Steroids In Eosinophil Negative Asthma
Phase: PHASE3
Conditions: Asthma
Sponsor: Milton S. Hershey Medical Center

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ASTHMANET 
 
 
Steroids In Eosinophil Negative Asthma 
(SIENA) 
 
Study Protocol  
 
November 12, 2015 
 
 
 
A study to determine if asthmatic participants who are persistently non-
eosinophilic require a different treatment strategy than those with sputum 
eosinophilia 

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Table of Contents  
 
I. 
PROPOSED TRIAL SUMMARY ...................................................................... 4 
II. 
BACKGROUND AND RATIONALE .................................................................. 7 
A.  Inflammation in Asthma is Heterogeneous ....................................................... 7 
B.  TH2-high vs. TH2-low Phenotypes .................................................................... 9 
C.  Treatment of Non-Eosinophilic Asthma ............................................................ 9 
D.  Rationale for Studying a Long-acting Muscarinic Antagonist ......................... 11 
III. 
HYPOTHESES TO BE TESTED IN THIS TRIAL ........................................... 14 
A.  Overall Research Question ............................................................................ 14 
B.  Co-Primary Research Questions.................................................................... 14 
C.  Secondary Research Question ...................................................................... 15 
D.  Exploratory Research Questions.................................................................... 15 
E.  Primary Research Hypotheses ...................................................................... 15 
F.  Secondary Research Hypothesis ................................................................... 16 
G.  Exploratory Research Hypotheses ................................................................. 16 
H.  Primary Outcome Measure ............................................................................ 16 
I. 
Secondary Outcome Measures ...................................................................... 18 
J.  Exploratory Outcome Measures ..................................................................... 18 
IV. 
PROTOCOL OVERVIEW ............................................................................... 20 
A.  Protocol Design .............................................................................................. 20 
B.  Run-In Period ................................................................................................. 21 
C.  Randomization ............................................................................................... 21 
D.  Double-Blind Treatment Period ...................................................................... 22 
E.  Characterization of Asthma Exacerbations .................................................... 23 
F.  Sputum Induction to Characterize Eosinophilia .............................................. 27 
G.  Choice of 2% Eosinophils For Sputum Eosinophilia Cutpoint ........................ 29 
V. 
STUDY POPULATION INCLUSION AND EXCLUSION ................................ 30 
A.  Rationale for Inclusion and Exclusion Criteria ................................................ 30 
B.  Inclusion criteria for enrollment (Week 0) ....................................................... 32 
C.  Exclusion criteria for enrollment (Week 0) ...................................................... 33 
D.  Exclusion criteria for Randomization (Week 6) .............................................. 35 
VI. 
PROTOCOL DETAIL AND VISIT STRUCTURE ............................................ 35 
A.  Overview of study ........................................................................................... 35 
B.  Supervised Washout ...................................................................................... 38 
C.  Single-Blind Placebo Run-In .......................................................................... 41 
D.  Double-Blind 3-Period Crossover Treatment Phase ...................................... 44 
E.  Detailed Visit Structure ................................................................................... 45 
VII. 
DRUG SUPPLIES .......................................................................................... 52 
VIII.  POWER CALCULATION AND STATISTICAL  ANALYSIS ............................ 54 
A.  Randomization ............................................................................................... 54 
B.  Masking .......................................................................................................... 55 
C.  Statistical Analysis Plan for the Primary and Secondary Outcomes .............. 55 
D.  Statistical Analysis Plan for Additional Secondary Outcomes ........................ 59 
E.  Missing Data .................................................................................................. 60 
F.  Interim Analyses ............................................................................................ 61 

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G.  Power Calculations ........................................................................................ 61 
H.  Anticipated Results ........................................................................................ 63 
IX. 
RISKS AND BENEFITS ................................................................................. 64 
A.  Risks and Benefits of Study Procedures ........................................................ 64 
B.  Risks of Study Design .................................................................................... 68 
C.  Risks and Benefits of Study Drugs ................................................................. 69 
X. 
ADVERSE EVENTS ....................................................................................... 71 
A.  Definition and reporting .................................................................................. 71 
B.  Adverse Events Unrelated to Asthma ............................................................ 72 
C.  Adverse Events Related to Asthma: Treatment Failure and Asthma 
Exacerbation ................................................................................................. 73 
D.  Adjustments to Trial Medications and Rescue Algorithms during Treatment 
Failures and Asthma Exacerbations .............................................................. 75 
E.  Rescue Algorithm for Asthma Exacerbations and Treatment Failure Non-
responders .................................................................................................... 76 
XI. 
PARTICIPATING PARTNERSHIPS ............................................................... 80 
XII. 
REFERENCES .............................................................................................. 81 
XIII.  APPENDICES ................................................................................................ 85 
A.  Visit Table ...................................................................................................... 85 
B.  List of Asthma Questionnaires to be used ...................................................... 87 
C.  Draft Acute Asthma Assessment Questionnaire ............................................ 88 
D.  Study Drug Procurement and Distribution ...................................................... 90 
E.  Adverse Event Reporting to Companies Donating Study Drug ...................... 92 
F.  EPR-3 Table 4-8b .......................................................................................... 95 
 
 

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I. 
PROPOSED TRIAL SUMMARY 
 
This is a randomized, stratified, 3-period double-blind placebo-controlled 
crossover study of patients with symptomatic mild-to-moderate asthma, not 
already taking an inhaled corticosteroid, in whom the effect of “medium-dose” 
inhaled corticosteroid (i.e., mometasone, 200-220 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D) will be 
compared with the effect of placebo and with a long-acting muscarinic antagonist 
(LMA, i.e., tiotropium RESPIMAT 5mcg QD).  Participants meeting the inclusion 
criteria will enter a 4-6 week long single-blind Placebo Run-in period and will be 
issued an electronic diary that tracks symptoms, medication use, and Peak 
Expiratory Flow (PEF).  Sputum induction will be performed at entry (BL) and at 3 
and 6 weeks (if necessary for eligibility), and sputum eosinophil percentage will 
be quantified.  Based on a "cut point" of ≥ 2% eosinophils and two measures of 
sputum eosinophil % during the run-in, participants will be categorized as 
"eosinophilic" (either persistently or intermittently eosinophilic) or "persistently 
non-eosinophilic" and stratified on this basis at randomization.  We will 
determine if asthmatic participants who are persistently non-eosinophilic 
require a different treatment strategy than those with sputum eosinophilia.  
Serum will be collected, at the same time as sputum collection, for later 
measures of periostin because it is a putative biomarker of TH2 inflammation, but 
it will be an exploratory measure and will not be used for stratification.  Similarly, 
eNO and blood eosinophils will be measured during the Run-In, at the same time 
as sputum collection, as exploratory biomarkers of treatment responses.  

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Maximum reversibility to albuterol and to ipratropium (Atrovent® HFA) will be 
assessed at baseline to see if these differ across strata and if they predict 
response.  Participants who are not able to provide two acceptable sputum 
samples (<80% squamous cells) will be excluded.  By measuring sputum 
eosinophil % two times during the Run-In (rather than just once), we will guard 
against misclassifying the sputum eosinophil phenotype which can show 
intermittent eosinophilia in many instances 1 2. Participants will also be evaluated 
during the Run-In for asthma control and for adherence to placebo-LMA and to 
diary completion.  Those who meet adherence criteria (≥ 75%) and NAEPP 
criteria for uncontrolled asthma will then enter a 9 month-long treatment period 
during which they will be randomly assigned to a treatment sequence consisting 
of three treatment arms (i.e., mometasone 200-220 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D, tiotropium 
RESPIMAT 5mcg QD, or PBO).  Each treatment arm will be 12 weeks in duration 
without formal washouts; data from the first 4 weeks of each treatment period will 
be censored.  Participants will be seen every 6 weeks for the duration of the 
study (9 visits total) and will be assessed by phone call at the 3-week point 
between visits.  All participants will continue their electronic diaries throughout 
the study.  At the time of randomization and at the end of each treatment period, 
participants will have an interim history, diary review, spirometry, and will 
complete questionnaires to assess asthma symptoms, asthma control, and 
quality of life. 

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The primary research question will be whether there is a preference for 
inhaled corticosteroids (ICS) or long-acting muscarinic antagonist (LMA) 
compared to placebo among the eosinophil-negative group for the following three 
measures of asthma control: Treatment Failure (TF), Asthma Control Days 
(ACD), FEV1.  
Safety criteria are built into this study to ensure that participants whose 
asthma control worsens receive treatment early and before development of an 
asthma exacerbation (see page 71 for asthma exacerbation definition).  
Exclusion criteria will be applied at baseline and again at the end of the Run-in 
period, to exclude participants with poorly controlled asthma.  Treatment Failure 
(TF) is an outcome in this study and will be defined as was done for the 
Symptom-Based Action Plan  in the IMPACT study 3, another NHLBI-sponsored 
study in which at least one treatment arm for participants with persistent asthma 
did not include an inhaled corticosteroid. Participants who meet TF status will 
receive high-dose ICS (i.e., mometasone 400-440 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D x 10 days), then 
return to randomized treatment and continue in the study.  TF will be assessed 
throughout the Run-in and Treatment Phases of the study. 
Recent studies have demonstrated the benefit of therapy targeted to a 
specific asthma phenotype.  The appropriate therapy for the eosinophil-negative 
phenotype is not known, and this study is designed to address this question. 
 
 

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II. 
BACKGROUND AND RATIONALE 
A. 
Inflammation in Asthma is Heterogeneous 
A growing body of evidence suggests that asthma is a heterogeneous 
disease, and many asthmatics do not respond well to currently available 
treatment, most of which targets eosinophilic inflammation.  Previous studies 
from the ACRN reported that ~ 50% of asthmatics respond poorly to 
corticosteroids 4-6.  Data from various groups suggest that eosinophilic airway 
inflammation is not ubiquitous in asthma.  Simpson et al. described “eosinophilic, 
neutrophilic, mixed, and 
paucigranulocytic” asthma 
7.  Haldar and Pavord 
described 
noneosinophilic, 
neutrophilic asthma 
8 , 
and Pavord has described 
a group of patients with 
severe 
corticosteroid 
unresponsive 
asthma 
without eosinophilia 9.  McGrath and Fahy recently analyzed sputum cell 
differentials from 995 asthmatic participants who participated in ACRN trials.  In 
cross-sectional analysis, sputum eosinophilia (≥2% eosinophils) was found in 
only 36% of asthmatics not taking an inhaled corticosteroid (Figure 1). In a 
subset of these asthmatic participants who underwent sputum induction 

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repeatedly (mean of 2.7 sputum inductions), 53% had sputum eosinophilia, and 
47% were persistently non-eosinophilic.  Among those with sputum eosinophilia, 
the majority (58%) expressed it intermittently 1. This finding was recently 
confirmed by Bacci et al. who reported that 40% of steroid naïve patients treated 
with salmeterol as monotherapy demonstrated transient sputum eosinophilia 2. In 
addition, in a post hoc analysis of the ACRN’s IMPACT study 3, a two week 
Period of Intense Combined Treatment (PICT) with oral prednisone, inhaled 
budesonide, and oral zafirlukast significantly improved FEV1 in the participants 
with persistent eosinophilia, but not in those who were persistently non-
eosinophilic, even though the latter had a significant bronchodilator response to 
albuterol (see Figure 2).   
 
 
 
The response to PICT in participants with intermittent eosinophilia was 
intermediate to that of eosinophilic and persistently non-eosinophilic asthma 1.  
 

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Between July 2014 and May 2015 the AsthmaNet Investigators performed 
sequential sputum inductions 3-6 weeks apart in 101 ICS-naïve individuals with 
mild persistent asthma that was not well-controlled.  Using the same cutpoint for 
sputum eosinophilia as described above (≥2%), 23% of subjects had sputum 
eosinophilia on at least 1 occasion and 77% were persistently non-eosinophilic.  
This suggests that in this very mild population, the majority of subjects may be 
non-eosinophilic. 
B. 
TH2-high vs. TH2-low Phenotypes 
 
Individuals with sputum eosinophilia may represent the "TH2 high" 
phenotype that has been described.  Using microarray and PCR techniques to 
define "TH2 high" and "TH2 low" asthma, Woodruff et al found that BAL 
eosinophil percentages were lower in the TH2 low subgroup than in the TH2 high 
subgroup, and that the TH2 low subgroup did not demonstrate an increased FEV1 
after 8 weeks of inhaled fluticasone 10. 
C. 
Treatment of Non-Eosinophilic Asthma 
 
Because approximately half of all mild-moderately-severe asthma is 
persistently non-eosinophilic, and the proportion of persistently non-
eosinophilic may be even larger in those with mild-persistent asthma, it is 
important to determine prospectively if these participants differ in their benefit 
from inhaled corticosteroid treatment.  If they do, the expense and potential risks 

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of long-term inhaled corticosteroid treatment in these patients will need to be 
reevaluated.  This reevaluation must include consideration of alternative 
treatment approaches for persistently non-eosinophilic asthma, including 
treatment with long-acting bronchodilators.  Prior studies have demonstrated the 
risk of monotherapy with long-acting beta-agonists (LABAs) 11.   Although it is 
possible that individuals with non-eosinophilic asthma respond differently to 
LABAs than do those with eosinophils, it seems inappropriate to conduct a small 
study of LABA monotherapy until the results of the large (n=53,000) FDA-
mandated studies are known.  Leukotriene modifier drugs are an option, but the 
participants in the IMPACT study did not respond to zafirlukast, 20 mg BID during 
the PICT 3.  Low-dose theophylline has been reported to improve asthma control, 
symptoms, and lung function in patients not receiving inhaled corticosteroids 12, 
but nausea, especially early in treatment, remains a problem with this drug.  
Roflumilast is a selective PDE4 inhibitor, but clinical benefit in asthma is 
unproven, and GI side effects remain a problem 13. 
 
 
 
 
 
 
 

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D. 
Rationale for Studying a Long-acting Muscarinic Antagonist 
  
Although tiotropium is a bronchodilator, it is completely unrelated to 
LABAs, works by a completely different mechanism, and there are no data to 
suggest a direct deleterious effect of 
tiotropium 
in 
asthma. 
 
Although 
developed and approved for use in 
COPD, there is a growing body of 
literature suggesting that tiotropium 
may also be useful in asthma.  For 
example, the NHLBI’s ACRN reported that tiotropium is effective and not-inferior 
to salmeterol in asthma participants whose symptoms were not controlled by 
inhaled corticosteroids alone (the TALC study, Figure 3) 14.  
In a similar study, Bateman et al examined the effect of tiotropium in 
patients with asthma who have a single nucleotide polymorphism at amino acid 
16 in the coding region of the Beta2-adrenergic receptor gene.  Until recently 
there was concern that Beta-adrenergic agonists were less effective and 
associated with worsening asthma in these “B16-Arg/Arg” patients.  Bateman 
and colleagues found that tiotropium was noninferior to salmeterol in maintaining 
improved lung function in B16-Arg/Arg patients with asthma (Figure 4) 15.   

