Bile Acid Receptors As Targets For Drug

REVIEWS
Bile acid receptors as targets for drug development

Frank G. Schaap, Michael Trauner and Peter L.M. Jansen
Abstract | The intracellular nuclear receptor farnesoid X receptor and the transmembrane Gprotein-coupled receptor TGR5 respond to bile acids by activating transcriptional networks and/or signalling cascades. These cascades affect the expression of a great number of target genes relevant for bile acid, cholesterol, lipid and carbohydrate metabolism, as well as genes involved in inflammation, fibrosis and carcinogenesis. PregnaneX receptor, vitaminD receptor and constitutive androstane receptor are additional nuclear receptors that respond to bile acids, albeit to a more restricted set of species of bile acids. Recognition of dedicated bile acid receptors prompted the development of semi-synthetic bile acid analogues and nonsteroidal compounds that target these receptors. These agents hold promise to become a new class of drugs for the treatment of chronic liver disease, hepatocellular cancer and extrahepatic inflammatory and metabolic diseases. This Review discusses the relevant bile acid receptors, the new drugs that target bile acid signalling andtheir possible applications.
Schaap, F.G. etal. Nat. Rev. Gastroenterol. Hepatol. advance online publication 27 August 2013; doi:10.1038/nrgastro.2013.151
Introduction
Traditional Chinese medicine recognized the therapeutic value of bear bile long before the era of modern medicine. Bear bile is replete with ursodeoxycholic acid (UDCA), a bile acid encountered in appreciable amounts only in Ursidae.1 Although bear bile gained scientific interest at the turn of the previous century with the isolation of a theretofore unknown bile acid (that is, UDCA) from bile of the polar bear by Olof Hammersten of the University of Uppsala in Sweden,1 it would last nearly eight more decades before the therapeutic potential of bile acids for dissolving gallstones and the treatment of bile acid biosynthesis defects and primary biliary cirrhosis (PBC) was realized.24 An early observation was made in 1938 by Nobel l aureate Philip Hench. He observed that rheumatic symptoms alleviated when patients with rheumatoid arthritis become jaundiced.5 Elevation of serum bile acids has been a candidate to explain this phenomenon ever since, and suggests an anti-inflammatory effect of bile acids. The discovery of receptors with affinity for bile acids, and subsequent Xray crystallography studies of their ligand-binding sites, has given the development of natural, semi-synthetic and fully synthetic drugs targeting these receptors and associated pathways a strong impetus and molecular base. These new agents offer novel therapeutic possibilities for the treatment and prevention of liver disease, atherosclerosis, obesity and type2 diabetes mellitus (T2DM). However, before this new approach can be fully appreciated, a more complete
Competing interests M. Trauner declares associations with the following companies: Falk Pharma, Intercept, Phenex. See the article online for full details of the relationships. F.G. Schaap and P .L.M. Jansen declare no competing interests.
understanding is needed of the complex networks that link bile acids and metabolism. In reading this Review, one has to appreciate that much of the research in this area has been undertaken in mice, which often does not translate directly to humans. Working with human cell systems only partially remedies this situation, as effects of bile acid signalling often rely on interactions between tissues rather than responses in single-cell systems. The final proof for the therapeutic value of bile acid analogues has to come from carefully planned, randomized human studies with clear endpoints. In this Review, we focus on bile acid signalling in humans, albeit it has to be acknowledged that much of the data and ideas are based on evidence from mouse models.
Bile acids
Excellent in-depth reviews covering the synthesis, metabolism, transport and physicochemical functions of bile acids have been published elsewhere.69 We will, therefore, only mention some elemental knowledge. Bile acids are a diverse class of water-soluble, cholesterolderived, amphipathic molecules that are formed in the liver (primary bile acids) with microbial transformation in the gut (secondary bile acids) greatly expanding the molecular repertoire. Bile acids typically occur as conjugates with either glycine or taurine, and are negatively charged over most of the physiological pH range. Although the term bile salt would be more appropriate from a chemical perspective, the expression bile acid is mostly used throughout this Review for congruence with colloquial terminology (such as UDCA and obeticholic acid). These chemical features necessitate dedicated transport proteins for efficient cellular permeation and largely confine intracellular bile
Department of Surgery, NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box616, 6200 MD, Maastricht,Netherlands (F.G.Schaap). Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 1820, 1090 Vienna, Austria (M. Trauner). Department of Gastroenterology and Hepatology, Academic Medical Centre, Meibergdreef 9, 1105AZ, Amsterdam, Netherlands (P.L.M.Jansen). Correspondence to: P .L.M. Jansen p.l.jansen@amc.uva.nl
NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY

2013 Macmillan Publishers Limited. All rights reserved
ADVANCE ONLINE PUBLICATION | 1
REVIEWS
Key points
