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Asthma resistance to glucocorticoid treatment is a major health problem with unclear etiology. Glucocorticoids inhibit adrenal androgen production. However, androgens have potential benefits in asthma. HSD3B1 encodes for 3β-hydroxysteroid dehydrogenase-1 (3β-HSD1), which catalyzes peripheral conversion from adrenal dehydroepiandrosterone (DHEA) to potent androgens and has a germline missense-encoding polymorphism. The adrenal restrictive HSD3B1 (1245A) allele limits conversion, whereas the adrenal permissive HSD3B1 (1245C) allele increases DHEA metabolism to potent androgens. In the Severe Asthma Research Program (SARP) III cohort, we determined the association between DHEA-sulfate and percentage predicted forced expiratory volume in 1 s (FEV 1 PP). HSD3B1 (1245) genotypes were assessed, and association between adrenal restrictive and adrenal permissive alleles and FEV 1 PP in patients with (GC) and without (noGC) daily oral glucocorticoid treatment was determined ( n = 318). Validation was performed in a second cohort (SARP I&amp;II; n = 184). DHEA-sulfate is associated with FEV 1 PP and is suppressed with GC treatment. GC patients homozygous for the adrenal restrictive genotype have lower FEV 1 PP compared with noGC patients (54.3% vs. 75.1%; P &lt; 0.001). In patients with the homozygous adrenal permissive genotype, there was no FEV 1 PP difference in GC vs. noGC patients (73.4% vs. 78.9%; P = 0.39). Results were independently confirmed: FEV 1 PP for homozygous adrenal restrictive genotype in GC vs. noGC is 49.8 vs. 63.4 ( P &lt; 0.001), and for homozygous adrenal permissive genotype, it is 66.7 vs. 67.7 ( P = 0.92). The adrenal restrictive HSD3B1 (1245) genotype is associated with GC resistance. This effect appears to be driven by GC suppression of 3β-HSD1 substrate. Our results suggest opportunities for prediction of GC resistance and pharmacologic intervention.

HSD3B1 genotype identifies glucocorticoid responsiveness in severe asthma