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Iwamota and colleagues investigated the efficacy of tiotropium in 17 asthmatic 
patients selected because they had severe persistent asthma despite treatment 
with the equivalent of 800 – 1,600 mcg/day of inhaled budesonide.  Tiotropium 
administered for 4 weeks improved FEV1 significantly (p=0.001).  There were no 
significant correlations between the improvement in FEV1 and demographic or 
clinical variables including age, sex, BMI, smoking history, atopy, and use of 
particular 
anti-asthmatic 
drugs.  
However, 
the 
percentages 
of 
eosinophils in induced sputum 
were 
inversely 
correlated 
(p=0.003) with the change in FEV1 
(see Figure 5) 16.  
Finally, Kerstjens et al. compared the addition of tiotropium to the addition 
of placebo to the treatment regimen of 912 patients whose asthma was poorly 
controlled with the standard combination treatment of ICS plus LABA.  In these 

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patients, who were symptomatic and had mean baseline FEV1 of 62% of 
predicted, the addition of tiotropium significantly increased FEV1 compared with 
placebo (Figure 6A and 6B), and significantly increased time to first severe 
asthma exacerbation (Figure 6C) 17. 
Figure 6 
 
 
Aclidinium is a new long-
acting muscarinic antagonist, 
approved by the FDA for use 
in COPD in July 2012. It 
appears 
to 
be 
at 
least 
comparable to tiotropium in 
COPD, and some studies 
suggest that blood levels are 
attained earlier (2d vs 7d), 
and that subjects have higher 
nighttime FEV1 and lower 
symptom scores. There are 
no studies of aclidinium in 
human asthma, but studies in 
COPD suggest that its effects 
in asthma may be comparable 
to 
tiotropium. 
In 
addition, 

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there is at least 1 study showing that aclidinium decreased bronchial hyper-
responsiveness and airway inflammation in a murine model of asthma29. 
For these reasons, we have chosen to compare inhaled corticosteroids to 
a long-acting muscarinic antagonist and to placebo in this study of non-
eosinophilic asthma. 
 
III. 
HYPOTHESES TO BE TESTED IN THIS TRIAL 
 
A. 
Overall Research Question 
 
Among asthmatic participants who are persistently non-eosinophilic (<2% sputum 
eosinophils in two induced sputum samples collected 3-6 weeks apart), is there a 
preference for inhaled corticosteroids (ICS) or long-acting muscarinic antagonist 
(LMA) compared to placebo?   
B. 
Co-Primary Research Questions 
 
1.  
Among 
asthmatic 
participants 
who 
are 
persistently 
non-
eosinophilic, is there a preference for ICS compared to placebo? 
2.  
Among 
asthmatic 
participants 
who 
are 
persistently 
non-
eosinophilic, is there a preference for LMA compared to placebo?  
(For both ICS and LMA, preference to treatment is defined as the following 
hierarchy of outcomes: Treatment Failure = TF, then Asthma Control Days = 
ACD, then FEV1) 

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C. 
Secondary Research Question 
 
1.   
Does the statistical preference for each of three alternative 
therapies (ICS, LMA, placebo) differ in participants with the non-eosinophilic 
phenotype compared with participants with sputum eosinophilia?   
D. 
Exploratory Research Questions 
 
1. 
Can other, easier to obtain biomarkers (blood periostin, blood 
eosinophils, or eNO) be used instead of sputum eosinophils to identify patients 
likely to respond to ICS? 
2.  
Among 
asthmatic 
participants 
who 
are 
persistently 
non-
eosinophilic, is there a preference for ICS compared to LMA? 
3.  
Among asthmatic participants with sputum eosinophilia, is there a 
preference for ICS compared to LMA? 
4.  
When do patients with prednisone-treated exacerbations recover 
from the impairment associated with this event? 
5. 
When do patients return to their pre-exacerbation state of 
work/school/physical activity? 
E. 
Primary Research Hypotheses 
1.  
Among 
asthmatic 
participants 
who 
are 
persistently 
non-
eosinophilic, the preference for ICS will be greater than placebo. 
2.  
Among 
asthmatic 
participants 
who 
are 
persistently 
non-
eosinophilic, the preference for LMA will be greater than placebo. 

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F. 
Secondary Research Hypothesis 
The differential response to three alternative therapies (ICS, LMA, 
placebo) will be different in participants with and without airway eosinophilia, as 
assessed by sputum eosinophils (i.e., asthmatics with airway eosinophilia 
[sputum eosinophils ≥2%] will prefer ICS and asthmatics who are persistently 
non-eosinophilic will prefer LMA).   
G. 
Exploratory Research Hypotheses 
1. 
Blood periostin (or other biomarkers such as blood eosinophils, or 
eNO) will be as effective as sputum eosinophils at identifying patients likely to 
respond to ICS. 
2. 
The Asthma Index, together with associated questionnaires, will 
characterize the time course and magnitude of morbidity associated with asthma 
exacerbations and serve as a tool for studying interventions for management of 
asthma exacerbations. 
3.  
Among 
asthmatic 
participants 
who 
are 
persistently 
non-
eosinophilic, the preference for ICS is not greater than for LMA. 
4.  
Among asthmatic participants with sputum eosinophilia, the 
preference for ICS is greater than for LMA. 
 
H. 
Primary Outcome Measure 
The primary outcome is a hierarchical composite of three measures of 
asthma control, assessed during the last 8 weeks of each 12 week treatment 

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period: Treatment Failure (TF), Asthma Control Days (ACD), FEV1. 
The definition of TF comes from the Symptom-Based Action Plan that was 
utilized successfully in the ACRN IMPACT Study 3  and includes: 
 Awakening from asthma three or more times in a two-week period 
or on two consecutive nights, or  
 Using albuterol for relief of symptoms four or more times/day for 
two or more consecutive days, or 
 Albuterol has been relieving symptoms for less than four hours after 
each treatment over a 12-hour period, or 
 Using albuterol for relief of symptoms daily for seven days, and this 
use exceeds two times the weekly use of albuterol in the baseline 
period, or  
 exercise induces unusual breathlessness. 
ACDs will be documented in daily diaries, and are defined as: A day with 
no rescue albuterol use (pre-exercise albuterol will not be counted), no 
non-study asthma medications, no daytime asthma symptoms (shortness 
of breath, wheezing, chest tightness, phlegm/mucus rated as mild, 
moderate or severe, or cough rated as moderate or severe), no nighttime 
asthma symptoms, no unscheduled healthcare visits for asthma, and no 
PEF < 80% of predetermined baseline. 
FEV1 is a standard outcome measure for asthma, and was used in a 
similar hierarchical preference analysis in BADGER18. 

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I. 
Secondary Outcome Measures 
Each of the three components of the composite outcome (TF, ACD, FEV1) 
will be analyzed separately as secondary outcomes.  Other secondary outcomes 
include PEF, asthma exacerbations, time to treatment failure and time to first 
exacerbation.   
J. 
Exploratory Outcome Measures 
An important exploratory question is whether other biomarkers such as 
blood periostin, blood eosinophils or eNO can be used instead of sputum 
eosinophils to identify patients with differential treatment preferences to ICS and 
LMA.  Although recent data suggest that airway eosinophilia, elevated FeNO, 
and serum periostin may all be markers of TH2 inflammation, we have chosen to 
stratify our populations based on sputum eosinophilia, a robust biomarker that 
has been well-characterized.  Periostin, a 90 kD protein produced by airway 
epithelium in response to IL-13, is an alternate candidate biomarker, but more 
information is needed about how blood periostin levels relate to airway eosinophil 
levels, and about the threshold value for defining abnormal periostin levels.  
FeNO is another candidate biomarker of airway eosinophilia and ICS 
responsiveness but two recent reports have questioned its utility as a biomarker 
of airway eosinophilia 1, 19.  In this prospective study we propose to collect serum 
for periostin and measure eNO and blood eosinophils so that we can evaluate 
the relative utility of these three simpler tests as biomarkers of airway 
eosinophilia and ICS treatment response in mild moderate asthma.  We also 
propose to assess the bronchodilator response (BR) to both beta agonist and 

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anticholinergic agents to determine whether the eosinophil-negative group has 
different bronchodilator responses to albuterol vs. ipratropium (Atrovent® HFA).  
We will include adolescents 12-18 years old in this study because asthma 
guidelines combine this group with adults, but the study will not be powered for 
the comparison between adults and adolescents.  This important exploratory 
analysis will provide clues as to the prevalence of eosinophil negative asthma in 
adolescents, the utility of and appropriate cut point for periostin, and the similarity 
or difference in the treatment response between adolescents and adults. 
Additional exploratory outcomes include a number of tools and endpoints 
to characterize the time course of asthma exacerbations.  The Protocol Review 
Committee previously suggested that AsthmaNet trials be used to gather 
preliminary information on exacerbations, as was also suggested in a recent NIH 
Outcomes Workshop 20.  These assessments will be incorporated within the main 
SIENA protocol and visit structure, to minimize both participant and site burden, 
and to enhance safety follow-up. 
 
 
 
 
 
 
 
 

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IV. 
PROTOCOL OVERVIEW 
A. 
Protocol Design 
This is a randomized, stratified, 3-period double-blind placebo-controlled 
crossover study of patients with symptomatic mild-to-moderate asthma, not 
already taking an inhaled corticosteroid, to determine if asthmatic participants 
who are persistently non-eosinophilic require a different treatment strategy than 
those with sputum eosinophilia.  Participants with mild-to-moderate asthma will 
be stratified by the presence (≥2%) or absence of sputum eosinophils, then 
treated in random sequence with ICS, LMA or placebo. 
 
Each treatment arm will be 12 weeks in duration without washout; data from the 
first 4 weeks of each period will be censored.  The primary outcome is a 

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composite based on Treatment Failure, Asthma Control Days, and FEV1, 
comparing the response to ICS vs. PBO and LMA vs. PBO in the non-
eosinophilic phenotype. 
B. 
Run-In Period 
At entry into the study, all participants will enter a 4-6 week long single-
blind Placebo Run-In period, the purpose of which is to define their level of 
asthma control and to characterize the inflammatory cells in their sputum.  At 
entry into the Run-in, participants will be required to have symptoms 
corresponding to mild-to-moderate asthma.  They will not be treated with ICS, but 
if they subsequently meet criteria for “Treatment Failure” (TF), they will be treated 
with high-dose ICS (i.e., mometasone 400-440 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D x 10 days).  The 
definition of TF and the rescue algorithm are identical to those used successfully 
for the "Symptom-Based Action Plan" in the ACRN IMPACT study 3.  Participants 
who experience <2 TFs will continue in the study; those with ≥2 TFs during the 
Run-In will be terminated for safety reasons.  Additional exclusion criteria will be 
applied at the end of the Run-In period, to ensure that participants whose asthma 
is poorly controlled do not proceed to randomization (See page 33). 
C. 
Randomization 
At the end of the 4-6 week Run-In Period, those participants who meet 
inclusion and exclusion criteria and whose adherence to single-blind Placebo-
LMA use and to diary completion is ≥75% will be randomized to the double-blind 

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treatment phase.  Based on a “cut point” of ≥ 2% eosinophils and two measures 
of sputum eosinophil % during the Run-in, participants will be categorized as 
“eosinophilic” (either persistently or intermittently), EOS+,  or “persistently non-
eosinophilic”, EOS-, and stratified on this basis at randomization.  Initially, sites 
will recruit and randomize all eligible participants, and not be restricted to a 
specific distribution of eosinophil positive and eosinophil negative.  Based on our 
prior ACRN experience with this very mild population, we anticipate that the 
distribution of eosinophil negative and eosinophil positive participants will be ≤ 
3.5:1 at each site.  The DCC will monitor enrollment and may subsequently 
restrict enrollment if necessary to create balanced accrual.  
D. 
Double-Blind Treatment Period 
Each treatment arm will be 12 weeks in duration without formal washouts; 
data from the first 4 weeks of each treatment period will be censored.  
Participants will be seen every 6 weeks for the duration of the study (9 visits 
total) and will be assessed by phone call at the 3-week point between visits.  All 
participants will continue their electronic diaries throughout the study.  At the time 
of randomization and at the end of each treatment period, participants will have 
an interim history, diary review, spirometry, and will complete questionnaires to 
assess asthma symptoms, asthma control, and quality of life.  Treatment Failure 
status will be defined and treated as in the Run-In.  Participants who experience 
≥2 Treatment Failures or an Asthma Exacerbation will cross over to the next 
treatment arm (or have their final visit should this occur during the final treatment 
period). Participants who experience an Asthma Exacerbation will be treated with 

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prednisone and seen at the clinic after 3 days to ascertain the severity of the 
event and ensure appropriate treatment.  Spirometry will be performed. During 
periods 1 and 2, this clinic visit will coincide with their crossover visit and during 
period 3, this visit will coincide with their final in-person visit.  Phone visits will be 
conducted on days 10, 14, and 21 following prednisone start to monitor 
exacerbation recovery, and additional safety visits will occur if necessary.  
E. 
Characterization of Asthma Exacerbations 
The AsthmaNet Investigators are interested in studying interventions for 
management of asthma exacerbations.  To accomplish this, better tools and 
endpoints are required, and the Protocol Review Committee previously 
suggested that AsthmaNet trials might provide the opportunity to gather useful 
preliminary information on exacerbations, which was also a major theme of a 
recent NIH Outcomes Workshop 20.   
 

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Thus, as an exploratory outcome, we will evaluate the responsiveness of a 
range of endpoints to characterize the time-course (onset and resolution) and 
magnitude of morbidity associated with an exacerbation and the use of systemic 
corticosteroids as part of the SIENA action plan. The assessments will be 
incorporated within the main SIENA protocol and visits, to minimize both 
participant and site burden.  The schematic for this assessment is shown in the 
Figure above. 
The Asthma Index:  The asthma index is a continuous variable that 
reflects the magnitude and the timing of changes in asthma control, with 
objective and subjective elements weighted similarly 21.  Data from 15 
participants of the ACRN-BASALT trial having exacerbations are presented in 
Figure 7 below, centered on the day (D0) of starting prednisone.   