The discovery of dedicated bile acid receptors and further research defined multiple bile acid signalling routes affecting bile acid synthesis, lipid synthesis, gluconeogenesis, inflammation, liver fibrosis and cancer Steroidal and nonsteroidal agonists of bile acid receptors have been developed as potential treatments for cholestatic and metabolic liver diseases, including primary biliary cirrhosis, primary sclerosing cholangitis and NASH Randomized, placebo-controlled clinical trials for the treatment of primary biliary cirrhosis and NASH with the farnesoid X receptor (FXR) agonist obeticholic acid are the first clinical trials initiated Future indications for FXR and TGR5 agonists include genetic cholestatic syndromes, intrahepatic cholestasis of pregnancy, atherosclerosis, IBS, bilereflux oesophagitis, IBD, hepatocellular and colon carcinoma
are controlled via an endocrine mechanism by fibroblast growth factor19 (FGF19, termed Fgf15 in rodents) produced in the ileum upon activation of FXR.16 It turned out that bile acids not only regulate their own synthesis and secretion,13 but also have a role in many other metab olic pathways (reviewed elsewhere17). In addition, bile acids affect such diverse processes as liver regeneration, intestinal integrity and shaping of the intestinal micro biome.1820 Bile acids are also known to have pro-apoptotic and proinflammatoryactions.21,22
Bile acid receptors

NHRs for which bile acids are relevant ligands include FXR (NR1H4),11 pregnaneX receptor (PXR, also known as NR1I2),23 vitaminD3 receptor (VDR, also known as NR1I1),24 and constitutive androstane receptor (CAR, also known as NR1I3).25 PXR and CAR are rather promiscuous receptors responding to a large variety of structurally unrelated xenobiotic compounds. In addition to these intracellular receptors, TGR5 is a cell-surface receptor of the Gprotein-coupled receptor family that binds and is activated by bile acids.26,27
acid signalling to the small intestine and liver where such transporters are expressed.6,8,9 In contrast to intracellular nuclear receptors such as the farnesoid X receptor (FXR, also known as bile acid receptor NR1H4, discussed below), activation of the cell-surface receptor TGR5 (also known as G-protein coupled bile acid receptor1) does not depend on transport systems for cellular ligand uptake. TGR5 is not only located in intestinal epithelium, Kupffer cells, sinusoidal endothelium and bile duct cells but also in tissues not participating in the enterohepatic circulation, suggesting that bile acids in the systemic circulation are relevant for activation of this receptor. This concept is entirely new as it brings into focus tissues (for example, muscle, brain, adipose tissue) and cell types (for example, macrophages and endothelial cells) that do not participate in classic bile acid cycling as possible targets of bile acid signalling. When the gallbladder contracts after food ingestion, bile and pancreatic juice enter the intestine and lipid breakdown starts. Here, bile acids in millimolar concentrations act as detergents and enable pancreatic lipase to digest emulsified fat into monoglycerides and fatty acids that together with fat-soluble vitamins can be absorbed in the proximal small intestine.9 Bile acids are also indispensable for solubilization of cholesterol in bile and absorption of cholesterol in the intestine.9 In addition, canalicularbile salt secretion is the main driving force for bile flow. Bileacids are, therefore, key agents for removal of cholest erol from the body. These traditional roles of bile acids have been known for more than 50years.10 In the 1990s, a number of ligand-activated transcription factors of the nuclear hormone receptor (NHR) family were discovered, later followed by recognition of bile acids as their endogenous ligands.11,12 These findings gave rise to the idea that bile acids in micromolar concentrations can act as signalling molecules. Feedback regulation of bile acid synthesis by bile acids was already known, but the responsible receptor remained elusive until the discovery of FXR.13,14 Upon binding of bile acids, FXR induces expression of the transcriptional repressor SHP (small heterodimer partner, or NR0B2).15 SHP subsequently interferes with the transcription of CYP7A1, which encodes the rate-determining enzyme cholesterol 7-monooxygenase in the multiplestep conversion of cholesterol to the primary bile acids chenodeoxycholic acid (CDCA) and cholic acid. 6 In addition, CYP7A1 and sterol12-hydroxylase (CYP8B1)
2 | ADVANCE ONLINE PUBLICATION
Farnesoid X receptor Among NHRs, FXR is the receptor most dedicated to signalling by bile acids. FXR was also the first identified bile acid receptor.11,12 There are two distinct FXR genes, encoding FXR (NR1H4) and FXR (NR1H5), with the latter having an unresolved function in mice and is considered a pseudogene in humans.28 Four functional isoforms of FXR have been identified that differ in transactivation potential and tissue distribution.29 Throughout this Review, the term FXR is used to denote (an unspecified isoform of) FXR. FXR is abundantly expressed in tissues engaged in the enterohepatic circulation of bile acids, with expression in the small intestine being highest at the site of bile acid reclamation, that is, the ileum (Figure1).30 In the mouse liver, Fxr is prominently expressed in parenchymal cells and to a lesser extent in endothelial, Kupffer and stellate cells.31,32 Studies in mice have largely focused on the function of Fxr in the small intestine and liver, with little information available on functionality in the kidneys, adrenal glands, cardiovascular system, thyroid gland, lungs, skin, adipose tissue, immune cells and human cancers.3337 Endogenous FXR agonists include (with decreasing affinity): CDCA, the secondary bile acid deoxycholic acid, cholic acid and lithocholic acid (LCA) (Table1). Muricholic acids, present in rodents but not in humans, were identified in a study published in 2013 as Fxr antagonistic bile acids.38 UDCA, a bile acid that is widely used in the treatment of cholestatic liver disease is not an FXR ligand. Neither is the synthetic side-chain-shortened UDCA analogue 24-nor-UDCA, despite a number of actions resembling bonafide Fxr activation (for example, maintenance of bile acid homeostasis, anti-inflammatory and anti-fibrotic effects, and improvement of serum lipids). Interestingly, 24-nor-UDCA suppresses Cyp7a1 in the context of reduced Shp expression in a genetic model of steatohepatitis in mice.39
