Classical statistical and functional enrichment analysis of the Flovent/placebo dataset provided little insight into the biological processes associated with the treated asthmatics. Results from the uncorrected tests contained many genes known to be associated with asthma, and some enriched pathways and GO terms linked these genes to inflammatory responses and metabolism of GCs. However, the high number of potential false positives hampered the results and correction for multiple testing eliminated most of these genes from the final list. Genes selected after multiple testing correction (FDR) identified the
SERPINB2 and
FKBP5 genes, which were previously validated [
9]. However, the FDR approach failed to identify
CLCA1, another gene experimentally confirmed [
9], although it was significantly altered based on uncorrected
P-values. This effect could partially be attributed to the reduced statistical power associated with the use of multiple testing correction methods compared to the uncorrected analysis [
21]. It has been well demonstrated that the excessive penalty imposed on
P-values following FDR adjustment increases the number of false negatives [
22]. On the other hand,
POSTN, which was also experimentally validated, had a
P
>
0.05 and therefore was not differentially expressed in our analysis. This comparison highlights some of the limitations associated with statistical analyses that rely on a single source of evidence to derive conclusions on biological function, and argues for the need for integrative approaches to data analysis.
Network analysis offers some advantages over classical analysis by being able to incorporate additional information from multiple sources [
21,
23,
24]. We applied a weight-of-evidence approach by using multiple methods that mine different aspects of the cellular processes, which converged to ‘Toll-like receptor signaling pathway’ and ‘PPAR signaling pathway’ as the most relevant pathways related to GC treatment (Figure

). Toll-like receptors (TLRs) regulate inflammatory responses by inducing the expression of inflammatory cytokines upon binding of viral or bacterial proteins and mediate the signaling pathways that regulate innate and Th2 responses in the epithelium [
3,
25,
26]. Toll-like receptors, including
TLR4 (found in module M6) and
TLR7 (found in module M1) mediate the production of interferons alpha and beta (type 1 interferons) [
27]. This important link between TLR and the interferon 1 pathway, not evident from the pathway enrichment analysis, was revealed by the promoter enrichment analysis.
Type 1 interferons act in an autocrine or paracrine manner and bind to interferon-alpha receptors in the membrane. This activates the Janus kinase and signal transducers and activators of transcription (JAK/STAT) pathway, which regulates the expression of inflammatory genes [
17]. Phosphorylation of STAT1 by JAK1 activates STAT1, which forms a heterodimer with STAT2 and recruits IRF9 to form the IFN-stimulated gene factor 3 (ISGF3) transcriptional complex [
18,
19]. The analysis of the human interactome identified
STAT1 and
IRF9, which are downregulated (
P
<
0.05) by Flovent (Figure

). In addition, promoter analysis identified
ISRE as the top enriched transcription factor motif in the list of differentially expressed genes (q

<

0.05). This suggests a mechanism in which GCs regulate the type 1 interferon pathway by downregulating the proteins involved in interferon signal transduction. However, although both
STAT1 and
IRF9 are suggested as differentially expressed (
P
<
0.05) and exhibited correlated expression profiles (r

=

0.771,
P
=

3.7E-07
), their correlation with treatment is less clear (Figure

). Interestingly, GCs are known to regulate the type 1 interferon pathway by suppressing the phosphorylation of
STAT1[
28], providing an alternative mechanism of regulation.
STAT1 phosphorylation also mediates the transduction of type 2 interferon (IFN-gamma) signaling by binding to gamma-activated sequence (GAS) elements as an homodimer. Therefore, it is possible that downregulation of
STAT1 and inhibition of phosphorylation of the protein represses type 2 interferon signaling. Indeed, GCs are known to inhibit IFN-gamma signaling by downregulating
STAT1 mRNA and protein expression in PBMCs [
29]. Gene expression for type 2 interferon and its receptor (IFN-gamma receptor, IFNGR) were found in the microarray dataset after filtering non-expressed genes (not shown). However, promoter analysis only identified enrichment of ISRE elements, the binding motif for the ISGF3 transcriptional complex, GAS elements were not detected. In addition, interrogation of the interferome database resulted in a list of interferon-regulated genes that were, in the majority of datasets assayed, regulated by type 1 interferons. Consequently, although a role of type 2 interferons cannot be excluded, our findings suggest that type 1 interferons are the target of GCs in the epithelium of asthmatics.
Peroxisome proliferator-activated receptors (PPAR) are lipid-activated transcription factors that regulate the expression of target genes [
30]. PPAR-alpha and -gamma modulate allergic inflammation, and agonists are able to reduce levels of inflammatory cytokines [
31,
32]. PPARs exert their activity by forming a heterodimer with the retinoid receptor
RXRA, which then binds to co-activator proteins, including
PPARGC1A (
PGC-1), to regulate gene expression. Transcriptional co-activators amplify the transcription of nuclear receptor regulated target genes [
33]. In particular, PPARGC1A can recruit other co-activator proteins with histone acetyltransferase (HAT) activity that open up the chromatin and enhance the expression of target genes [
34]. Consequently, an increase in the expression of
RXRA and
PPARGC1A co-activators can intensify the activity of the PPAR pathway, resulting in an increased repression of STAT1 phosphorylation. Both
RXRA and
PPARGC1A are present in the BioNet module and are upregulated by Flovent (Figure