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This tool is a composite measure that assesses symptoms, rescue 
medication use, and lung function to advance the understanding of the 
components of these events, involving a 48-hour rolling calculation of an acute-
to-baseline difference of scores generated from peak flow and asthma symptom 
diaries.  These data are captured twice-daily in the SIENA protocol using the 
Spirotel electronic diary recordings of asthma symptoms (0 = no symptoms, 1 = 
mild symptoms, 2 = moderate symptoms, 3 = severe symptoms), nocturnal 
awakenings, rescue albuterol use (# rescue puffs), and peak expiratory flow data.    
The reference period for the Asthma Index will be derived from the Spirotel-
collected diary data during the most stable week within the context of the trial, 
which we have previously defined as that with the lowest standard deviation of 
the asthma scores collected during the course of the week 30.  The Asthma Index 
will be calculated serially using the diary data during each treatment period.  We 
will define the peak asthma index as the highest value that occurs within 14 days 
after declaration of an asthma exacerbation requiring prednisone.  The time to 

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resolution of the exacerbation will be assessed by the number of days between 
the peak and the point at which the index has been below 50% of the peak for at 
least 4 consecutive days.  This instrument will allow for study of factors related to 
the speed of recovery from exacerbations. 
The Asthma Specific-Work Productivity and Activity Impairment Score 
(WPAI:Asthma):  This instrument captures asthma impairment by measuring the 
patient’s assessment of disease impact on productivity at work, school, or daily 
activities 22.  It has been validated in >2000 patients with asthma in the TENOR 
study and administered in the AsthmaNet VIDA study.  This questionnaire is 
validated for and applicable to individuals ages 12 and up.   Baseline values 
using this instrument (recall of past 7 days) will be measured at the SIENA 
Randomization Visit.  This survey will be part of an exacerbation kit to be 
completed at home on the day that the participant starts prednisone (Day 0).  
This will also be completed on Days 10, 14, and 21 after initiating the action plan.  
This tool will allow us to assess impairment associated with exacerbations and 
the extent to which recovery has occurred by the time of the next study visit. 
Acute Asthma Assessment Questionnaire (See Appendix C).  An Acute 
Asthma Assessment will be included in the exacerbation kit, to be completed at 
home by the participant on the day he/she starts prednisone. It will also be 
completed on Days 3, 10, 14 and 21 after initiating prednisone as per action plan. 
Participants will be asked to report the precipitating factor for the asthma 
exacerbation (viral illness, exercise, allergen exposure, pollutant/irritant 
exposure, medication non-adherence), as well as a 72 hour review of number of 

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asthma awakenings, albuterol rescue use, missed school/work, and peak flows.   
This tool will help evaluate exacerbation severity with the goal of establishing 
correlation between acute scores and the risk of subsequent adverse events. To 
introduce the questionnaire to the study participants and to establish a baseline, 
the Acute Asthma Assessment will be administered to participants at Visit 3. 
 
Asthma Exacerbation Follow-up.  Specific medication and health care 
utilization questions will be asked on Days 10, 14, and 21 to capture the 
following:  1) additional systemic corticosteroids prescribed by AsthmaNet 
personnel or other healthcare providers due to persistent symptoms and which 
are not included in the initial burst, 2) antibiotics prescribed by health care 
providers, and 3) unscheduled office visit, urgent care/emergency department 
visit, or hospitalization for respiratory symptoms. 
F. 
Sputum Induction to Characterize Eosinophilia 
All participants will undergo sputum induction up to 3 times during the 
Run-in in order to obtain 2 acceptable sputum samples for assessment of sputum 
cell counts.  The decision to require 2 analyzable sputum samples was based on 
analysis of 48 participants with moderate asthma in the NHLBI-ACRN SOCS 
trial11 who had sputum induction on 4 occasions over time while treated with 
placebo.  Sputum eosinophilia (persistent, intermittent, or non-eosinophilia), was 
identified correctly based on 2 sputa in 88% of participants.  A third sputum 
correctly identified 96% of participants; a 4th sputum correctly identified 100% 
(Figure 8).   While multiple sputum samples obtained over time will identify 

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phenotypes with greater precision, this imposes a greater burden on research 
participants and coordinators.    
 
 
 
 
The Steering Committee felt that the incremental benefit of >2 samples did 
not warrant the added burden.  For this reason, we elected to analyze 2 sputum 
samples.  Participants whose initial sputum sample is unacceptable, based on 
our standard criteria (≥80% squamous cells), will be asked to provide a second 
sample.  If this is also unacceptable, they will be excluded from the study.  We 
will perform sputum induction up to three times, in order to obtain 2 acceptable 
samples. 
 
This protocol is based on our analysis of 505 participants from ACRN 
studies who had repeated sputum analyses.  Of the 8.5% who had a poor quality 
baseline sample, 46% went on to provide only good quality samples at all follow-
up visits (range from 2-7 visits), 35% subsequently provided only poor quality 
samples, and 19% went on to provide a mix of both poor and good quality 
samples (Figure 9). Two samples are needed to identify a participant as 
persistently non-eosinophilic.  A participant who has ≥2% eosinophils on sputum 

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#1 or #2 will be classified as "eosinophilic" and need not undergo sputum 
induction #3. 
 
 
 
 
G. 
Choice of 2% Eosinophils For Sputum Eosinophilia Cutpoint 
The cutpoint of ≥2% eosinophilis has been validated in number of small 
studies and 2 large studies in which the distribution of sputum eosinophils in 
healthy individuals has been described.  Belda and colleagues from Hamilton 
examined 118 healthys and found 0.4 ± 1.4% eosinophils 23.  In 114 healthy 
individuals Spanevello et al reported 0.6 ± 0.8% eosinophils, and found no 
healthy participant with >2.4% eosinophils 24 (Figure 10). 

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V. 
STUDY POPULATION INCLUSION AND EXCLUSION  
A. 
Rationale for Inclusion and Exclusion Criteria 
Criteria are based on the NAEPP Classification of Asthma Severity for 
children ≥ 12 years of age and adults.  Our goal is to recruit participants with 
mild-moderate asthma for whom an inhaled corticosteroid would normally be the 
recommended treatment.  Because all participants will receive no controller 
during the Run-In, and because we believe that the eosinophil negative 
participants will not respond to ICS, we have defined a Treatment Failure status 
that will trigger intervention.  We believe that the criteria for Treatment Failure are 
sufficiently conservative that participants whose asthma control deteriorates will 
be "rescued" before they develop an exacerbation.  This rescue algorithm was 
used successfully in the NHLBI-ACRN IMPACT study 3 - a  comparison of daily 
versus "as-needed" ICS for mild persistent asthma.  Participants who meet 
Treatment Failure status during the Run-in will be treated according to a rescue 

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algorithm and will continue in the study.  If necessary, the run-in will be extended 
so that ≥ 3 weeks elapse after TF before randomization.  To provide an additional 
level of safety, we have added additional exclusion criteria at the end of the Run-
in that must be met before participants can be randomized.  Finally, TF criteria 
will also be used throughout the treatment period - to ensure the safety of 
participants. 
 
NAEPP Classification of Asthma Severity ≥ 12 years of age (Figure 4-6) 
 
Mild 
Moderate 
Severe 
Symptoms 
> 2 days/week 
Daily 
Throughout day 
Nighttime awakenings 
3-4/month 
> 1x/week 
Often 7x/week 
SABA use (not for EIB) 
> 2 days/week 
Daily 
Several times/day 
FEV1 
> 80% 
60-80% 
< 60% 
 
SIENA Inclusion, Exclusion and Treatment Failure Criteria 
 
  Inclusion 
   Exclusion 
   Week 0 
     Exclusion 
      Week 6 
Treatment Failure* 
Symptoms 
 > 2 days/week, 
OR 
 
 
Daily 
Nighttime 
awakenings 
 >2 nights/month, 
OR 
 
> 2x/week 
≥ 3x in 2 weeks OR 
2 consecutive nights 
SABA use 
(not for EIB) 
  >2 days/week 
 
Daily 
  Daily x 7 consec. days, OR 
 ≥ 4x/day x ≥ 2 consec days, 
OR 
 Relief < 4 hrs x 12 hrs, OR 
Unusual DOE 
FEV1 
  AND ≥70% 
< 70% 
< 70% 
Not done at home 
Treatment Failure 
 
 
 ≥ 2 during Run-In 
 
*  These are the criteria for initiation of the Symptom Based Action Plan 
from IMPACT – so their use has been validated in a study in which 
participants were not treated (undertreated) by guidelines – and so 
demonstrate the safety of this rescue approach. 
 
[See below for additional/more detailed Inclusion/Exclusion Criteria]  
 
 
 
 
 
 

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B. 
Inclusion criteria for enrollment (Week 0)  
  
All participants will meet ALL of the following inclusion criteria: 
1. 
Males or females age 12 or greater (at week 0);  
2. 
Physician-diagnosed asthma or a history consistent with asthma for 
at least previous 12 months (at week 0); 
3. 
Asthma confirmed by:  
(a) ß-agonist reversibility of FEV1 ≥12% and ≥ 200ml following 4 
puffs albuterol (at week 0) OR 
(b) methacholine PC20 ≤ 16 mg/ml (at visit 1A).  Source 
documentation for PC20 from an AsthmaNet methacholine 
challenge completed within 6 months of week 0 will be 
accepted; 
4. 
No use of oral corticosteroid for at least 6 weeks or inhaled corticosteroid for 
at least 3 weeks (at week 0).  Individuals who are taking low-dose ICS 
(equivalent of BDP 80-240 mcg/day),  intermittent (<5 days/week) ICS or 
intermittent ICS/LABA who are well controlled may be withdrawn from ICS 
or ICS/LABA prior to enrollment in the Run In (see Supervised Washout, 
page 36) 
5. 
No use of leukotriene modifier for at least 3 weeks (at week 0). Individuals 
who are taking LTRA who are well controlled may be withdrawn from LTRA 
prior to enrollment in the Run In (see Supervised Washout, page 36) 
6. 
Prebronchodilator FEV1 ≥ 70% of predicted (at week 0); 
7. 
At least 1 of the following indications for chronic controller therapy: 

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(a) Asthma Symptoms > 2 days/week  OR 
(b) Nocturnal Asthma Symptoms > 2 nights/month OR 
(c) 
Short-acting beta-2 agonist use for symptom control (not 
prevention of EIB) > 2 days/week  
8. 
Ability to provide screening and baseline information at week 0;  
9. 
Ability and willingness to provide informed consent at week 0;  
10. Ability to perform spirometry as per ATS criteria; 
11. For women of childbearing potential: not pregnant, non-lactating, and 
agree to practice an adequate birth control method (abstinence, 
single barrier methods or combination barrier and spermicide, or 
hormonal) for the duration of the study (at week 0);  
12. If intranasal steroids might be needed, willingness to take a single 
agent at a stable dose throughout the trial, starting prior to or on 
enrollment in the run-in period at week 0.  
 
C. 
Exclusion criteria for enrollment (Week 0) 
All participants will be excluded for ANY of the following exclusion criteria at week 0:  
1. 
Chronic oral corticosteroid therapy; OR 
2. 
Chronic inhaled corticosteroid therapy OR 
3. 
New allergen immunotherapy within the past 3 months or anticipated 
changes to an ongoing immunotherapy regimen. Stable allergen 
immunotherapy for at least the past 3 months is acceptable.;  OR 
4. 
Use of omalizumab within 3 months, OR 

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5. 
History of bladder-neck obstruction, urinary retention, BPH, OR 
6. 
History of narrow angle glaucoma, OR 
7. 
History of significant cardiovascular disorders and arrhythmias, OR 
8. 
History of life-threatening asthma requiring treatment with intubation 
or mechanical ventilation within the past 5 years; OR 
9. 
Prebronchodilator FEV1 < 70% of predicted OR 
10. Asthma exacerbation within past 6 weeks requiring systemic 
corticosteroids (evaluated at week 0) OR 
11. Respiratory tract infection within past 4 weeks; OR  
12. History of smoking (cigarettes, cigars, pipes, marijuana or any other 
substances) within the past 1 year, or > 10 pack-years total if ≥ 18 
years of age, or > 5 pack-years total if < 18 years of age; OR 
13. Chronic diseases or medical conditions (other than asthma) that in 
the opinion of the investigator would prevent participation in trial or 
put the participant at risk by participation, e.g. chronic diseases of the 
lung (other than asthma), heart, liver, kidney, endocrine or nervous 
system, or immunodeficiency; OR 
14. Use of investigative drugs or enrollment in intervention trials in the 30 
days prior to screening or during the study;  OR 
15. Use of any drug prohibited during the study or within the washout 
period prior to week 0; OR 
16. Any condition or compliance issue which, in the opinion of the 
investigator, might interfere with participation in the study; OR 

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17. Inability or unwillingness to perform required study procedures. 
  
 
 
D. 
Exclusion criteria for Randomization (Week 6)   
 
1. 
Any of the exclusion criteria for Enrollment (Week 0), OR 
2. 
Nocturnal Asthma Symptoms > 2x/week, OR 
3. 
Short-acting beta-2 agonist use for symptom control (not prevention 
of EIB) Daily, OR 
4. 
≥ 2 Treatment Failure events during the Run-In, OR 
5. 
≥1 Asthma Exacerbation during the Run-In, OR 
6. 
Inability to provide 2 acceptable sputum samples during the Run-In, 
OR 
7. 
Failure to take ≥75% of doses of single-blind PBO-LMA during the 
Run-In, OR 
8. 
Failure to complete diary on ≥75% of days during the Run-In 
 
VI. 
PROTOCOL DETAIL AND VISIT STRUCTURE 
A. 
Overview of study 
This is a randomized, stratified, 3-period double-blind placebo-controlled 
crossover study of patients with symptomatic mild-to-moderate asthma, not 
already taking an inhaled corticosteroid, in whom the effect of “medium-dose” 
inhaled corticosteroid (i.e., mometasone, 200-220 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D) will be 
compared with the effect of placebo and with a long-acting muscarinic antagonist 

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(i.e., tiotropium, RESPIMAT 5mcg QD).  Participants meeting the inclusion 
criteria will enter a 4-6-week long single-blind Placebo Run-in period and will be 
issued an electronic diary that tracks symptoms, medication use, and Peak 
Expiratory Flow (PEF).  Sputum induction will be performed at entry (BL) and at 3 
and 6 weeks (if necessary for eligibility), and sputum eosinophil percentage will 
be quantified.  Based on a "cut point" of ≥ 2% eosinophils and two measures of 
sputum eosinophil % during the run-in, participants will be categorized as 
"eosinophilic" (either persistently or intermittently eosinophilic) or "persistently 
non-eosinophilic" and stratified on this basis at randomization.  We will determine 
if asthmatic participants who are persistently non-eosinophilic require a different 
treatment strategy than those with sputum eosinophilia.  Serum will be collected, 
at the same time as sputum collection, for later measures of periostin because it 
is a putative biomarker of TH2 inflammation, but it will be an exploratory measure 
and will not be used for stratification.  Similarly, eNO and blood eosinophils will 
be measured during the run-in, at the same time as sputum collection, as 
exploratory biomarkers of treatment responses.  Reversibility to albuterol and to 
ipratropium (Atrovent® HFA) will be assessed at baseline to see if these differ 
across strata and if they predict response.  Participants who are not able to 
provide an acceptable sputum sample (<80% squamous cells) will be excluded.  
By measuring sputum eosinophil % two times during the run in (rather than just 
once), we will guard against mis-classifying the sputum eosinophil phenotype 
which can show intermittent eosinophilia in many instances 1 2.  Participants will 
also be evaluated during the run-in for asthma control and for adherence to 

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placebo-LMA and to diary completion.  Those who meet adherence criteria (≥ 
75%) and NAEPP criteria for uncontrolled asthma will then enter a 9 month-long 
treatment period during which they will be randomly assigned to a treatment 
sequence consisting of three treatment arms (i.e., mometasone 200-220 mcg 
BID, dose dependent on mometasone device randomized to at Visit 3 – See 
Appendix D, tiotropium RESPIMAT 5mcg QD, or PBO).  Each treatment arm will 
be 12 weeks in duration without formal washouts; data from the first 4 weeks of 
each treatment period will be censored.  Participants will be seen every 6 weeks 
for the duration of the study (9 visits total) and will be assessed by phone call at 
the 3-week point between visits.  All participants will continue their electronic 
diaries throughout the study.  At the time of randomization and at the end of each 
treatment period, participants will have an interim history, diary review, 
spirometry, and will complete questionnaires to assess asthma symptoms, 
asthma control, and quality of life. 
The primary research question will be whether there is a preference for 
inhaled corticosteroids (ICS) or long-acting muscarinic antagonist (LMA) 
compared to placebo among the eosinophil-negative group for the following three 
measures of asthma control: Treatment Failure (TF), Asthma Control Days 
(ACD), FEV1.  
Safety criteria are built into this study to ensure that participants whose 
asthma control worsens receive treatment early and before development of an 
asthma exacerbation.  Exclusion criteria will be applied at baseline and again at 
the end of the Run-in period, to exclude participants with poorly controlled 