www.nature.com/nrgastro
REVIEWS
FXR exerts its functions by eliciting transcriptional alterations. The protein has a multidomain structure with distinct regions engaged in DNA binding, ligand binding and transactivation. FXR is thought to be bound in an unliganded state to target promoter elements either as a monomer or as a heterodimer with the retinoic acid receptor RXR (RXRA, also known as NR2B1). Ligand binding results in dissociation of co-bound co-repressors and recruitment of co-activator proteins, thus, promoting target gene expression. Regulatory modes distinct from direct induction, including direct repression and indirect repression via SHP, as well as effects exclusively at a post-transcriptional level, have been described for FXR.40 FXR is part of a complex network of interacting transcription factors that include hepatocyte nuclear factor 1, peroxisome proliferatoractivated receptor (PPARA, also known as NR1C1), PXR, oxysterols receptor LXR (NR1H3) and CAR.4145 In the liver and intestine, FXR controls a number of important metabolic pathways (Figure1, Table1, reviewed elsewhere46,47). Its pivotal role in maintaining bile acid homeostasis and, thus, preventing bile acid toxi city includes induction of: bile acid conjugation (upregulation of the conjugating enzyme bile acid-CoA:amino acid Nacetyltransferase, BAAT);48 canalicular bile salt secretion (upregulation of bile salt export pump, BSEP);49 and basolateral efflux (overflow) systems that provide an altern ative route of bile acid elimination (for example, OST/).50 Moreover, FXR represses bile acid synthesis via upregulation of ileal FGF1916 and hepatic SHP.14 SHP differs from other typical NHRs in lacking a ligand-binding domain; it represses gene expression by interfering with the function of transcription factors and co-activators required for basal gene expression.14 In the case of CYP7A1, these factors include liver receptor homologue1 (LRH1, also known as NR5A2), hepatocyte nuclear factor4- (HNF4, also known as NR2A1) and peroxisome proliferator-activated receptor co-activator 1 (PGC1). FXR was reported to be expressed in hepatic stellate cells, explaining the anti-fibrotic action of FXR agonists in rat models of liver fibrosis.51 However, Fickert etal.32 have cast doubt on this concept; they found rather low levels of FXR expression in human and mouse hepatic stellate cells and portal myofibroblasts. Moreover, models of biliary typefibrosis in Fxr/ mice showed less fibrosis than wildtype mice, and absence of Fxr had no effect in traditional models of liver fibrosis.32 Fxr/ mice have a high incidence of hepatocellular carcinoma (HCC) and other degenerative features in the liver.52 Two studies have shown that Fxr controls the expression of tumour suppressor genes. In one study, a direct effect of Fxr on Ndrg2 (N-myc downstream-regulated gene2) mRNA expression was shown and the other study reported that Fxr reduces gankyrin expression53,54 (this oncoprotein is a proteasomal subunit that has a role in the degradation of anumber of tumour suppressor proteins). In agreement with a role for Fxr in hepatocarcinogenesis, it was shown that nonsteroidal Fxr agonists reduce tumour size in a mouse xenograft model.53 Bile acid homeostatic actions of Fxr in the small intestine include buffering of intracellular bile acid levels
2013 Macmillan Publishers Limited. All rights reserved Cholesterol Primary bile acids (e.g. CDCA)
FXR agonist
Hepatocyte FXR CYP7A1
Bile canalicus CDCA NTCP CDCA BSEP

Bile acid synthesis Lipogenesis Gluconeogenesis Regeneration
FGFR4 FGF19
Ileal epithelial cell OST/ CDCA FXR FGF19
ASBT CDCA FXR agonist
CDCA
FXR agonist
Figure 1 | Enterohepatic actions of FXR. Bile acids (exemplified as the primary bileacid CDCA) are produced in the liver by CYP7A1-initiated conversion of cholesterolin primary bile acids. Bile salts are secreted via BSEP into the canalicular lumen. Inthe ileum, bile salts are reabsorbed via ASBT in terminal ileum enterocytes. Here, they bind and activate FXR and this stimulates the transcription of FGF19, which encodes a protein that is secreted into the portal circulation. In the liver, FGF19 binds to its receptor FGFR4, which activates a signalling pathway involving MAP kinases and causes repression of CYP7A1, thus downregulating bile acid synthesis. After OST/mediated secretion into the portal circulation, bile acids are taken up by the liver via NTCP , thus, completing theenterohepatic cycle. In the liver, bile acids bind to FXR, which transcriptionally upregulates a protein called SHP (not shown) that interferes with expression of CYP7A1. Oral FXR agonists will affect FXR in both liver and intestine and this strongly downregulates CYP7A1 both by FGF19-dependent and FGF19independent effects. FGF19 additionally affects lipogenesis, gluconeogenesis and liver regeneration. Abbreviations: ASBT, apical sodium-dependent bile salt transporter; BSEP , bile salt export pump; CDCA, chenodeoxycholic acid; CYP7A1, cholesterol 7-monooxygenase; FGF19, fibroblast growth factor19; FGFR4, fibroblast growth factor receptor4; FXR, farnesoid X receptor; NTCP , Na+-taurocholate cotransporting polypeptide; OST, organic solute transporter; SHP , small heterodimer partner.
