Nuclear receptor ligands: rational and effective therapy for chronic cholestatic liver disease?

p r f c t p p f c he regulation of genes that are essential to many hepatic metabolic and transport functions are medited in large part by the action of small molecules that unction as nuclear receptor ligands.1 This process has een labeled chemical genomics.2 These ligands bind to heir specific nuclear receptors, activating the receptor hat then binds to specific elements in a gene’s promoter esulting in stimulation or inhibition of gene expresion.3 In the liver many drugs, metabolites, and herbal ompounds exert their biologic properties as ligands for uclear receptors.4,5 Some familiar examples of drugs hat activate nuclear receptors include phenobarbital and t John’s wort. Both drugs induce hepatic drug metablizing enzymes by acting as ligands for the pregnane X eceptor (PXR), which binds to specific response eleents in the promoter of cytochrome P-450 3A CYP3A), a major hepatic microsomal drug–metabolizng enzyme. This induction then indirectly affects the etabolism and systemic effects of a wide variety of other ompounds metabolized by CYP3A. An extract of 4 ifferent plants, Yin Zhi Huang, has been used tradiionally for treating neonatal jaundice in China and is a igand for the constitutive androstane receptor (CAR) hat up-regulates the expression of several different liver ransporters and enzymes involved in the hepatic clearnce of serum bilirubin.5 Indeed, more than 10% of edically useful drugs are known to exert their biologic ehavior by binding to ligand-binding domains on speific nuclear receptors.4 Table 1 shows some of the most mportant nuclear receptors and their physiologic ligands hat determine the hepatic transport and metabolism of variety of xenobiotics and endogenous substrates. In this issue of GASTROENTEROLOGY, Marschall et al6 eport that rifampicin and ursodeoxycholic acid (UDCA), wo well-known drugs used in the treatment of cholesatic liver disease, each stimulate the transcription of a istinct set of genes that together decrease bile acid ptake, enhance bile acid detoxification and excretion, nd stimulate the clearance of bilirubin. Rifampicin inreased the expression of CYP3A4, uridine 5=-glucuonosyl transferase (UGT1A1), and multidrug-resisance–associated protein (MRP2) whereas UDCA timulated the bile salt export pump (BSEP), and mulidrug resistance protein (MDR3), and MRP4. Although hese effects were observed in patients undergoing choecystectomy who otherwise were healthy, these separate ut complementary effects on gene and protein expresion are predicted to have beneficial effects if they ocurred in patients with cholestatic liver disease. These ndings thus suggest that there is therapeutic benefit rom combining drugs such as rifampicin and UDCA hat target nuclear receptors that have coordinated effects n the transcriptional regulation of hepatobiliary excreory mechanisms.7 How does this occur? The hepatic clearance of bile acids and bilirubin can be ivided into 4 phases that include the following: phase 0, epatic uptake; phase I, metabolism (eg, hydroxylation); hase II, detoxification (eg, conjugation); and phase III, xcretion. Nuclear receptors and their ligands that are he major determinants of the functional expression of enes that determine these pathways are shown in Figure , together with enzymes that control bile acid synthesis. In the enterohepatic circulation, the hepatic uptake of onjugated bile acids (phase 0) is mediated predominantly y the sodium taurocholate cotransporting polypeptide TCP (SLC10A1), whereas unconjugated bile acid uptake s facilitated by several organic anion transporting polypepides (OATPs) on the sinusoidal membrane, but predomi-