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asthma.  Treatment Failure (TF) is an outcome in this study and will be defined 
and treated using the criteria for the Symptom-Based Action Plan as was done 
successfully in the IMPACT study 3, another NHLBI-sponsored study in which at 
least one treatment arm for participants with persistent asthma did not include an 
inhaled corticosteroid.  Just as in IMPACT, participants who meet TF status will 
receive high-dose ICS (i.e., mometasone 400-440 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D x 10 days), then 
return to randomized treatment and continue in the study.  TF will be assessed 
throughout the Run-in and Treatment Phases of the study.  Participants who 
experience ≥2 TF during the Run-in will be excluded from randomization, for 
safety.  Participants who experience ≥2 TF or an Asthma Exacerbation during a 
double-blind treatment arm will cross over to the next treatment arm (or have 
their final in-person visit should this occur during the final treatment period). 
B. 
Supervised Washout 
Both EPR-3 25 and GINA 26 recommend step-down of pharmacologic 
therapy in individuals whose asthma is well-controlled for a period of time.  For 
this reason, participants who at entry into the study are well-controlled and who 
are taking ICS intermittently or are taking low-dose ICS (equivalent of BDP 80-
240 mcg/day) or LTRA may be withdrawn from medication prior to enrollment 
into the Run-In.  Although guidelines do not address intermittent ICS or 
ICS/LABA, individuals who are well-controlled on these medications taken <5 
days/week are likely not dependent on this intermittent treatment for control, and 

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thus may also undergo a supervised washout prior to enrollment.  For entry into 
the Supervised Washout, participants must meet the following criteria: 
A history over at least 3 months of: 
 ICS ≤ BDP 80-240 mcg/day (or equivalent), OR 
 Daily LTRA, OR 
 ICS or ICS/LABA < 5 days/week 
AND 
 Symptoms ≤ 2 days/week, AND 
 Nocturnal symptoms ≤ 2 times/month, AND 
 SABA use < 2days/week (not for EIB), AND 
 FEV1 > 70% of predicted 
2-Step Washout: Participants taking low dose ICS (See Appendix F: EPR-
3 Table 4-8b) daily at a dose that is amenable to 50% reduction will enter a 2-
Step Washout. At Visit 0A, informed consent will be obtained for those 
participants who meet the above criteria.  A complete medical history will be 
obtained, and a complete physical exam will be completed.   Spirometry will be 
performed, and participants will reduce their ICS dose by 50%, adhering to the 
standard recommended BID or QD dosing schedule (i.e., BID for all except 
mometasone which may be BID or QD).  Participants will be issued an electronic 
diary that tracks symptoms and PEF. They will be instructed 

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to contact the study personnel for any significant change in symptoms, or for a 
drop in PEF <65% of baseline.  Participants will return for a Visit at week 2 (Visit 
0B), diary and peak flow data will be reviewed for asthma control, interim history 
and brief physical exam performed and spirometry will be repeated; those 
participants who continue to meet the criteria for well controlled (see above) will 
discontinue ICS.  Participants will continue to monitor symptoms and PEF, and 
will return to the study center at week 5 (Visit 1).    At that time, diary and peak 
flow data will be reviewed for asthma control and spirometry will be repeated.  An 
interim history and brief physical exam performed.  Participants who meet 
symptom-based inclusion/exclusion criteria (See page 30) will be entered into the 
Run-In. 
1-Step Washout:  Participants who are taking a low dose of ICS that 
cannot be halved, intermittent (<5 days/week) ICS, intermittent ICS/LABA, or 
LTRA may skip the 50% reduction in the Washout, stop their medication, and 
complete a 3 week Supervised Washout.  The same procedures performed at 

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Visit 0A for participants undergoing the 2-Step Washout will be performed for 
those undergoing the 1-Step Washout.  
Participants in the 1-Step Washout will return to the study center at week 3 (Visit 
1).    At that time, diary and peak flow data will be reviewed for asthma control 
and spirometry will be repeated.  An interim history and brief physical exam 
performed.  Participants who meet symptom-based inclusion/exclusion criteria 
(See page 30) will be entered into the Run-In.   
 
C. 
Single-Blind Placebo Run-In 
All participants in the SIENA trial will undergo an initial screening visit at 
Week 0 (Visit 1).  If the participant entered the study not on inhaled corticosteroid 
(i.e. did not undergo the Supervised Washout), informed consent will be 
obtained.  The major goals of this visit are to confirm the diagnosis of asthma, 

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obtain baseline information about demographics and asthma control, and to 
characterize the cellular components of each participant’s sputum.  During Visit 
1, a complete medical history will be obtained, and the diagnosis of asthma will 
be confirmed with spirometry and albuterol bronchodilator reversibility.  A 
complete physical exam will be completed.  (Participants undergoing Supervised 
Washout will have interim history and short physical exam.)  Female participants 
will undergo a urine pregnancy test. Asthma control will be assessed using the 
Asthma Control Test.  Body mass index (BMI, kg/m2) will be calculated from 
obtained height and weight in all participants; waist circumference and other 
body measurements will be measured. These data will be utilized to assess if 
any of these covariates influence asthma control.  Participants who do not 
demonstrate bronchodilator reversibility at Visit 1 will return within 1-2 days for 
Visit 1A, at which methacholine bronchoprovocation will be performed.  
Participants who meet either reversibility or PC20 criteria for asthma will undergo 
sputum induction, and blood will be drawn for a complete blood count with 
differential (eosinophils), periostin, total serum IgE, and allergy testing 
(immunoCAP).  FeNO will be assessed on all participants.  Participants eligible to 
continue will be provided single-blind placebo-long-acting muscarinic antagonist, 
as well as an electronic diary/peak flow meter device (for those who did not 
participate in Supervised Washout).  Each participant will be provided with open 
label high dose ICS (i.e., mometasone 400-440 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D x 10 days) which 
they will take BID x 10 days if they experience treatment failure. 

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At Visit 2 (Week 3) participants will provide an interim history and undergo 
a brief physical exam.  Spirometry and ipratropium (Atrovent® HFA) 
bronchodilator reversibility will be performed. Participants will undergo sputum 
induction, blood will be drawn for periostin and eosinophils (CBC with 
differential), and FeNO will be measured.  DNA from whole blood will be obtained 
for future genotyping studies, and plasma will be banked for future proteomic 
studies.  Household Socio-Economic Information and Home Environment 
questionnaires will be given.  The diary and peak flow data will be reviewed for 
asthma control as well as adherence.   Treatment failure criteria will be 
evaluated. 
At Visit 3 (Week 6), participants will provide an interim history and undergo 
a brief physical exam.  Spirometry will be performed.  Participants who have not 
yet provided 2 satisfactory sputum samples will undergo sputum induction, blood 
will be drawn for periostin and eosinophils (CBC with differential), and FeNO will 
be measured.  The diary and peak flow data will be reviewed for asthma control 
as well as adherence, and asthma control questionnaires will be completed.  The 
Perceived Stress Scale and Sinonasal Questionnaire also will be completed.  
Treatment failure criteria will be evaluated.  If adherence and other study criteria 
are met, participants will be considered eligible to continue in the study and will 
be stratified based on sputum eosinophils (≥2% vs. <2%) and randomized 1:1:1 
to enter the 3 arm cross-over treatment phase of the study.  An Asthma 
Exacerbation packet will be dispensed. 

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D. 
Double-Blind 3-Period Crossover Treatment Phase 
During the treatment phase (Weeks 6-42, Visits 3-9), participants will take 
ICS, inhaled LMA or inhaled placebo, in random sequence, each for 12 weeks. 
They will be seen every 6 weeks and will complete a telephone visit at the 
intervening 3-week time points.  At each Visit, they will provide an interim history, 
undergo a brief physical exam (long physical exam at Visit 9), perform 
spirometry, and complete asthma control questionnaires.  At Visits 5, 7 and 9, the 
Sinonasal Questionnaire also will be completed.  Female participants will 
undergo a urine pregnancy test at Visit 9. Study coordinators will review 
medication adherence and peak flow records.  Treatment failure criteria will be 
thoroughly evaluated at each clinic and phone visit, and participants will be asked 
to contact the clinical site between visits if they experience symptoms of 
treatment failure.   
If a participant meets criteria for treatment failure, he/she will take high-
dose open label ICS BID x 10 days, and will continue assigned double-blind 
study drug (unless the investigator has reason to believe that study drug 
contributed directly to the treatment failure).  If the treatment failure event 
resolves, the participant will continue in the study.  If treatment failure occurs <3 
weeks before the end of a treatment period, that period will be extended so that 
≥3 weeks will have elapsed before a participant crosses over to the next 
treatment arm (or has their final visit should this occur during the final treatment 
period).  Participants who experience ≥2 Treatment Failures or an Asthma 
Exacerbation will cross over to the next treatment arm (or have their final visit 

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should this occur during the final treatment period). Participants who experience 
an Asthma Exacerbation will be treated with prednisone and seen at the clinic 
after 3 days to ascertain the severity of the event and ensure appropriate 
treatment.  During periods 1 and 2, this clinic visit will coincide with their 
crossover visit and during period 3, this visit will coincide with their final in-person 
visit.  Phone visits will be conducted on days 10, 14, and 21 following prednisone 
start to monitor exacerbation recovery, and additional safety visits will occur if 
necessary. Participants will complete questionnaires to characterize the 
exacerbation and recovery, as described in section IV E, Characterization of 
Asthma Exacerbations. 
E. 
Detailed Visit Structure 
Visit 0A (pre-screen; Supervised Washout)  
 
We anticipate that only a minority of participants will participate in the 
Washout.  This includes individuals with well-controlled asthma on low-dose ICS, 
intermittent ICS, intermittent ICS/LABA or LTRA.  The goal of this visit is to 
explain the study to potential participants, obtain informed consent, perform a 
detailed medical history and physical examination, perform spirometry, and 
assess their asthma control to determine if they may reduce (2-Step Washout) 
their ICS or eliminate (1-Step Washout) their ICS, ICS/LABA or LTRA under 
supervision.   
Procedures Performed: 
 Informed consent 
 Medical history 

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 Physical Exam 
 Spirometry 
 Dispense/Explain electronic diary and PEF meter 
 50% reduction in ICS dose for those undergoing 2-Step Washout or 
medication elimination for those undergoing 1-Step Washout 
Visit 0B (2 weeks after Visit 0A for those undergoing 2-Step Washout) 
 
The goal of this visit is to assess the participant’s asthma control and to 
repeat spirometry.  If the participant continues to be well-controlled, he/she will 
be directed to discontinue ICS and to continue to monitor asthma control using 
the electronic diary and PEF meter. 
Procedures Performed: 
 Interim medical history 
 Limited Physical Exam 
 Spirometry 
 Diary and PEF review  
Visit 1 (End of Supervised Washout; Must occur 3 weeks after Visit 0B or 3 
weeks after Visit 0A for those undergoing 1-Step Washout) 
 
The goal of this visit is to confirm that participants have maintained 
satisfactory asthma control during the Supervised Washout, and continue with 
Visit 1 below. 
Procedures Performed:  
 Interim medical history 

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 Limited Physical Exam 
 Spirometry 
 Diary and PEF review  
 
Visit 1 (Week 0; Entry to Single-Blind Run-In) 
 
For the majority of subjects, this will be their initial visit; for those who 
participate in the Supervised Washout this will occur 5 weeks after Visit 0A for 
those undergoing 2-Step Washout and 3 weeks after Visit 0A for those 
undergoing 1-Step Washout. 
 
The goals of this visit are to explain the study to potential participants, 
obtain informed consent, confirm the diagnosis of asthma, and characterize the 
cellular components of each participant's sputum, and start single-blind Placebo-
LMA.   
Procedures Performed: 
 Informed consent 
 Complete medical history 
 Physical Exam 
 Pregnancy test 
 Height, weight; waist, hip, neck measurements (anthropometrics) 
for adults 
 Spirometry 
 Albuterol Bronchodilator Reversibility 

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 Asthma Control Test 
 Sputum Induction 
 Blood for eosinophils (CBC with differential), IgE, allergy tests, and 
periostin 
 Measurement of FeNO 
 Dispense/Explain electronic diary and PEF meter 
 Dispense single-blind Placebo-LMA inhaler  and explain use 
 Dispense open label “high-dose” ICS for Treatment Failure “rescue” 
 Dispense prednisone 
Visit 1A (Week 0, 1-2 days after V1; Methacholine Visit) 
 
For individuals who did not meet the bronchodilator reversal criteria at 
Visit 1, this visit serves to confirm the diagnosis of asthma. 
 
Procedures Performed 
 Pregnancy test 
 Spirometry 
 Methacholine Bronchoprovocation 
 Remaining procedures from V1 (See Visit Table in Appendix) 
 
Visit 2 (Week 3) 
 
The purpose of this visit is to perform additional study procedures and to 
obtain the second induced sputum sample.  
 
Procedures Performed:  

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 Interim History 
 Limited Physical Exam 
 Ipratropium (Atrovent® HFA) Bronchodilator Reversibility 
 Household Socio-Economic Information Questionnaire 
 Home Environment Questionnaire 
 Spirometry 
 Sputum Induction 
 Blood for eosinophils (CBC with differential) and periostin 
 Genetics blood draw 
 Measurement of FeNO 
 Review electronic diary, PEF meter and medication use 
 Treatment Failure Assessment 
Visit 3 (Week 6; Randomization; Start of Treatment Phase) 
 
The purpose of this visit is to assess the participant’s asthma control and 
adherence at the end of the 4-6 week Run-In period, and to determine if they 
meet inclusion/exclusion criteria for Randomization.  Participants for whom only 1 
of the 2 prior induced sputum samples were satisfactory will again undergo 
Sputum Induction (SI). Sputum induction, and additional procedures noted below, 
will be performed at an additional visit (Visit 2A) at least 1 week prior to Visit 3 to 
confirm eligibility prior to randomization.   
 
Procedures Performed: 
 Interim History 
 Limited Physical Exam 

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 Review electronic diary, PEF meter and medication use 
 Spirometry 
 Sputum Induction (for participants with <2 satisfactory samples) 
 Blood for eosinophils (CBC with differential) and periostin (for 
participants who perform SI) 
 Measurement of FeNO (for participants who perform SI) 
 Asthma Control Test (ACT) 
 Asthma Symptom Utility Index (ASUI) 
 Asthma Bother Profile (Quality of Life) 
 Impact of Asthma on Quality of Life (RAND-IAQL-12)31 
 Sinonasal Questionnaire (SNQ) 
 Asthma-Specific Work Productivity and Activities Impairment 
Questionnaire (WPAI-AS) 
 Perceived Stress Scale (PSS) 
 Acute Asthma Assessment Questionnaire (AAAQ) 
 Dispense Exacerbation Packet 
 Treatment Failure Assessment 
 Review Eligibility Criteria 
 Randomize 
 Dispense Randomized Study Drugs 
Visit 4, Visit 6, Visit 8 (Weeks 12, 24, 36; midpoint of each treatment period) 
 
The purpose of these visits is to assess participants’ asthma control and to 
encourage adherence to the treatment and documentation regimen. 