(through upregulation of intestinal bile acid protein, Ibabp), and feedback inhibition of hepatic bile acid synthesis via induction of the secreted enterokine FGF19 (or Fgf15 in rodents).16 Fxr also has an important role in maintaining intestinal barrier integrity and antibacterial defence; the underlying mechanisms are poorly understood and seem to include induction of antibacterial p roteins such as angiogenin.19 Some of the effects of FXR are mediated by the enterokine FGF19 (Figure1). FGF19 is an unusual member of the FGF family in being secreted into the (portal) circulation and having an endocrine mode of action. Ileal bile acid uptake induces FGF19 (Fgf15 in rodents) expression via FXR-mediated transcriptional induction.16 In addition, LCA might induce intestinal FGF19 expression via PXR-dependent and VDR-dependent pathways. 55,56 In humans, systemic FGF19 levels peak 34h after a fatty meal.57 After portal delivery, FGF19 signals in the liver via hepatocytic FGF receptor4 (FGFR4) and possibly
REVIEWS
Table 1 | Bile acid receptors and targets of action Receptor
FXR (NR1H4)
Cytogenetic location
12q23.1
Exemplary ligands
Bile acids: (un)conjugated CDCA>DCA>LCA>CA159 Bile acid analogues: 6-ethyl-CDCA (INT747),111 6-ethyl3,7,23-trihydroxy24-nor5-cholan23-sulphate (INT767)113 Nonsteroidal ligands: GW4064, fexaramine, GSK2324, Way362450, PX102160164
Affected pathways and/or processes

Bile acid synthesis14,16 50 Bile acid export 49 Bile formation 48 PhaseI/II metabolism Lipogenesis46 Gluconeogenesis46 52,53 Tumour suppression Liver regeneration165 Liver inflammation166 Liver fibrosis32,51 Intestinal barrier function19 Glucose homeostasis80 82 Energy expenditure Gallbladder relaxation84 Anti-inflammatory77 Bile acid synthesis96 94 PhaseI/II metabolism 93,94 PhaseIII efflux 94,98 Lipogenesis Gluconeogenesis94 Anti-inflammatory94,95 Bile salt synthesis56,101 24 PhaseI metabolism Ca2+,phosphatehomeostasis100 Bone mineralization100 Antimicrobial defence105 PhaseI/II metabolism 45,106110 PhaseIII efflux 93 Lipogenesis 173 Gluconeogenesis 109,173
Target tissues
Liver, intestine, kidney
Target disease
Cholestatic liver disease, NASH, T2DM, HCC, IBD
TGR5
2q35
Bile acids: (un)conjugated LCA>DCA>CDCA>CA,26,27102 Bile acid analogues: INT767, 6-ethyl23(S)-methyl3,7,12trihydroxy5-cholan24-oic acid (INT777)112,113 Xenobiotic ligands: oleanolic acid75 Bile acids: LCA, 3keto-LCA>>CDCA, DCA, CA167 Other steroidal ligands: pregnenolone, progesterone Xenobiotic ligands: herbal medicine107 (e.g. hyperforin, guggulsterone), drugs (e.g. rifampicin, paclitaxel, lovastin)168,169
Liver, intestine, gallbladder, muscle, brain Liver, intestine
T2DM, NASH
PXR (NR1I2)
3q13.33
Cholestatic liver disease,pruritus, IBD
VDR (NR1I1)
12q13.11
Bile acids: (un)conjugated LCA, 3keto-LCA24,102 Non-bile acid ligands: vitamin D3 (calcitriol) and synthetic analogues (e.g. 2MbisP , BXL010772)170 Nonsteroidal ligands: LY2108491, LY2109886171 Bile acids: CA, 6keto-LCA, 12-keto-LCA108,172 Xenobiotic ligands: CITCO, TCPOBOP , herbal medicine (e.g.6,7-dimethylesculetin), drugs (e.g. phenobarbital)107
Intestine, kidney, bone
Osteoporosis
CAR (NR1I3)
1q23.3
Liver
Cholestatic liver disease, pruritus
Abbreviations: >, higher affinity than; >>, much higher affinity than; , decreased activity; , increased activity; 2MBisP, 2-methylene-19-nor-(20S)-1-hydroxy-bishomopregnacalciferol; CA, cholic acid; CDCA, chenodeoxycholic acid; CITCO, 6(4-Chlorophenyl)imidazo[2,1b][1,3]thiazole5-carbaldehyde O(3,4-dichlorobenzyl)oxime; DCA, deoxycholic acid; HCC, hepatocellular carcinoma; LCA, lithocholic acid; T2DM, type2 diabetes mellitus; TCPOBOP, 1,4-Bis[2(3,5-dichloropyridyloxy)]benzene, 3,3',5,5'-Tetrachloro1,4-bis(pyridyloxy)benzene.
FGFR1c. Physiological FGF19 signalling requires the presence of Klotho, a membrane protein expressed in the liver and white adipose tissue, whose exact function in FGFR-mediated FGF19 signalling is being explored.58,59 FGF19-responsive receptors FGFR4 and FGFR1c are receptor tyrosine kinases that exert their effects on target gene expression via activation of signalling cascades including the mitogen-activated protein kinase pathway.59 FGF19 regulates bile acid synthesis via downregulation of CYP7A1 expression in a SHP-dependent way.60 As hepatic FXR can directly downregulate CYP7A1 expression via the induction of SHP, this mechanism seems redundant. However, tissue-specific Fxr-knockout models have shown that under normal conditions the intestinal FxrFgf15 axis is more important for downregulation of hepatic Cyp7a1 than hepatic FxrShp in mice.61 Apart from its role in bile acid homeostasis, postprandial actions of FGF19 include inhibition of gluconeogenesis and stimulation of glycogen synthesis.62 These metabolic actions resemble that of insulin with a notable exception that FGF19 does not stimulate hepatic lipogenesis.63 FGF19 reduces key enzymes and regulators of hepatic lipid synthesis.64 Studies using Fgf15/ mice revealed that Fgf15 is involved in gallbladder relaxation. Human FGF19 can take over this function in Fgf15/ mice.65 Whether FGF19 is also involved in relaxation of the human gallbladder is currently unknown. Evidence indicates that FGF19 has
anti-inflammatory actions66 and has a role in liver regeneration.67 Human, but not mouse, bile contains substantial amounts of FGF19, produced in the biliary tree and in the gall bladder;68 its presence in bile might provide a ntiinflammatory protection to the bile ducts. FGF19 and FGF19-inducing drugs have potential for a number of therapeutic applications. However, FGF19 transgenic mice develop HCC.69 Although this finding could be because of supraphysiological circulating levels, FGF19 might be procarcinogenic.70 This undesired activity can be eliminated by replacement of a 7amino-acid stretch that comprises an FGFR4 interaction domain. This engineered variant retains the metabolic functions of FGF19, but is devoid of mitogenic activity.71
Transmembrane Gprotein-coupled receptor TGR5 is highly expressed in the gallbladder and bile duct epithelial cells, brown adipose tissue, muscle, intestine, kidney, placenta and brain (Figure2). In the liver, TGR5 is expressed in sinusoidal endothelial cells, bile duct epithelial cells and Kupffer cells, but not in hepatocytes.7274 LCA is the strongest natural agonist of TGR5, but TGR5 also responds to (un)conjugated deoxycholic acid, CDCA, UDCA and cholic acid26,27 (Table1). Oleanolic acid from olive tree leaves is a nonsteroidal selective TGR5 agonist,75 whereas INT77776 (6-ethyl23(S)-methyl-CDCA) is a semi-synthetic TGR5 agonist (Figure3).
