing will be publicly available with the rest of deidentified genetic data results residing behind a firewall accessible only via direct query to the Epiphany investigators and establishment of a data use agreement.