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Procedures Performed: 
 Interim History 
 Limited Physical Exam 
 Review electronic diary, PEF meter and medication use 
 Treatment Failure Assessment 
 Spirometry 
 Asthma Control Test (ACT) 
 Asthma Symptom Utility Index (ASUI) 
 Dispense Randomized Study Drugs 
Visit 5, Visit 7, Visit 9 (Weeks 18, 30, 42; end of each treatment period) 
 
The purpose of these visits is to assess participants’ asthma control and to 
encourage adherence to the treatment and documentation regimen. 
 
Procedures Performed: 
 Interim History 
 Limited Physical Exam at Visit 5, 7; Physical Exam at Visit 9 
 Height, weight; waist, hip, neck measurements (anthropometrics) at 
Visit 9 for adults 
 Pregnancy test (Visit 9 only) 
 Review electronic diary, PEF meter and medication use 
 Treatment Failure Assessment 
 Spirometry 
 Asthma Control Test (ACT) 
 Asthma Symptom Utility Index (ASUI) 

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 Asthma Bother Profile (Quality of Life) 
 Impact of Asthma on Quality of Life (RAND-IAQL-12) 
 Sinonasal Questionnaire (SNQ) 
 Asthma-Specific Work Productivity and Activities Impairment 
Questionnaire (WPAI-AS) 
 Dispense Randomized Study Drugs (excluding Visit 9) 
 Satisfaction Questionnaire (Visit 9 only) 
Exacerbation Visit 
 
Procedures Performed: 
 Interim History 
 Physical Exam 
 Review electronic diary, PEF meter and medication use 
 Spirometry 
 Asthma Exacerbation Questionnaire 
 Acute Asthma Assessment Questionnaire 
 
VII. DRUG SUPPLIES 
 
Participants for the SIENA study will receive a single-blind Placebo-LMA 
during the Run-In Period and will be treated in a double-blind cross-over fashion 
during the treatment period with an ICS, LMA, and placebo.  

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During the double-blind treatment phase, participants will receive "medium 
dose" ICS (i.e., mometasone, 200-220 mcg BID, dose dependent on 
mometasone device randomized to at Visit 3 – See Appendix D) or matching 
ICS-placebo.  As has been done with previous ACRN and AsthmaNet studies, all 
pharmaceutical companies who make inhaled corticosteroids were invited (by 
letter) to provide drug and matching placebo for the study.  As there is no 
scientific rationale for choosing one ICS preparation over another, the final 
decision is based on the availability of an appropriate dose/device, and the 
expense. 
 
 
Participants will also receive inhaled LMA (i.e., tiotropium RESPIMAT 
5mcg QD) or LMA-placebo during the double-blind treatment phase.  We invited 
the manufacturers of tiotropium and aclidinium, Boehringer Ingelheim and Forest, 
to provide active drug and matching placebo.   
 
Based on these factors, we anticipate conducting the study with tiotropium 
and tiotropium-placebo via Respimat, and with mometasone and mometasone-
placebo via DPI device.  The DCC has experience with drug acquisition, masking 
and distribution as well as with obtaining placebos.  The budget includes funds 
for this work. (See Appendix D: Study Drug Procurement and Distribution) 
 
 
 
 
 

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VIII. POWER CALCULATION AND STATISTICAL  ANALYSIS 
A. Randomization 
 
 
The target sample size for the SIENA trial is 336 randomized participants 
(74 in the eosinophilic phenotype and 262 in the non-eosinophilic phenotype). 
 
This study incorporates a design in which each participant will receive 
each of three treatment regimens over three 12-week periods (known as a three-
way crossover design). If we denote the three treatment regimens as A, B, and 
C, then each SIENA participant will be randomized to one of the following six 
sequences: 
 
 
 
ABC, ACB, BAC, BCA, CAB, CBA  
 
Because SIENA invokes a three-way crossover design, a stratified 
randomization based on prognostic factors is not critical. Instead, we only will 
invoke clinical site within phenotype (eosinophilic, non-eosinophilic) as a 
stratifying variable with permuted blocks of size six (one complete cycle of the six 
sequences).  When a participant at a particular Clinical Center is deemed eligible 
for the study, the Clinic Coordinator will access the AsthmaNet Randomization 
Module.  After entering the participant’s pertinent information, the Clinic 
Coordinator will be asked to verify that all of the entered information is correct.  If 
so, the Clinic Coordinator will be given inhaler numbers to be dispensed to that 
participant.  At certain visits, the coordinator will access the Randomization 
Module again to generate new inhaler numbers containing the regimen 
consistent with the participant’s randomized drug sequence. In order to maintain 
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coordination staff will receive automatically a notice from the AsthmaNet server 
that a participant has been randomized and/or had a new inhaler number 
generated. 
B. 
Masking 
 
To minimize the bias due to possible knowledge of the sequence 
assignment, the study will be double-blinded. Thus, the investigators and the 
participants will not know which treatments are being administered during the 
treatment periods. 
C. 
Statistical Analysis Plan for the Primary and Secondary 
Outcomes 
 
The SIENA trial invokes a three-way crossover design. Each of the three 
treatment periods endures for 12 weeks, but the data from the first four weeks of 
each treatment period are not used in the statistical analyses because of the lack 
of wash-out periods in the crossover design.  
 
The primary outcome in the SIENA trial is a composite based on the three 
components of treatment failure, asthma control days (ACDs), and FEV1. For 
each SIENA participant, we will compare ICS to placebo and LMA to placebo in a 
hierarchical manner based on the data from the latter eight weeks of their 
respective treatment periods. The process is described as follows for the generic 
comparison of treatment regimen A to treatment regimen B: 
1. If the SIENA participant does not experience treatment failure on 
treatment regimen A, but does experience treatment failure on treatment 

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regimen B, then treatment regimen A is deemed to be superior to 
treatment regimen B and the process is terminated. If not, then continue to 
the next step.  
2. If the SIENA participant experiences at least 31 greater annualized ACDs 
on treatment regimen A as compared to treatment regimen B, then 
treatment regimen A is deemed to be superior to treatment regimen B and 
the process is terminated. If not, then continue to the next step. 
3. If the SIENA participant displays at least a 5% improvement in FEV1 on 
treatment regimen A as compared to treatment regimen B, then treatment 
regimen A is deemed to be superior to treatment regimen B and the 
process is terminated. If not, then the two treatment regimens are deemed 
to be “equivalent” or “tied” for that SIENA participant. 
 
In order to describe the primary and secondary null hypotheses, we 
introduced the following notation: 
 pEos–,ICS>Placebo = probability that ICS is superior to placebo within the non-
eosinophilic phenotype 
 pEos–,Placebo>ICS = probability that placebo is superior to ICS within the non-
eosinophilic phenotype 
 pEos–,ICSPlacebo = probability that ICS and placebo are equivalent within the 
non-eosinophilic phenotype = 1 – pEos–,ICS>Placebo – pEos–,Placebo>ICS 
 pEos–,LMA>Placebo = probability that LMA is superior to placebo within the non-
eosinophilic phenotype 

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 pEos–,Placebo>LMA = probability that placebo is superior to LMA within the non-
eosinophilic phenotype 
 pEos–,LMAPlacebo = probability that LMA and placebo are equivalent within 
the non-eosinophilic phenotype = 1 – pEos–,LMA>Placebo – pEos–,Placebo>LMA 
 pEos+,ICS>Placebo = probability that ICS is superior to placebo within the 
eosinophilic phenotype 
 pEos+,Placebo>ICS = probability that placebo is superior to ICS within the 
eosinophilic phenotype 
 pEos+,ICSPlacebo = probability that ICS and placebo are equivalent within the 
eosinophilic phenotype = 1 – pEos+,ICS>Placebo – pEos+,Placebo>ICS 
 pEos+,LMA>Placebo = probability that LMA is superior to placebo within the 
eosinophilic phenotype 
 pEos+,Placebo>LMA = probability that placebo is superior to LMA within the 
eosinophilic phenotype 
 pEos+,LMAPlacebo = probability that LMA and placebo are equivalent within 
the eosinophilic phenotype = 1 – pEos+,LMA>Placebo – pEos+,Placebo>LMA 
 
The co-primary research hypotheses are that within the non-eosinophilic 
phenotype, ICS is superior to placebo and LMA is superior to placebo. In 
statistical terms, the null hypotheses are 
(1) 
H0: pEos–,ICS>Placebo = pEos–,Placebo>ICS 
(2) 
H0: pEos–,LMA>Placebo = pEos–,Placebo>LMA 

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Since pEos-,ICSPlacebo, pEos-,LMAPlacebo, pEos+,ICSPlacebo, and, pEos+,LMAPlacebo do 
not factor into the null hypotheses, participants who do not have a differential 
response (i.e., treatment was equivalent to placebo) will not be included in the 
analyses.  We will apply two-sided, exact binomial tests at the 0.025 significance 
level (Bonferroni correction) for each of these null hypotheses. To assess 
potential period and seasonal effects, a sensitivity analysis will be performed by 
applying logistic regression models to those who had a differential response (i.e., 
the treatments were not equivalent), with covariates to adjust for period 
differences, season of enrollment, and ICS delivery (DPI/MDI). 
 
Secondary analyses with the primary outcome include the following: 
 
1. Comparisons within the eosinophilic phenotype in terms of the null 
hypotheses H0: pEos+,ICS>Placebo = pEos+,Placebo>ICS and H0: pEos+,LMA>Placebo = 
pEos+,Placebo>LMA, which we will test via two-sided, exact binomial tests at the 
0.025 significance level (Bonferroni correction) for each of these null 
hypotheses. 
2. Comparisons between the non-eosinophilic and eosinophilic phenotypes 
in terms of the null hypotheses H0: pEos–,ICS>Placebo = pEos+,ICS>Placebo and H0: 
pEos–,LMA>Placebo = pEos+,LMA>Placebo, which we will test via two-sided, 0.025 
significance level Fisher exact tests (Bonferroni correction). 
3. Comparison of the ICS and LMA treatments in the manner described 
above for the primary and secondary analyses (within the non-eosinophilic 

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phenotype, within the eosinophilic phenotype, and between the 
eosinophilic and non-eosinophilic phenotypes, respectively).  
4. Application of univariable and multivariable logistic regression that uses 
sputum eosinophils, blood eosinophils, FENO and serum periostin, as well 
as bronchodilator reversibility, measures of atopy, and other phenotypic 
characteristics from both eosinophilic and non-eosinophilic participants to 
construct ROC curves and c (concordance) statistics to identify “cutpoints” 
for each biomarker (which also can be compared with previously 
suggested cutpoints) to examine the value of these biomarkers as 
predictors of response to treatments. 
 
 
All of the analyses described above will follow the intention-to-treat 
paradigm whereby all available data from randomized participants are included in 
the analyses regardless of information about deviations from study protocol. 
D. 
Statistical Analysis Plan for Additional Secondary Outcomes   
 
We will analyze separately each of three components of the composite 
outcome as secondary outcomes. We will apply a proportional hazards 
regression analysis for the time to treatment failure, with a random effect term 
(frailty) for the SIENA participant to account for the correlations within the SIENA 
participant 27. The proportional hazards regression model will include fixed terms 
for treatment regimen, sequence, period, and season of enrollment and an 
additional random effect term for clinical site. We will apply a linear mixed-effects 
model for longitudinal data on ACDs and FEV1. The statistical model will include 

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(1) fixed effects for treatment regimen, sequence, period, and season of 
enrollment (spring, summer, fall, winter) nested within each of the eosinophilic 
and non-eosinophilic phenotypes. (2) a random effect for clinical site within each 
of the eosinophilic and non-eosinophilic phenotypes, and (3) a 7  7 unstructured 
variance-covariance matrix for the seven measurements per participant  
(baseline and two timepoints within each of the three periods). We will apply a 
similar statistical approach for the other secondary outcomes that are measured 
on a continuum, such as diary peak flow values and logarithmic-transformed 
methacholine challenge PC20. We will analyze time to asthma exacerbation in a 
manner similar to that for time to treatment failure. 
 
We will pursue additional secondary analyses to investigate whether 
baseline measurements of the biomarkers (blood eosinophils, periostin, and 
exhaled nitric oxide) significantly predict any of these secondary outcomes. We 
will achieve this by including the biomarkers in the statistical models described in 
the previous paragraph. 
 
Finally, we will perform exploratory subgroup analyses of the primary and 
secondary outcomes within levels of gender, minority status, age group, baseline 
BMI, and baseline FEV1. 
E. 
Missing Data 
 
Because of the possibility of drop-outs and other missed visits, there will be 
some missing data. The statistical models and analyses that are planned for the 

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primary and secondary outcomes assume that the data are missing-at-random 
(MAR). Because we are applying likelihood-based methods for the data adjustment 
with primary outcome and for all of the secondary outcomes, MAR data still yield 
valid estimates. Although not expected, if it appears that the MAR assumption is not 
reasonable, then we will invoke shared parameter models to simultaneously model 
the time to drop-out and the individual secondary outcome 28. 
F. 
Interim Analyses 
 
There will be no formal interim analysis of efficacy in this trial. 
Nevertheless, interim statistical analyses to evaluate the safety of the three 
treatment regimens will be presented to the AsthmaNet Data and Safety 
Monitoring Board (DSMB) semi-annually for review. Based on the results of 
these interim analyses, the DSMB will recommend to the NHLBI the continuation 
or discontinuation of the trial. In addition, the DSMB will be monitoring all of the 
safety data throughout the course of the trial and will be notified within 72 hours 
of any serious adverse event (SAE) that is deemed both unexpected and related 
to the study. All SAEs will be reviewed at each 6-month review.  
G. 
Power Calculations 
 
The target sample for the SIENA trial is 336 randomized participants, 74 in 
the eosinophilic phenotype and 262 in the non-eosinophilic phenotype, because 
we anticipate a 1-to-3.5 ratio, or smaller, of the eosinophilic phenotype to the 
non-eosinophilic phenotype. 

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For the co-primary comparisons within the non-eosinophilic phenotype, 
the sample size of 262 yields statistical power of 0.9 with two-sided, 0.025 
significance level tests (Bonferroni correction), while allowing for a 15% drop-out 
rate, to detect pEos–,ICS>Placebo – pEos–,Placebo>ICS = 0.20 (and to detect pEos–
,LMA>Placebo – pEos–,Placebo>LMA = 0.20). We assume that 30% of the participants will 
not display a preference for ICS versus placebo and therefore not included in the 
primary analysis (and that 30% of the participants will not display a preference for 
LMA versus placebo). The following table illustrates the level of statistical power 
for selected sample sizes. 
 