REVIEWS
Ligand binding to TGR5 results in stimulation of a denylate cyclase, with elevation of cAMP levels, triggering subsequent activation of protein kinaseA and further downstream signalling events.77 In lipopolysaccharidestimulated mouse macrophages, activation of Tgr5 has antiinflammatory effects by inhibiting nuclear translocation of nuclear factorB, thereby reducing production of pro inflammatory cytokines and mediators such as Tnf, Il1, Il6, Ifn- and inducible nitric oxide synthase.78,79 INT777 reduced inflammation and lipid-loading of plaque macrophages in mice.78 Activation of Tgr5 in enteroendocrine cells leads to secretion of glucagon-like peptide 1 (GLP1).80,81 This incretin improves pancreas function, insulin secretion and insulin sensitivity (Figure2). Tgr5 in muscle and brown adipose tissue has a role in energy homeostasis via activation of cAMP-dependent iodothyronine deiodinase2, an enzyme that converts inactive thyroxine (T4) into active thyroid hormone (T3).82 Thus, activation of Tgr5 in these tissues leads to an increase in energy expenditure and oxygen consumption. This action probably underlies the prevention of obesity, hepatic steatosis and improvement of insulin sensitivity in mice on a high-fat diet supplemented with either bile acid or INT777.81,82 Elevation of systemic bile acid levels in cholestatic disorders or after Roux-enY gastric bypass surgery in humans83 can be expected to result in metabolic effects through activation of TGR5. Moreover, stimulation of Tgr5 in sinusoidal endothelial cells can result in nitric oxide production, which might affect the haemodynamics of sinusoidal perfusion.74 In the biliary tree, activation of Tgr5 causes gallbladder relaxation and activates the chloride channel CFTR and enhances secretion of bicarbonate.72,84 By increasing the pH of bile, a higher proportion of bile acids will be in theionized form, which reduces their ability to diffuse into the biliary epithelium. This process protects bile duct e pithelium against the detergent effect of bile acids.85
T4 DIO2 T3 Brown adipose tissue T4 DIO2 T3 Muscle
cAMP TGR5 TGR5
cAMP
TGR5 agonists LPS Cytokines TGR5 cAMP cAMP TGR5 Insulin secretion Insulin sensitivity GLP-1
Kupffer cell
Enteroendocrine cells in intestine
Energy expenditure Insulin secretion and/or sensitivity Inflammation
Figure 2 | TGR5-expressing tissues and targets. TGR5 signalling in skeletal muscle and brown adipose tissue results in local activation of the deiodinase DIO2 that generates active thyroid hormone (T3), an important regulator of metabolism and energy homeostasis. Bile acids in the intestinal lumen activate TGR5 in enteroendocrine cells, resulting in release of the incretin GLP1. In Kupffer cells and macrophages, TGR5 activation inhibits LPS-induced cytokine production. Abbreviations: DIO2, type II iodothyronine deiodinase; GLP1, glucagon-like peptide 1; LPS, lipopolysaccharide; T3, active thyroid hormone; T4, inactive thyroxine; TGR5, transmembrane G protein-coupled receptor TGR5 (also known as GPBAR1).
Pregnane X receptor In mice, Pxr (also referred to as the steroid and xeno biotic receptor in humans) is highly expressed throughout the gastrointestinal tract and to a lesser extent in the kidneys.30,8689 In humans, PXR is expressed in liver, gastrointestinal tract and brain.90 In mouse liver, Pxr is expressed primarily in parenchymal cells.31 The main, if not only, bile acid ligand of PXR is LCA and its oxidized 3keto form. LCA is a cytotoxic bile acid formed mainly by bacterial deconjugation and 7-dehydroxylation of conjugated CDCA, and is passively absorbed in the colon where it is considered pro-oncogenic.91 LCA induces experimental cholestasis that results in extensive liver damage. PXR serves as a xenobiotic sensor, and induces phaseI and II metabolism of many endogenous and exogenous compounds, including bile acids.92 PXR-mediated detoxification of LCA includes 6-hydroxylation by members of the CYP3A subfamily and sulphation by the bile acid sulphotransferase SULT2A1. Apart from (3-keto) LCA, a great number of prescription drugs qualify as PXR a gonists with rifampicin on top of the list (Table1). PXR binds as a heterodimer with RXR to response elements in the promoter region of target genes, which
include phaseI metabolizing mono-oxygenases of the cytochrome P450 family (for example, CYP1A, CYP2B, CYP2C, CYP3A members), phaseII conjugating enzymes (for example, UDP-glucuronosyltransferases, glutathione Stransferases and sulphotransferases), and phaseIII efflux pumps (for example, canalicular multi specific organic anion transporter 1 [ABCC2], also known as multidrug resistance-associated protein2). ABCC2 is a multispecific organic anion transporter that mediates canalicular secretion of glucuronidated substrates including bilirubin and divalent bile salts; its expression is affected not only by PXR, but also by FXR and CAR.93 Besides its role in drug metabolism, PXR has additional functions in bile acid, lipid and glucose metabolism, endocrine homeostasis, androgen metabolism, bone mineral homeostasis, vitaminD metabolism and immuno suppression, as well as having an anti-inflammator y action.94,95 Treatment with the PXR agonist rifampicin results in downregulation of CYP7A1 expression, which seems to result from binding of PXR to HNF4, thereby displacing PGC1 and interfering withHNF4 PGC1-stimulated CYP7A1 transcription.96 This SHPindependent pathway of CYP7A1 suppression causes downregulation of bile acid synthesis.