). Promoter analysis also resulted in an enrichment of genes with PPARG:RXRA motifs (
P
~

0.01). This suggests that GCs modulates the activity of the PPAR pathway by upregulating co-transcriptional activators. Supporting this evidence, the expression profiles for
RXRA and
PPARGC1A are correlated (r

=

0.4078,
P
=

0.022) and show a trend of higher levels in Flovent-treated patients (Additional file
3: Figure S8).
Our results link GCs to type 1 interferon and PPAR pathways. There is previous evidence that connects PPARs to interferons, providing an interesting mechanism integrating GC actions. Activation of the PPAR-alpha (
PPARA) pathway was found to suppress STAT1 phosphorylation in rat glia [
35]. However, in our study promoter analysis identified PPARG, but not PPARA (P

~

0.2), motifs enriched in the list of differentially expressed genes. This lack of significance could be explained by the fact that PPARA motifs are missing in the JASPAR database, which retrieved higher significant results for the complex PPARG:RXRA transcription factor motif. In addition, our search strategy looked for motifs in the 1

kb region upstream of the transcription start site, whereas some transcription factors can bind to more distal locations. Alternatively, as our data suggest, GC action on type 1 interferons may be mediated via a PPAR-gamma-dependent process. For example, it has been shown that PPAR-gamma can repress the type 1 interferon pathway by downregulating the production of INF-beta upon TLR4 activation [
36]. Treatment with the PPAR-gamma agonist troglitazone and challenge with LPS and poly(I:C) impaired IRF3 binding to the IFN-beta-promoter. Downregulation of IFN-beta prevented activation of the IFN-beta receptor and subsequent STAT1 phosphorylation and ISRE activation [
36]. However, in our dataset type 1 interferons were present, but not differentially expressed (average
P
~

0.58 for type 1 interferon genes in the microarray). Interestingly, activation of the PPAR-gamma pathway was previously found to downregulate the expression of IFN-gamma activated genes [
37]. These findings highlight the complex nature of PPAR-mediated interferon regulation, which can affect different pathways (type 1 vs. type 2) at multiple regulatory points.
Our findings provide a link between interferon, PPARs and GCs that suggests a model similar to that presented in Figure

. In this model, allergens activate the TLR signaling, which in turn activates the production of type 1 interferons. The alpha/beta interferons then bind to interferon receptors (IFNAR1/2) that stimulate the phosphorylation of STAT1 and promote the expression of genes with a number of inflammatory effects. Treatment with GCs upregulates
PPARGC1A and
RXRA coactivator molecules, which consequently enhance the PPAR pathway. Activation of the PPAR pathway inhibits phosphorylation of STAT1 and therefore inhibits the interferon pathway. In addition, GCs may repress the interferon pathway by downregulation of
STAT1 and
IRF9 transcription factors. In this model, PPARs could be potential mediators of the anti-inflammatory actions of GCs. Both PPAR-alpha and -gamma inhibit airway inflammation in a murine module of asthma [
32]. The use of PPAR-gamma agonists has been shown to evidence improvements in lung function of smokers with asthma (improved FEV
1; forced expiratory volume in 1

sec), who had previously demonstrated a reduced response to GC treatment [
38]. While the mechanism for the observed improvements in lung function was unclear, it was postulated that PPAR-gamma could independently modulate a set of inflammatory genes relative to GCs [
39].
A link between GCs and the interferon pathways has been previously reported [
5,
40-
42], and interferons are known to affect symptoms in asthmatics [
43-
46]. Interferon-alpha has been associated with severe exacerbation of asthma symptoms [
43], which provides a simple mechanistic interpretation of the beneficial effects of GC-mediated repression of the interferon pathway. On the other hand, low doses of interferon-alpha have been associated with therapeutic effects in GC-resistant patients [
44-
46]. It is unclear if these disparate responses are due to differences in interferon dose or different patient phenotype. This clearly highlights the inherent complexity of the underlying regulatory networks and the need of further studies investigating the mechanisms of GCs and their relation with the interferon pathway.