 
 
N 
pEos–,ICSPlacebo 
or 
pEos–,LMAPlacebo 
pEos–,ICS>Placebo -  pEos–,LMA>Placebo 
or 
pEos–,Placebo>ICS -  pEos–,Placebo>LMA 
 
 
 
Statistical Power 
202 
0.30 
0.20 
 
80% 
228 
0.30 
0.20 
 
85% 
262 
0.30 
0.20 
 
90% 
 
 
 
With respect to the secondary analysis of the primary outcome, the 
following table illustrates the statistical power for detecting pEos+,ICS>Placebo = 0.71 
and pEos–,ICS>Placebo = 0.45, yielding a difference of 0.26 between the two 
phenotypes (and for detecting pEos+,LMA>Placebo = 0.71 and pEos–,LMA>Placebo = 0.45, 
yielding a difference of 0.26 between the two phenotypes). 
 
 
 
 

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EOS-Negatives 
EOS-Positives 
 
 
 
 
Statistical Power 
 
 
N 
pEos–,ICS>Placebo 
or 
pEos–,LMA>Placebo 
 
 
N 
pEos+,ICS>Placebo 
or 
pEos+,LMA>Placebo 
 
 
202 
 
0.45 
 
58 
 
0.71 
 
 
80% 
 
228 
 
0.45 
 
66 
 
0.71 
 
 
85% 
 
262 
 
0.45 
 
74 
 
0.71 
 
 
90% 
 
For the secondary analysis of comparing the ICS and LMA treatments within the 
non-eosinophilic phenotype, there is 90% statistical power with a sample size of 
262 to detect a difference of 0.185 (= pEos–,LMA>ICS – pEos–,ICS>LMA) with a two-
sided, 0.05 significance level test.  
H. 
Anticipated Results 
Our primary hypothesis is that the response to ICS and LMA will be 
different in participants with and without airway eosinophilia.  We anticipate that 
ICS will be more effective in asthmatics with airway eosinophilia and that LMA 
will be more effective in asthmatics who are persistently non-eosinophilic. 
Our study design, power calculations, and statistical analyses are 
predicated on prior observations from ACRN studies that demonstrate 
heterogeneity of sputum inflammatory cells in 997 subjects with mild-moderate 
asthma.  Based on these data, we predicted that approximately 50% of recruited 
participants will have ≥2% eosinophils in sputum, which led to our target sample 
size of 384.  However, more recent data demonstrated that ~75% of ICS-naïve 
individuals with very mild, yet uncontrolled, asthma have < 2% eosinophils in 
sputum.  It is possible that the actual distribution of eosinophil positive vs 

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eosinophil negative participants will be different – with <50% of these mild 
patients demonstrating ≥2% sputum eosinophils.  If this is the case, then this 
study takes on even greater significance, for it would suggest that there is a 
larger-than-anticipated population of asthmatic patients who are non-eosinophilic 
– and for whom the best therapy remains undetermined. 
   
IX. 
RISKS AND BENEFITS  
 
A. 
Risks and Benefits of Study Procedures 
 
Venipuncture: Blood samples will be obtained by venipuncture of an antecubital 
vein to determine IgE, allergen sensitivity, periostin, eosinophils, and for DNA 
extraction for future genotyping  studies.  
Risks: The risks of venipuncture are minimal.  The possible risks include bruising 
and/or infection at the site of the venipuncture and vasovagal episodes 
experienced by the blood donors.  Pressure will be applied to the venipuncture 
site to prevent bruising.  Aseptic technique will be used to prevent infection. 
Blood will be obtained while the donors are in a seated position and medical and  
nursing personnel will be available at the study sites to treat and manage 
vasovagal episodes.   
Benefits: IgE and allergen sensitivity are necessary to characterize (phenotype) 
the participants.  Periostin and eosinophils are being examined as exploratory 
biomarkers of TH2-high asthma.  The DNA isolated for future genotyping studies 
will provide important insight into potential genetic modifiers of responses to 
inhaled corticosteroids and to long-acting muscarinic antagonists.  

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The potential benefits justify the potential risks. 
 
Pulmonary function testing (spirometry):  
Risks: Spirometry will be performed to determine the participants' pulmonary 
function.  The risks of spirometry are minimal.  The possible risks include 
precipitation of bronchospasm and light-headedness from repeated blowing 
attempts.  Medical and nursing personnel and medications will be available at the 
study sites to treat and manage bronchospasm.  Inhalation of a short acting beta-
2 adrenergic agonist (albuterol) and a short-acting anti-cholinergic (ipratropium, 
Atrovent® HFA) will be used to assess reversibility. The possible risks of inhaled 
beta-2 adrenergic agonists include tachycardia and hand tremors.  Ipratropium 
(Atrovent® HFA) is an anticholinergic bronchodilator that is FDA approved for the 
treatment of chronic bronchitis, emphysema and chronic obstructive pulmonary 
disease (COPD).   Although ipratropium has not been FDA-approved for use in 
asthma, it is widely used for asthma, and an NIH Task Force 32 and US and 
International guidelines 
33 all recommend ipratropium in this dose for 
characterization of asthma.  This is another test to measure improvement in 
spirometry but showing improvement with this test is not a screening 
requirement.  Taking the 4 puffs of ipratropium (Atrovent® HFA) required for this 
test can cause adverse effects including headache, dry mouth, nausea, 
bronchitis, and shortness of breath.  These side effects were reported in patients 
with COPD who took ipratropium for 12-weeks.  Since participants will only take 

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ipratropium once, the likelihood of these side effects is much less.  The safety of 
ipratropium in children is not known. 
 
Benefits: Spirometry with assessment of reversibility to a short acting beta-2 
adrenergic agonist and to ipratropium (Atrovent® HFA) will be used to determine 
if the participants meet the inclusion criteria for this study and to examine 
whether a differential response to beta-2 adrenergic agonists vs anti-cholinergics 
predicts response to ICS vs. LMA.  Spirometry will be used during the study to 
monitor for asthma control and treatment failure.  
The potential benefits justify the potential risks.  
  
Methacholine inhalation challenge: Methacholine challenge will be used to 
assess airway hyper-responsiveness.  
Risks: The major risk of methacholine challenge is the induction of severe 
bronchoconstriction.  As a precaution, participants will not undergo methacholine 
challenge if their FEV1 is less than  55% of predicted or 1.0 liter.  Medical and 
nursing personnel, medications and equipment will be available at the study sites 
to treat and manage any bronchoconstriction episodes.  
Benefits: There are two benefits to this procedure. First, for the participants who 
do not demonstrate a 12% improvement in FEV1, a positive methacholine 
challenge would allow them to meet one of the inclusion criteria for this study. 
Second, the comparison of the methacholine PC20 in eosinophil positive vs 
eosinophil negative participants will provide important characterization of these 2 

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phenotypes - which may be important in predicting or interpreting response to 
asthma treatments.  
The potential benefits justify the potential risks.  
 
Induced sputum: Sputum will be induced with hypertonic saline to collect an 
airway sample and to assess for airway inflammation.  
Risks: Like any bronchoprovocation challenge, sputum induction can provoke 
bronchospasm and warrants close supervision during its performance.   
Benefits: There are no direct benefits to the participant.  This procedure will 
allow us to characterize participants as "eosinophilic" or "non-eosinophilic" and is 
a requirement for stratification prior to randomization.  
The potential benefits justify the potential risks.  
 
Exhaled Nitric Oxide:  Exhaled Nitric Oxide will be measured each time a 
participant undergoes sputum induction.  This involves exhaling gently into a 
small, handheld device that measures FeNO. 
Risks:  The risks of this maneuver are minimal.  As with spirometry, it is possible 
that a participant could become lightheaded from blowing, but these are not 
forced maneuvers. 
Benefits:  There is no direct benefit to participants.  This information provides an 
assessment of the amount of inflammation in the airways, which may relate to 
asthma control.  This measurement is an exploratory outcome of the study, to be 
compared with sputum eosinophils. 

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68 
The potential benefits justify the potential risks.  
 
B. 
Risks of Study Design 
Risks: Participants in the study have persistent symptomatic asthma and will not 
receive regular inhaled corticosteroids during the 4-6 week Run-In Period and 
during 2 of the 3 three-month-long double-blind Treatment Periods.  (All 
participants will, however, receive inhaled corticosteroids if their asthma control 
deteriorates).  In addition, we believe that the "eosinophil negative" participants 
will not respond to inhaled corticosteroid treatment.  It is therefore likely that a 
significant number of participants will experience deterioration of asthma control 
during the study.  For this reason, we have defined a Treatment Failure status 
that we believe is sufficiently conservative that participants whose asthma control 
deteriorates will be "rescued" before they develop an asthma exacerbation.  This 
rescue algorithm was used successfully in the NHLBI-ACRN IMPACT study 3 - a  
comparison of daily versus "as-needed" ICS for mild persistent asthma.  
Participants who meet treatment failure status during the Run-in will be treated 
according to a rescue algorithm and will continue in the study.  If necessary, the 
run-in will be extended so that ≥ 3 weeks elapse after TF before randomization.  
Participants with ≥2 TFs during the Run-In will be excluded from the double-blind 
Treatment Period.  To provide an additional level of safety, we have added 
additional exclusion criteria at the end of the Run-In that must be met before 
participants can be randomized.  Finally, TF criteria will also be used throughout 
the treatment period - to ensure the safety of participants. 

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We have designed the study with frequent study visits and phone visits 
(every 3 weeks) to allow for close monitoring of asthma control.  All participants 
will be given an electronic diary/peak flow device at entry into the Run-In, which 
will provide objective data for assessment of control.  Participants who do not 
adhere to this monitoring on 75% of days will not be permitted to proceed to the 
double-blind Treatment Period. 
 
Participants who experience an Asthma Exacerbation will be treated with 
prednisone and seen at the clinic after 3 days to ascertain the severity of the 
event and ensure appropriate treatment.  As part of our "characterization of 
asthma exacerbations", they will be evaluated in person or by phone on days 3, 
10, 14, and 21.  
Benefits: Although we can guarantee no direct benefit for participants, it is 
possible that those individuals who are "eosinophil negative" and who we believe 
do not respond to ICS, may respond favorably to LMA.   
 
With all of these safeguards in place, we believe we have designed a 
study where the potential benefits justify the potential risks. 
 
C. 
Risks and Benefits of Study Drugs 
Inhaled Corticosteroid (ICS):  ICS is the standard treatment for chronic 
persistent asthma. 
Risks:  The potential risks of ICS are well-known, and include oropharyngeal 
candidiasis, thinning of skin, osteoporosis, and cataracts.  There is no reason to 
believe that the risk is greater in this patient population. 

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Benefits:  We may learn that participants who are eosinophil negative do better 
with LMA than with ICS, which may allow them to minimize their potential risk in 
the future. 
The potential benefits justify the potential risks. 
 
Long-acting Muscarinic Antagonist (LMA):  All participants will take an LMA 
(tiotropium RESPIMAT 5mcg QD) during 1 of 3 double-blind Treatment Periods. 
Risks:  In general, LMAs have a well-established safety profile in COPD.  
Tiotropium Respimat was approved for treatment of COPD in the US in 
September 2014, and for treatment of asthma in the US in September 2015.  It is 
also approved in many other countries for treatment of chronic obstructive 
pulmonary disease (COPD).  A different form of tiotropium (Spiriva® HandiHaler) 
has been approved and used in the US for the treatment of COPD since 2004.  
Tiotropium Respimat has been tested in 3282 patients with COPD and 
1634 adult and adolescent patients with asthma.  The most commonly reported 
adverse reactions were pharyngitis, cough, dry mouth and sinusitis.  Tiotropium 
should not be taken by patients with narrow angle glaucoma (high pressure in the 
eyes), prostatic hypertrophy (enlarged prostate), bladder-neck obstruction 
(difficulty in urination), or renal insufficiency (kidney disease). A few reports 
suggested the possibility that tiotropium Respimat might increase the risk of 
stroke, heart attack, and death in patients with COPD when compared with the 
FDA-approved tiotropium Handihaler formulation available for treatment.  To 
clarify this question and to exclude a relation between treatment with tiotropium 

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71 
Respimat and an increased rate of deaths, a large long-term study of 17,135 
patients with COPD was conducted.  Analysis of the data from the trial concluded 
that tiotropium Respimat had a safety profile similar to tiotropium HandiHaler in 
patients with COPD, and was not associated with an increased risk of death. 
Participants with history of urinary retention, elevated intraocular pressure, 
and significant cardiovascular disease will be excluded from the study. 
An IND has been obtained from the FDA (#121996) for the SIENA study. 
 
Benefits:  Tiotropium has been shown to be not inferior to salmeterol as add-on 
treatment in asthma, and in a small study tiotropium increased FEV1 in 
asthmatics with low sputum eosinophil counts. Because all patients do not 
respond to inhaled corticosteroids, and some appear to have adverse effects 
associated with their use, there is a need for additional controller medications 
which can be used when inhaled corticosteroid does not provide adequate 
asthma control.  If tiotropium bromide is found to be effective when used in this 
manner, important benefits to asthma patients would be anticipated. 
The potential benefits justify the potential risks. 
 
 
 
X. 
ADVERSE EVENTS 
A. 
Definition and reporting  
 
 
Participants are at risk of developing adverse events during study 
enrollment. A clinical adverse event is any unintended worsening in the structure 
(signs) or function (symptoms) of the body, whether or not considered to be 

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72 
study-related. This includes any side effect, injury, or sensitivity reaction, as well 
as any intercurrent event. A laboratory adverse event is any clinically-important 
worsening in a test variable which occurs during the course of the study, whether 
or not considered to be drug-related. An adverse event is deemed serious if it 
suggests a significant hazard, contraindication, side effect, or precaution. Serious 
adverse events include any experience that is fatal or life-threatening, is 
permanently disabling, requires or prolongs inpatient hospitalization, or is a 
congenital anomaly, cancer, or overdose.   
 
Documentation of an adverse event will be recorded on the Clinical 
Adverse Event Report Form and will include the following information: 
Description of the condition, dates of condition, treatment of condition 
(medications, doses, dates), whether hospitalization or emergency treatment was 
required, treatment outcome, relationship of the adverse event to the study 
medication(s), and severity of the event.  
B. 
Adverse Events Unrelated to Asthma    
 
Adverse events due to concurrent illnesses other than asthma may be 
grounds for withdrawal if the illness is considered significant by the study 
investigator or if the participant is no longer able to effectively participate in the 
study. Participants experiencing minor intercurrent illnesses may continue in the 
study provided that the nature, severity, and duration of the illness are recorded 
and that any unscheduled medications required to treat the illness are also 
recorded. Examples of minor intercurrent illnesses include acute rhinitis, sinusitis, 
upper respiratory infections, urinary tract infections, and gastroenteritis. 

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Medications are allowed for treatment of these conditions in accordance with the 
judgment of the responsible study physician. 
C. 
Adverse Events Related to Asthma: Treatment Failure and 
Asthma Exacerbation  
 
Since participants have persistent symptomatic asthma and will not 
receive regular inhaled corticosteroids during the 4-6 week Run-In Period and 
during 2 of the 3 three-month long double-blind Treatment periods, we anticipate 
that asthma treatment failures will occur. Safety net procedures, including visits 
and frequent telephone contacts, are in place to identify participants who 
experience a treatment failure (a primary outcome) or asthma exacerbation 
during the study.  
 