REVIEWS
FXR agonists CO2H O Cl HO OH Intercept INT-747 Obeticholic acid TGR5 agonists (S) CO2H HN HO O Cl Phenex PX-102 (PX20606) O NH CH2 HO OH Intercept INT-777 S O O HO 6-methyl-2-oxo-4-thiophen-2yl-1,2,3,4-tetrahydro-pyrimidine-5carboxylic acid benzyl ester Oleanolic acid CO2H O N Cl NH O N O
F F
O Pfizer WAY-362450 (FXR450, XL335)
Figure 3 | Steroidal and nonsteroidal agonists of FXR and TGR5. The semi-synthetic bile acid obeticholic acid (6-ethyl-CDCA, INT747) and non-steroidal compounds PX102 and WAY362450 are potent FXR agonists. Side-chain modification (for example, addition of a methyl group) turns obeticholic acid into the potent and selective TGR5 agonist INT777. Oleanolic acid is a naturally occurring TGR5 agonist found in olive tree leaves. Abbreviations: FXR, farnesoid X receptor; TGR5, transmembrane G protein-coupled receptor TGR5 (also known as GPBAR1).
In general, PXR activation has a protective effect by enhancing drug metabolism and suppressing bile acid synthesis. These are favourable actions of PXR agonists. PXR agonists might therefore have value in the treatment of chronic inflammatory diseases of liver and bowel.95,97 However, Pxr activation leads to hepatic stea tosis in mice,98 and enhanced drug metabolism might cause unwanted drugdrug interactions in patients who are dependent on more than one drug. This interaction could be harmful in patients with NASH and patients on anti-coagulants, chemotherapeutics or HIV inhibitors. Additional undesirable effects of PXR activation include osteoporosis, disturbances of the glucocorticoid and mineralocorticoid balance, disturbances of androgen metabolism and enhanced breakdown of vitamins.99
in caveolin domains at the cell membrane where it serves as a receptor. The genomic action is fairly slow (hours) and includes downregulation of CYP7A1 expression and induction of CYP3A4 expression, an enzyme that detoxifies LCA.24,101,104 By contrast, the response initiated at the membrane is rapid (minutes) and results in activation of signalling cascades that, in the liver, contribute to CYP7A1 repression. In the bile duct epithelium, VDR (together with FXR) has been shown to stimulate production of antimicrobial proteins such as cathelicidin, which might add to the immunomodulatory function of vitaminD.105 Activation of Vdr by intraperitoneal injections of vitaminD3 in mice causes induction of Fgf15 and repression of Cyp7a1.56
VitaminD receptor VDR is widely expressed in human tissues such as the intestine and kidneys, as well as in pancreatic cells,osteoblasts, adipocytes, vascular smooth muscle cells, monocytes and immune-competent cells.100 Evidence indicates that VDR is also expressed in human (but not mice) hepatocytes.31,101 VDR has a central role in mineral and bone homeostasis, and is engaged in control of cellular growth and differentiation.100 Calcitriol (1,25-dihydroxyvitaminD3), a steroid-like molecule with a disrupted steroid nucleus, and the bile acid LCA (but not CDCA and cholic acid) are endogenous VDR ligands (Table1).102 Activation of VDR by pro-oncogenic LCA is achieved at concentrations lower than required to activate PXR.102 A special feature of VDR is its function as both an intracellular nuclear receptor and membrane receptor.103 Upon ligand binding, VDR moves to the nucleus where it binds to DNA response elements to modulate gene transcription. In addition, unliganded VDR resides
Constitutive androstane receptor As with its closest relative PXR, CAR is expressed mainly in the liver and gastrointestinal tract. Here, CAR actsin concert with PXR to detoxify and eliminate endogenous (for example, LCA, bilirubin) and foreign compounds.23,92,106 In line with this function, CAR binds a broad variety of structurally diverse molecules such as certain bile acids (for example, cholic acid and 6keto-LCA), drugs including the prototypical CAR activator phenobarbital as well as herbal medicines107 (Table1). Activation of CAR results in its nuclear trans location, a process that does not necessarily require interaction between ligand and the ligand-binding domain. Indeed, phenobarbital is a potent activator of CAR target gene expression yet does not bind to its ligand-binding domain.108 CAR forms a heterodimer with RXR and binds to retinoic-acid-response elements of target genes. Reflected in its name, CAR is unusual among NHRs in functioning as an transcriptional activator in the absence of ligand, which has been attributed to ligandindependent recruitment of transcriptional co-activators,
REVIEWS
with agonists (for example, TCPOBOP) promoting coactivator recruitment and CAR transactivation, and inverse agonists (for example, androstanol) inhibiting the constitutive activity of CAR by blocking co-activato r recruitment. CAR-binding bile acids seem to act as inverse agonists that repress CAR activity.108 CAR targets include genes encoding proteins involved in phaseI and II drug metabolism (for example, CYP2B monooxygenases, UDP-glucuronosyltransferases and sulpho transferases) and elimination (MRP2 and MRP3). As with PXR, CAR not only targets the metabolism of xenobiotics, but also regulates lipid and glucose metabolism.109 Studies with Pxr/Car double knockout mice revealed that Pxr and Car cooperate in the detoxification of LCA.106,110 Fxr expression is decreased in Car/ mice, suggesting i nteraction between Car and Fxr.45 another study showed that FXR activation induces hepatic expression of a flavin-containing monooxygenase (that is, FMO3) that converts the choline metabolite trimethylamine into atherogenic trimethylamine Noxide.121 How these seemingly disparate findings in mice could lead to useful drug therapy in humans requires further study. Synthetic FXR and TGR5 agonists have been developed to serve as next-generation drugs for the treatment of metabolic diseases and cholestatic liver disease (Figure3).37,76,122,123 Of note, these drugs undergo enterohepatic cycling and will be most effective in liver and intestine. Apical sodium-dependent bile salt transporter (ASBT, also known as ileal sodium/bile acid cotransporteror SLC10A2) inhibitors and bile salt sequestrants (discussed later) are developed as possible drugs for treatment of hypercholesterolaemia, cholestatic liver disease and T2DM.124 In addition, colestyramine, originally developed for treatment of hypercholesterolaemia, improves insulin sensitivity and causes weight loss; as such, colesty ramine, colesevalam and other sequestrants are being reinvestigate d for treatment of T2DM.125
