Circulating 4β-hydroxycholesterol as a biomarker of CYP3A4 activity: beyond drug development

Intestinal and hepatic expression of cytochrome P450 3A4 (CYP3A4) is essential to the oxidative metabolism of many steroids, environmental toxins, and pharmaceutical drugs. The enzyme also produces 4β-hydroxycholesterol (4β-OHC) from cholesterol, an oxysterol involved in several metabolic signaling pathways and detectable in human circulation. Circulating 4β-OHC is increasingly used in drug development research as an endogenous biomarker of CYP3A4 activity to understand agent metabolism and the potential for drug-drug interactions. The relatively long half-life of 4β-OHC in blood provides temporal stability, while still retaining sensitivity to increase 2- to 4-fold within a week in response to a strong CYP3A4 inducer. Beyond pharmacometric studies, circulating 4β-OHC is emerging as a biomarker of cumulative CYP3A4-related detoxification capacity in epidemiologic studies of liver disease, renal disease, hypertension, diabetes, cancer, and other conditions. Discoveries in lipid biology have distinguished 4β-OHC from other oxysterols, revealing mechanisms by which endobiotic and xenobiotic metabolism can disrupt the homeostasis of cholesterol, fatty acids, and glucose. This review summarizes the expanding relevance of circulating 4β-OHC in epidemiologic research, focusing on clinical and demographic characteristics as sources of variation. Consistent with between-person variability in CYP3A4 activity, circulating 4β-OHC is typically higher for women, lean individuals, and genetically-determined CYP3A5 expressers, factors potentially affecting its application in both drug optimization and disease phenotyping.