Between in-person study visits (as described above), participants will be 
contacted by telephone by the clinic coordinator to assure that they are 
continuing to participate appropriately in the study protocol, to answer any 
questions that may arise, and to assure that their asthma is under adequate 
control, as assessed by the participant. The coordinator will attempt to determine 
whether the participant is showing signs of treatment failure using specific 
criteria.  If it is determined that the participant fulfills criteria for treatment failure, 
they will be advised to initiate high-dose ICS rescue treatment (i.e., mometasone 
400-440 mcg BID, dose dependent on mometasone device randomized to at 
Visit 3 – See Appendix D x 10 days).  
 
If, between phone contacts or in-person visits, an asthma exacerbation 
has occurred, the participant should contact the clinic coordinator and/or be 

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74 
evaluated at the study site or the nearest medical emergency facility as quickly 
as possible (within 72 hours) for initiation of rescue prednisone. For both adults 
and children, the recommended prednisone dose for acute exacerbations is 2 
mg/kg/day (maximum 60 mg) as a single morning dose for three days followed 
by 1 mg/kg/day (maximum 30 mg) as a single morning dose for 2 days.   All 
administered doses will be rounded down to the nearest 5 mg in children. Phone 
visits will be conducted on days 10, 14, and 21, to monitor exacerbation 
recovery. 
 
Definition of Treatment Failure: 
  
The definition of TF is based on the Symptom-Based Action Plan that was 
used successfully in the ACRN IMPACT Study 3 and includes: 
 Awakening from asthma three or more times in a two-week period 
or on two consecutive nights, or  
 Using albuterol for relief of symptoms four or more times/day for 
two or more consecutive days, or 
 Albuterol has been relieving symptoms for less than four hours after 
each treatment over a 12-hour period, or 
 Using albuterol for relief of symptoms daily for seven days, and this 
use exceeds two times the weekly use of albuterol in the baseline 
period, or  
 exercise induces unusual breathlessness. 
 
Definition of Asthma Exacerbation: 

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75 
 
Although all participants with an asthma exacerbation will also meet the 
criteria outlined for treatment failure above, asthma exacerbations are more 
severe episodes of acute worsening, defined by meeting criteria for treatment 
failure AND one or more of the following:   
 Failure to respond within 48 hours to treatment failure rescue algorithm  
 FEV1 <50% of baseline on 2 consecutive measurements  
 FEV1 <40% of predicted on 2 consecutive measurements 
 Use of ≥ 16 puffs of "as needed" β-agonist per 24 hours for a period of 48 
hours  
 Experiencing an exacerbation of asthma in the opinion study investigator 
or personal physician  
 Use of oral/parenteral corticosteroid due to asthma 
 
D. 
Adjustments to Trial Medications and Rescue Algorithms 
during Treatment Failures and Asthma Exacerbations 
 
Participants who develop treatment failure during the Run-In period or 
double-blind Treatment Period will be treated as described previously with high-
dose ICS (i.e., mometasone 400-440 mcg BID, dose dependent on mometasone 
device randomized to at Visit 3 – See Appendix D x 10 days), and continue in the 
study.  Participants who experience two treatment failures during the run-in 
period will not be allowed to participate in the study further.  Participants who 
meet criteria for treatment failure during the double-blind Treatment Period will 
continue in the study.  If the treatment failure occurs <3 weeks before the end of 

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76 
a treatment period, that period will be extended so that ≥3 weeks will have 
elapsed before the participant crosses over to the next treatment arm (or has 
their final visit should this occur during the final treatment period).  Participants 
who experience ≥ 2 Treatment Failure episodes or an Asthma Exacerbation 
during a treatment arm will cross over to the next treatment arm (or have their 
final in-person visit should this occur during the final treatment period). 
 
Participants who experience a treatment failure event that also meets the 
criteria for an asthma exacerbation, will be treated with Prednisone.  For both 
adults and children, the recommended prednisone dose for acute exacerbations 
is 2 mg/kg/day (maximum 60 mg) as a single morning dose for three days 
followed by 1 mg/kg/day (maximum 30 mg) as a single morning dose for 2 days; 
all administered doses will be rounded down to the nearest 5 mg in children.    
Participants will be assessed in person and by phone on days 0, 3, 10, 14, and 
21. Additional visits and treatment for exacerbations is at the discretion of the 
treating physician. 
E. 
Rescue Algorithm for Asthma Exacerbations and Treatment 
Failure Non-responders 
Participants who are not responsive to the treatment failure rescue 
algorithm or those who develop asthma exacerbations will be managed 
according to the following rescue algorithms. Rescue algorithms are based on 
recommendations from the NAEPP Guidelines for Diagnosis and Management of 
Asthma and prior ACRN trials.  Albuterol and oral prednisone are the principal 
medications for rescue management and participants will be instructed in their 

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77 
use for home management. Oral prednisone will be used if alteration of inhaled 
corticosteroid does not resolve the exacerbation. For severe acute episodes of 
asthma, treatment will be administered according to the best medical judgment of 
the treating physician. 
 
Home Care 
Asthma exacerbations will be recognized by criteria described above. 
Participants will be educated to recognize exacerbations as early as possible to 
facilitate prompt treatment and to lessen morbidity. 
Participants who recognize increased symptoms and/or a fall in PEF to 
≤65% baseline will use albuterol by MDI, 2-4 puffs, every 20 min up to 60-90 min 
if needed and then every 4 hours, or less, if needed.  
If the PEF does not increase to >65% baseline or if symptoms are not 
improved after the first 60-90 min of therapy, the participant should contact the 
investigator, their primary physician or seek care in the emergency department. 
Failure of albuterol to control or maintain PEF >65% baseline may necessitate 
the use of oral steroids (see below). 
 
Physician’s Office or Emergency Room Treatment 
Participants will be assessed by history, physical examination, and by 
physiological monitoring including spirometry or PEF. If the participant’s PEF 
and/or FEV1 are less than 25% predicted or if the participant shows evidence of 
altered mental status, cyanosis, labored breathing, or use of accessory muscles, 

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78 
sampling of arterial blood for respiratory gas analysis is indicated, with 
appropriate action taken depending on the results obtained.  
When treated in the physician’s office or the hospital emergency room, 
participants should initially be given albuterol by nebulization (0.5 cc of 0.5% 
solution) every 20 min over the first 60-90 min. 
If the PEF increases to >65% baseline after the first 60-90 min, the 
participant can be discharged to continue treatment at home. Prednisone may be 
administered at the discretion of the physician to augment therapy. 
If symptoms persist and PEF remains ≤65% baseline, nebulized albuterol 
should be continued as often as every 20 min at the discretion of the treating 
physician.  Oral or parenteral corticosteroids should be considered.  Monitoring of 
PEF or spirometry should continue every hour. Within 4 hours of treatment, a 
decision should be made regarding participant disposition.  
If PEF increases to >65% baseline within 4 hours, the participant can be 
discharged to continue treatment at home.  Home treatment should include a 5-
day course of prednisone (see below). 
If PEF remains >40% but ≤65%, an individualized decision should be 
made to hospitalize the participant for more aggressive therapy or to continue 
therapy at home with a course of prednisone. 
If PEF is ≤40% baseline after repeated albuterol treatments, the 
participant should be admitted to the hospital unless in the physician’s best 
judgment alternative treatment could suffice. 
Prednisone Treatment 

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79 
The recommended dose of prednisone used during an acute exacerbation 
is 2 mg/kg/day (maximum 60 mg) as a single morning dose for three days 
followed by 1 mg/kg/day (maximum 30 mg) as a single morning dose for 2 days; 
all administered doses will be rounded down to the nearest 5 mg in children.    
Participants will be assessed in person and by phone on days 0, 3, 10, 14, and 
21. Additional visits and treatment for exacerbations is at the discretion of the 
treating physician. 
 

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80 
XI. 
PARTICIPATING PARTNERSHIPS 
 
Nine AsthmaNet Clinical Center partnerships (and their associated satellites) will 
participate in the SIENA study.  Each partnership has recruitment and retention 
plans in place to maximize enrollment. These nine partnerships include: 
Brigham and Women’s Hospital, Boston, MA  
Chicago Metropolitan Asthma Consortium, Chicago, IL  
National Jewish Health, Denver, CO  
University of Wisconsin, Madison, WI  
University of Pittsburgh, Pittsburgh, PA  
Washington University, St. Louis, MO  
University of California, San Francisco, CA  
University of Arizona, Tucson, AZ 
Wake Forest University, Winston-Salem, NC  

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81 
XII. REFERENCES 
 
1. 
McGrath KW, Icitovic N, Boushey HA, et al. A Large Subgroup of Mild-to-
Moderate Asthma Is Persistently Noneosinophilic. Am J Respir Crit Care 
Med 2012;185:612-9. 
 
2. 
Bacci E, Latorre M, Cianchetti S, et al. Transient sputum eosinophilia may 
occur over time in non-eosinophilic asthma and this is not prevented by 
salmeterol. Respirology 2012. 
 
3. 
Boushey HA, Sorkness CA, King TS, et al. Daily versus as-needed 
corticosteroids for mild persistent asthma. N Engl J Med 2005;352:1519-
28. 
 
4. 
Martin RJ, Szefler SJ, Chinchilli VM, et al. Systemic effect comparisons of 
six inhaled corticosteroid preparations. Am J Respir Crit Care Med 
2002;165:1377-83. 
 
5. 
Martin RJ, Szefler SJ, King TS, et al. The Predicting Response to Inhaled 
Corticosteroid Efficacy (PRICE) trial. J Allergy Clin Immunol 2007;119:73-
80. 
 
6. 
Deykin A, Lazarus SC, Fahy JV, et al. Sputum eosinophil counts predict 
asthma control after discontinuation of inhaled corticosteroids. J Allergy 
Clin Immunol 2005;115:720-7. 
 
7. 
Simpson JL, Scott R, Boyle MJ, Gibson PG. Inflammatory subtypes in 
asthma: assessment and identification using induced sputum. Respirology 
2006;11:54-61. 
 
8. 
Haldar P, Pavord ID. Noneosinophilic asthma: a distinct clinical and 
pathologic phenotype. J Allergy Clin Immunol 2007;119:1043-52; quiz 53-
4. 
 
9. 
Pavord ID, Brightling CE, Woltmann G, Wardlaw AJ. Non-eosinophilic 
corticosteroid unresponsive asthma. Lancet 1999;353:2213-4. 
 
10. 
Woodruff PG, Boushey HA, Dolganov GM, et al. Genome-wide profiling 
identifies epithelial cell genes associated with asthma and with treatment 
response to corticosteroids. Proc Natl Acad Sci U S A 2007;104:15858-63. 
 
11. 
Lazarus SC, Boushey HA, Fahy JV, et al. Long-Acting ß2-Agonist 
Monotherapy vs Continued Therapy With Inhaled Corticosteroids in 
Patients With Persistent Asthma.  A Randomized Controlled Trial. JAMA 
2001;285:2583-93. 
 

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12. 
Clinical trial of low-dose theophylline and montelukast in patients with 
poorly controlled asthma. Am J Respir Crit Care Med 2007;175:235-42. 
 
13. 
Field SK. Roflumilast: an oral, once-daily selective PDE-4 inhibitor for the 
management of COPD and asthma. Expert Opin Investig Drugs 
2008;17:811-8. 
 
14. 
Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up 
therapy for adults with uncontrolled asthma. N Engl J Med 2010;363:1715-
26. 
 
15. 
Bateman ED, Kornmann O, Schmidt P, Pivovarova A, Engel M, Fabbri 
LM. Tiotropium is noninferior to salmeterol in maintaining improved lung 
function in B16-Arg/Arg patients with asthma. J Allergy Clin Immunol 
2011;128:315-22. 
 
16. 
Iwamoto H, Yokoyama A, Shiota N, et al. Tiotropium bromide is effective 
for severe asthma with noneosinophilic phenotype. Eur Respir J 
2008;31:1379-80. 
 
17. 
Kerstjens HA, Engel M, Dahl R, et al. Tiotropium in asthma poorly 
controlled with standard combination therapy. N Engl J Med 
2012;367:1198-207. 
 
18. 
Lemanske RF, Jr., Mauger DT, Sorkness CA, et al. Step-up therapy for 
children with uncontrolled asthma receiving inhaled corticosteroids. N Engl 
J Med 2010;362:975-85. 
 
19. 
Nair P, Kjarsgaard M, Armstrong S, Efthimiadis A, O'Byrne PM, Hargreave 
FE. Nitric oxide in exhaled breath is poorly correlated to sputum 
eosinophils in patients with prednisone-dependent asthma. J Allergy Clin 
Immunol 2010;126:404-6. 
 
20. 
Fuhlbrigge A, Peden D, Apter AJ, et al. Asthma outcomes: exacerbations. 
J Allergy Clin Immunol 2012;129:S34-48. 
 
21. 
Sorkness RL, Gonzalez-Fernandez G, Billmeyer EE, Evans MD, Gern JE, 
Jarjour NN. The asthma index: a continuous variable to characterize 
exacerbations of asthma. J Allergy Clin Immunol 2008;122:838-40. 
 
22. 
Chen H, Blanc PD, Hayden ML, Bleecker ER, Chawla A, Lee JH. 
Assessing productivity loss and activity impairment in severe or difficult-to-
treat asthma. Value Health 2008;11:231-9. 
 

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23. 
Belda J, Leigh R, Parameswaran K, O'Byrne PM, Sears MR, Hargreave 
FE. Induced sputum cell counts in healthy adults. Am J Respir Crit Care 
Med 2000;161:475-8. 
 
24. 
Spanevello A, Confalonieri M, Sulotto F, et al. Induced sputum cellularity. 
Reference values and distribution in normal volunteers. Am J Respir Crit 
Care Med 2000;162:1172-4. 
 
25. 
Expert Panel Report 3: guidelines for the diagnosis and management of 
asthma. US Department of Health and Human Services, National 
Institutes of Health, National Heart, Lung, and Blood Institute., 2007. 
(Accessed at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.) 
 
26. 
Bateman ED, Hurd SS, Barnes PJ, et al. Global strategy for asthma 
management and prevention:  GINA Executive Summary. Eur Respir J 
2008;31:143-78. 
 
27. 
Liu L, Huang X. The use of Gaussian quadrature for estimation in frailty 
proportional hazards models. Statistics in Medicine 2008;27:2665-83. 
 
28. 
Vonesh EF, Greene T, Schluchter MD. Shared parameter models for the 
joint analysis of longitudinal data and event times. Statistics in Medicine 
2006;25:143-63. 
 
29. 
Damera G, Jiang M, Zhao H, Fogle HW, Jester WF, Freire J, Panettieri 
RA.  Aclidinium bromide abrogates allergen-induced hyperresponsiveness 
and reduces eosinophilia in muring model of airway inflammation.  Eur J 
Pharm 2010, 649:349-353. 
 
30. 
Denlinger LC, Sorkness RL, Lee WM, Evans MD, Wolff MJ, Mathur SK, 
Crisafi GM, Gaworski KL, Pappas TE, Vrtis RF, Kelly EA, Gern JE, Jarjour 
NN. Lower airway rhinovirus burden and the seasonal risk of asthma 
exacerbation. Am J Respir Crit Care Med 2011; 184:1007-14. 
 