Bile acid receptors as drug targets

The dedicated bile acid receptors FXR and TGR5 have been prime targets for drug development. Obeticholic acid (6-ethyl-chenodeoxycholic acid, also known as INT747 or OCA), INT777 (6-ethyl23(S)-methyl-cholic acid) and INT767 (the 23-sulphate derivative of obeticholic acid) are agonists of FXR, TGR5 and both FXR and TGR5, respectively (Figure3).111113 Development of these agonists has been greatly stimulated by the elucidation of the 3D structure of the ligand-binding domains of FXR and TGR5. FXR agonists have to fit into a tight pocket in the ligandbinding domain, for binding to TGR5 both the steroid nucleus and side-chain structure are important molecular features.111,112 Side-chain modification (for example, methylation or sulphation) turns bile acid derivatives into TGR5 agonists. In Mdr2/ mice with extensive chronic cholangiopathy, the mixed FxrTgr5 agonist INT767 led to stronger improvement of liver injury parameters than obeticholic acid or INT777 alone.114 FXR agonists have considerable therapeutic potential. Obeticholic acid is currently being investigated in phaseIII and phaseII trials in patients with PBC and NASH, respectively. 111,115 Synthetic FXR agonists include fexaramine, PX102, GSK2324 and WAY362450 (Figure3). Synthetic FXR agonists are in phaseI and phaseII of drug development.37 In view of the pleiotropic spectrum of FXR actions, unexpected effects and off-target effects might occur, which could complicate drug development. For instance, FXR agonists cause elevation of circulating FGF19 levels. FGF19 transgenic mice develop HCC.69 The question therefore arises as to what the effect would be of chronic treatment with FXR agonists and persistent elevation of FGF19. Currently, no answer is available, and the role ofFGF19 in human tumorigenesis is unresolved. For application of FXR agonists in atherosclerosis, the picture is not entirely clear either. The potent FXR a gonists obeticholic acid and WAY362450 both reduced aortic plaque formation in Apoe/ mice on a high-fat diet.116,117 By contrast, the FXR antagonist guggulsterone decreased hepatic cholesterol in wild-type mice and Fxr deficiency reduced atherosclerosis in Ldlr/ and Apoe/ mice. In both studies, mice were fed a high-fat diet.118120 Furthermore,
UDCA and bile salt sequestrants

Although UDCA is not an FXR agonist and only a weak PXR agonist, it has a number of actions that contribute to UDCA being a drug for the treatment of PBC and intrahepatic cholestasis of pregnancy.126 UDCA stimulates bile flow by virtue of its own biliary secretion, by stimulating biliary bicarbonate secretion, and by promoting insertion of transporter proteins into the canalicular membrane.127129 In a study published in 2013, Gohlke etal.130 showed that 51 integrin functions as an intracellular sensor for tauroUDCA and might be involved in the latter process. Whether this activity is maintained in the cholestatic liver, and to what extent previously reported actions of UDCA as Ca2+ agonist and activator of protein kinase C also has a role in stimulating hepatocyte secretion in the cholestatic liver, needs to be studied.127,131 Reabsorption of (de)conjugated bile acids in the terminal ileum occurs mainly via ASBT (or SLC10A2) (Figure1).132 Via this transporter ~90% of luminal bile acids are reclaimed. Inhibition of bile acid transport in the ileum will lead to spillover of bile acids into the colon where at high concentrations (millimolar range) they stimulate chloride and water secretion and cause bile acid diarrhoea.133 Bile acids, brought into the colon by nonabsorbable anion exchange resins, activate Tgr5 in enteroendocrine Lcells leading to release of the incretin Glp1.134 Against this background, inhibition of bile salt reabsorption by anion exchange resins or ASBT inhibitors might be considered as a possible therapy for T2DM.134,135 Moreover, the ASBT inhibitor SC435 decreased LDL-cholesterol and reduced atherosclerosis in Apoe/ mice, indicating that these inhibitors have potential in the treatment of hypercholesterolaemia.136 Inhibition of bile salt reabsorption decreases the circulating bile salt pool, reduces FGF19 levels, increases the conversion of cholesterol into bile acids and reduces serum cholesterol levels.137 Similar effects on serum glucose and serum LDL-cholesterol levels can be achieved with the bile acid sequestrant colesevalam, an anion exchange
REVIEWS
Pancreas Insulin Hyperglycaemia Diet Fatty liver FFA Muscle Adipocytes FFA FGFR4 ROS ATP Intestine GLP-1 FGF19 Kupffer cell LPS Microbiome OxLDL Inflammation Liver Stellate cell TNF, IL-1, chemokines Fibrosis FFA AMPK SREBP-1 Triglycerides Oxidative stress TGF- VLDL Apoptosis FXR agonist TGR5 agonist
Figure 4 | Potential targets of FXR and TGR5 agonists in NASH. NASH is characterized by hepatic fat accumulation with concurrent inflammation and fibrosis. Steatosis is the result of ongoing lipogenesis, in the face of elevated influx of fatty acids derived from adipocyte lipolysis and impaired VLDL-lipid export. Inflammation can arise from compromised gut barrier function, lipotoxic effects of adipocyte-derived fatty acids and modified lipoproteins such as oxLDL. Inflammatory stimuli result in activation of resident Kupffer cells and release of inflammatory factors that recruit immune cells and initiate fibrogenesis through activation of stellate cells. NASH can progress through fibrotic and cirrhotic stages to hepatocellular carcinoma. Possible sites of action of FXR (blue) and TGR5 (green) agonists are indicated by arrows, and are discussed inmore detail in the main text. Abbreviations: FFA, free fatty acid; FGF19, fibroblast growth factor19; FXR, farnesoid X receptor; GLP-1, glucagon-like peptide1; LPS, lipopolysaccharide; oxLDL, oxidized LDL; ROS, reactive oxygen species; SREBP-1, sterol regulatory element-binding protein1; TGR5, transmembrane G protein-coupled receptor TGR5 (also known as GPBAR1); VLDL, very low density lipoprotein.