31. 
Stucky BD, Edelen MO, Sherbourne CD, Eberhart NK, Lara M. 
Developing an item bank and short forms that assess the impact of 
asthma on quality of life (under review). 
 
32. 
Tepper RS, Wise RS, Covar R, Irvin CG, Kercsmar CM, Kraft M, Liu MC, 
O'Connor GT, Peters SP, Sorkness R, Togias A, Asthma Outcomes: 
Pulmonary Physiology. J Allergy Clin Immunol 2012; 129(3 Suppl):S65-87. 
 
33. 
Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, 
Crapo R, Enright P, van der Grinten CP, Gustafsson P, Jensen R, 
Johnson DC, MacIntyre N, McKay R, Navajas D, Pedersen OF, Pellegrino 

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R, Viegi G, Wanger J.  ATS/ERS Task Force: Standardization of Lung 
Function Testing.  Eur Resp J 2005; 26(2):319-38. 
 

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XIII. APPENDICES 
A. 
Visit Table 
 
 
Supervised 
Washout1 
Run-in 
Randomized Treatment Period 
Visit 
0A8 
0B8 
1 
1 
 PC 
2 
PC 
3 
PC 
4 
PC 
5 
PC 
6 
PC 
7 
PC 
8 
PC 
9 
AE 
Week 
-5/-3 
-3 
0 
0 
1.5 
3 
4.5 
6 
9 
12 
15 
18 
21 
24 
27 
30 
33 
36 
39 
42 
 
Window (regular/extended)(Days) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Full medical history 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Interim history 
 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Long physical exam 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
Short physical exam 
 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
Height/weight/BMI 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Body measurements (waist, hip, neck) - age ≥18 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Genetics blood sample2 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC 
 
 
 
X3 
 
X 
 
X5 
 
 
 
 
 
 
 
 
 
 
 
 
 
IgE, ImmunoCAP 
 
 
 
X3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Periostin 
 
 
 
X3 
 
X 
 
X5 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine pregnancy test 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Spirometry 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Albuterol bronchodilator reversal  
 
 
 
X 
 
 
 
X5,6 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ipratropium bronchodilator reversal 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Methacholine challenge 
 
 
 
X4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sputum induction 
 
 
 
X3 
 
X 
 
X5 
 
 
 
 
 
 
 
 
 
 
 
 
 
FeNO 
 
 
 
X3 
 
X 
 
X5 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dispense Exacerbation Packet7 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asthma Control Test (ACT) 
 
 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Asthma Bother Profile (QOL) (ABP) 
 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
Asthma Symptom Utility Index (ASUI) 
 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 

SIENA Protocol – Version 4.3 
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86 
 
Supervised 
Washout1 
Run-in 
Randomized Treatment Period 
Visit 
0A8 
0B8 
1 
1 
 PC 
2 
PC 
3 
PC 
4 
PC 
5 
PC 
6 
PC 
7 
PC 
8 
PC 
9 
AE 
Week 
-5/-3 
-3 
0 
0 
1.5 
3 
4.5 
6 
9 
12 
15 
18 
21 
24 
27 
30 
33 
36 
39 
42 
 
Window (regular/extended)(Days) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asthma-Specific Work Productivity and Activities 
Impairment Questionnaire (WPAI:Asthma) 
 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
Home Environment Questionnaire (HEQ) 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Household Socio-Economic Information 
questionnaire (HOUSEHOLD_SEI) 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perceived Stress Scale (PSS) 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sinonasal Questionnaire (SNQ) 
 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
Impact of Asthma on Quality of Life (IAQL)31 
 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
Acute Asthma Assessment Questionnaire (AAAQ) 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Review electronic diary  
 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Review medication use 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Satisfaction questionnaire 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Treatment failure assessment 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Dispense e-diary/PEF meter 
X 
 
 
X3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dispense run-in medications (placebo LMA) 
 
 
 
X3 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dispense open label “high-dose” ICS for 
Treatment Failure 
 
 
 
X3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dispense rescue prednisone supply 
X 
 
 
X3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dispense randomized medication 
 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
50% reduction in ICS dose 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discontinuation of ICS if well-controlled 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1 For those taking ICS or ICS/LABA intermittently, low-dose ICS, or LTRA 
2 Genetics blood sample is optional 
3 Done at V1A if participant does not qualify by Reversibility 
4 Methacholine challenge ONLY done (at V1A) if participant does not qualify by Reversibility 
5 If Sputum Induction necessary for eligibility at V3, these procedures will be performed at an additional visit (V2A) at least 1 week prior to V3 
6 Reversibility testing done to qualify for sputum induction 
7 Includes WPAI:Asthma, Wisconsin Upper Respiratory Symptom Score – 21 (WURSS-21) and AAAQ 
8 2-Step Washout participants have Visit 0A at -5 weeks and Visit 0B at -3 weeks;1-Step Washout participants have Visit 0A at -3 weeks and skip Visit 0B 

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B. 
List of Asthma Questionnaires to be used 
 
 
 
 

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C. 
Draft Acute Asthma Assessment Questionnaire  
 

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D. 
 Study Drug Procurement and Distribution 
 
All pharmaceutical companies that manufacture long-acting muscarinic 
antagonists and inhaled corticosteroids were invited to participate in SIENA by 
providing active drug and placebo for the study. 
 
Long-Acting Muscarinic Antagonist and Placebo:  Boehringer Ingelheim has 
agreed to provide tiotropium, in the form of tiotropium Respimat, 2.5 mcg per 
actuation and tiotropium placebo.  Participants will take 2 puffs each day (total 
dose active drug = 5mcg).  Boehringer Ingelheim will coordinate the blinding and 
labeling of drug with input and assistance from the DCC.   
 
Inhaled Corticosteroid and Placebo:  Merck has agreed to provide 
mometasone and mometasone placebo.  Mometasone will be in the form of 
Asmanex® DPI, 110 mcg/puff.  Participants will take 2 puffs twice daily (total dose 
active drug = 440 mcg).  Merck will coordinate the blinding of drug with 
information provided by the DCC.  A third-party packager will label with additional 
regulatory information.   
 
Production of mometasone DPI was discontinued shortly after SIENA study start 
following FDA approval of mometasone MDI.  Since this was a known possibility, 
Merck provided AsthmaNet all available active and placebo mometasone DPI 
devices in 2014 with the goal of providing sufficient quantities to complete the 
SIENA protocol.  However, Merck agreed to provide additional mometasone in 
MDI form if that became necessary to complete SIENA.   
 
While the quantity of DPI product provided is adequate to complete SIENA, 
product expiration will become a problem if SIENA recruitment lags. Limited 
quantities of active mometasone DPI are available with expiration dating beyond 
November 2016, and those limited quantities have an expiration of April 2017. 
Thus, if recruitment is not completed by May 2016, then a switch to MDI product 
will be required.  Based on drug availability, a switch to MDI cannot be made 
earlier than November 2015. 
 
The AsthmaNet Steering Committee will monitor SIENA recruitment and 
continually reevaluate the likelihood of completing recruitment by May 2016.  
Depending on the results of this evaluation, the Steering Committee may 
recommend to the DSMB that a switch to MDI should be made. If a switch is 
made, all participants will complete the study using whichever formulation they 
receive at randomization. No participants will switch from DPI to MDI during the 
course of the study.  The randomization plan and the statistical analysis plan will 
be modified accordingly. In particular, we will insert an additional level of 
stratification for randomization according to DPI/MDI assignment. The current 
statistical plan is to include the stratifying variables as blocking factors, so 
DPI/MDI assignment will be included as a blocking factor in the statistical 

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analysis. 
 
Update November 2015:  Due to lagging recruitment and mometasone DPI 
expiration issues, a switch to mometasone MDI is necessary.  Merck has 
provided mometasone and mometasone placebo in the form of Asmanex® HFA, 
200 mcg/puff.  Participants will take 1 puff twice daily (total dose active drug = 
400 mcg).  Merck will coordinate the blinding of drug with information provided by 
the DCC.  A third-party packager will label with additional regulatory information.   
 
Contingent Statistical Analysis 
 
Because SIENA invokes a three-way crossover design, a stratified randomization 
based on prognostic factors is not critical. Instead, we only will invoke clinical site 
within phenotype (eosinophilic, non-eosinophilic) as a stratifying variable with 
permuted blocks of size six (one complete cycle of the six). As indicated above, if 
a DPI/MDI switch occurs, then we will include this as another stratification 
variable. In particular, the stratification will be according to DPI/MDI status nested 
within clinical center, which is nested within phenotype. 
 
The statistical analysis plan for the primary and secondary outcomes is described 
in Section VIII.C. With respect to the primary outcome variable, we will apply a 
linear mixed-effect model that includes (1) fixed effects for treatment regimen, 
sequence, period, and season of enrollment (spring, summer, fall, winter) nested 
within each of the eosinophilic and non-eosinophilic phenotypes, (2) random 
effects for clinical site within each of the eosinophilic and non-eosinophilic 
phenotypes, and (3) a 7  7 unstructured variance-covariance matrix for the 
seven measurements per participant within each of the eosinophilic and non-
eosinophilic phenotypes. We will account for the additional stratifying variable of 
DPI/MDI status by including it as another fixed-effect variable in linear mixed-
effects model. 
 
Obviously, completion of the entire study with the same manufacturer's lot of 
active drug and placebo is ideal. However, if Merck is not able to provide us with 
sufficient placebo DPI, we do not believe that the switch from active DPI to active 
MDI will negatively impact the scientific validity of the study. 
 
The goal of the study is to examine whether subjects with mild-to-moderate 
asthma who are persistently non-eosinophilic require a different treatment 
strategy than those with sputum eosinophilia.  Preliminary data suggest that 
subjects without sputum eosinophilia (presumed "TH2-low" asthma) do not 
respond to inhaled corticosteroids or to prednisone. In SIENA we will enroll 
subjects with persistent asthma who meet the EPR-3 criteria for Mild-to-Moderate 
Asthma and for whom Step 2 Treatment (Preferred = Low-dose ICS) is 
recommended. However, because we believe that ~50% of these subjects will 
not respond to ICS, we will provide Step 3 Treatment (Medium-dose ICS), to 
ensure that the issue is not too little ICS.  In the case of Mometasone, EPR-3 

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defines "low-dose" as 200 mcg/day and "medium dose" as 400 mcg/day. 
Because Merck will be fulfilling FDA criteria for equivalence, we anticipate that 
the doses delivered will be comparable, but even if there is a small difference in 
dose delivered between the DPI and MDI preparations, that dose should be 
sufficiently high on the flat portion of the dose-response curve that it will not 
impact the outcome. 
 
High-dose Inhaled Corticosteroid for Treatment Failure:  Merck has agreed 
to provide open-label mometasone (Asmanex® DPI, 220 mcg/puff) for use as 
high-dose Inhaled Corticosteroid Rescue for participants who experience 
Treatment Failure. 
 
Update November 2015:  Merck has agreed to provide open-label mometasone 
MDI (Asmanex® HFA, 200 mcg/puff) for use as high-dose Inhaled Corticosteroid 
Rescue for participants who experience Treatment Failure. 
 
Albuterol for Rescue:  TEVA has agreed to provide open label albuterol (Pro-
Air® HFA, 90 mcg albuterol/puff) as bronchodilator rescue for the study. 
 
E. 
Adverse Event Reporting to Companies Donating Study 
Drug 
 
Adverse event 
An adverse event (AE) is defined as any untoward medical occurrence, including 
an exacerbation of a pre-existing condition, in a patient in a clinical investigation 
who received a pharmaceutical product. The event does not necessarily have to 
have a causal relationship with this treatment. 
 
Serious adverse event 
A serious adverse event (SAE) is defined as any AE which results in death, is 
immediately life-threatening, results in persistent or significant disability / 
incapacity, requires or prolongs patient hospitalisation, is a congenital anomaly / 
birth defect, or is to be deemed serious for any other reason if it is an important 
medical event when based upon appropriate medical judgement which may 
jeopardise the patient and may require medical or surgical intervention to prevent 
one of the other outcomes listed in the above definitions. 
Patients may be hospitalised for administrative or social reasons during the study 
(e.g. days on which infusion takes place, long distance from home to site,). 
These and other hospitalisations planned at the beginning of the study do not 
need to be reported as a SAE in case they have been reported at screening visit 
in the source data and have been performed as planned. 
 
Intensity of adverse event 

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The intensity of the AE should be judged based on the following: 
 Mild: Awareness of sign(s) or symptom(s) which is/are easily tolerated 
 Moderate: Enough discomfort to cause interference with usual activity 
 Severe: Incapacitating or causing inability to work or to perform usual 
activities 
 
 
 
Causal relationship of adverse event 
Medical judgment should be used to determine the relationship, considering all 
relevant factors, including pattern of reaction, temporal relationship, de-challenge 
or re-challenge, confounding factors such as concomitant medication, 
concomitant diseases and relevant history. Assessment of causal relationship 
should be recorded in the case report forms and on each company’s SAE form.  
Yes: There is a reasonable causal relationship between the 
investigational product administered and the AE.  
No: 
There is no reasonable causal relationship between the 
investigational product administered and the AE.  
 
Worsening of the underlying disease or other pre-existing conditions 
Worsening of the underlying disease or of other pre-existing conditions will be 
recorded as an (S)AE in the (e)CRF. 
 
Changes in vital signs, ECG, physical examination, and laboratory test 
results 
Changes in vital signs, ECG, physical examination and laboratory test results will 
be recorded as an (S)AE in the (e)CRF, if they are judged clinically relevant by 
the investigator. 
 
Responsibilities for SAE reporting 
The Sponsor shall report (i.e., from signing the informed consent onwards 
through the trial defined follow-up period) all SAEs and non-serious AEs which 
are relevant for a reported SAE  by fax or other secure method using each 
company’s SAE form to the company’s Unique Entry Point in accordance with 
timeline specified below. The trial defined follow-up period ends on the date 
when the Termination of Study Participation case report form is completed and 
signed.  This generally occurs at the final study visit (see section VI.E. above) 
unless the participant drops out of the study prior to the final visit.  
 within two (2) business days upon receipt of initial and follow-up SAEs 
containing at least one fatal or immediately life-threatening event;  
 within two (2) business days upon receipt of any other initial and follow-up 
SAEs.  
 

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BIPI Unique Entry Point:  
 
Boehringer Ingelheim Pharmaceuticals, Inc.  
 
900 Ridgebury Road Ridgefield, CT  
 
Fax: 1-203-837-4329  
 
E-mail: PV_global_casemanagement@boehringer-ingelheim.com 
 
Merck Unique Entry Point:  
 
Fax: 1-215-993-1220  
 
 
 
TEVA Unique Entry Point:  
 
E-mail: us.clinops.sae.tevepharm.com 
 
For each adverse event, the investigator will provide the onset date, end date, 
intensity, treatment required, outcome, seriousness, and action taken with the 
investigational drug. The investigator will determine the expectedness of the 
investigational drug to the AEs as defined in the Listed or BI Drug Information 
e.g. Summary of Product Characteristics (SmPC) or Product Information (PI) for 
the authorised Study Drug provided by BI [Boehringer Ingelheim, Investigator’s 
Brochure, Doc. No: U92-0551-19, pp 195-200, July 13, 2012]. 

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F. 
 EPR-3 Table 4-8b