resin that is used for treatment of bile acid diarrhoea, h ypercholesterolaemia and T2DM.138,139
Candidate diseases
Most studies on the effect of FXR and TGR5 agonists have been done in mouse models of human disease. Randomized trials in humans are still in their infancy. The first human trials focus on the efficacy of obeticholic acid in PBC (phaseIII, NCT01473524) and NASH (phaseII, FLINT trial, NCT01265498).140,141 Endpoints of these studies are decreased alkaline phosphatase levels after 6 and 12months in PBC,140 and improvement of histological score after 72weeks treatment in NASH.141 A phaseII trial on the effect of the addition of obeticholic acid to UDCA that was completed in 2012, revealed a ~22% decrease of alkaline phosphatase levels after 12weeks in the obeticholic acid group (NCT00550862).142 The rationale of the PBC studies is that bile acid toxicity contributes to the symptomatology of this cholestatic disorder. In addition, bile acid toxicity causes necrosis and apoptosis of resident hepatocytes and leads to inflammation, fibrosis, cirrhosis and HCC. However, severe c holestasis leads to an adaptive response by endogenous FXR activation.143 Thus, questions arise on what would be the best disease phase for optimal use of FXR agonists; they will probably work best in moderate cholestasis when endogenous FXR activation is suboptimal. FXRagonists
are strong repressors of denovo bile acid synthesis. This aspect is particularly important when bile flow is obstructed. In this setting, input of extra bile acid into the biliary space would cause bile acid overload and bile-acidmediated necrosis and apoptosis.144 Pruritus has been noted as an adverse effect of obeti cholic acid in the treatment of PBC;145 a potential drawback for the use of the drug in PBC as pruritus is already a cumbersome symptom in baseline PBC. Cholestatic p r uritus has long been attributed to bile acids, but studies indicate that lysophosphatidic acid produced by the enzyme autotaxin might be the responsible pruritogen.146,147 However, this issue has not been settled yet as bile acids might still have a role. In a study published in 2013, bile acids and TGR5 have been implicated in the development of cholestatic pruritus.148 Highly selective FXR agonists, without any activity against TGR5, might therefore be better c andidates for the treatment of PBC. As a result of their anti-inflammatory and antifibrotic properties, FXR agonists are candidate drugs for treatment of primary sclerosing cholangitis, a disease p r imarily affecting the large intrahepatic and extra hepatic bile ducts and giving rise to biliary fibrosis of the liver. FXR agonists have anti-inflammatory effects in the inflamed colon of mouse models of IBD.149 80% of patients with primary sclerosing cholangitis also have ulcerative colitis or Crohns disease and there are good
REVIEWS
arguments for an aetiological role of an impaired intestinal integrity in the pathogenesis of primary sclerosing cholangitis.150 Drugs that target both diseases (primary sclerosing cholangitis and IBD) are therefore particularly attractive. However, it should be realized that FXR agonists are stimulators of bile flow and caution is needed in using these drugs in patients with severely damaged extrahepatic bile ducts as seen in primary sclerosing cholangitis. Moreover, Fickert etal.32 reported that loss of Fxr in mouse models of biliary fibrosis decreased fibrosis. How this translates to humans needs to be studied. Other indications for FXR-agonist-mediated repression of bile acid synthesis include inborn errors of bile acid synthesis, progressive familial intrahepatic cholestasis (in particular type1 and 3) and cholestasis of pregnancy. Increased bile acid synthesis, with spillover of bile acids into the colon, might have a role in bile-acid-induced diarrhoea and perhaps also in IBS; conversely, impaired bile acid excretion has been linked to constipation.151 In view of the actions of FXR and TGR5 on lipid and glucose metabolism, FXR and/or TGR5 agonists are candidate drugs for the treatment of NASH, hyper cholesterolaemia, hypertriglyceridaemia and T2DM. The action of FXR and TGR5 agonists in NASH is shown in Figure4. A phaseII trial of obeticholic acid, administered in two different doses (25 and 50mg per day) during 6weeks to patients with NAFLD and T2DM, showed an increase in insulin sensitivity, a decrease in levels of glutamyltransferase and alanine aminotransferase, and dose-dependent weightloss.152 An interesting application of FXR agonists might be in the treatment of diabetic renal disease. Fxr deficiency leads to acceleration of diabetic nephropathy in a mouse model for type1 diabetes, and obeticholic acid improved proteinuria and podocyte function and decreased renal tubulointerstitial fibrosis and inflammation.153 Testing FXR agonists in diabetic nephropathy would therefore be of interest. In addition, FXR agonists have potential for the prevention and treatment of HCC, atherosclerosis, (bile) reflux oesophagitis, IBD and colon carcinoma. Bariatric surgery, in particular Roux-enY gastric bypass surgery provides an interesting example of the actions of FXR, TGR5 and VDR in the intestine (Figure5). After this procedure, digestive juices and food mix late in the small intestine. Thus, limited spillover of bile acids into the colon occurs, where bile acids activate TGR5 and VDR resulting in secretion of GLP1 and, possibly, FGF19. GLP1 will improve insulin sensitivity and secretion and FGF19 might reduce hepatic steatosis by inhibiting lipogenesis. Weight reduction is obtained mainly by incomplete absorption of nutrients in the small intestine. In line with this model, GLP1 and FGF19 levels are increased after Roux-enY gastric bypass surgery,83,154 which makes this procedure a plausible treatment for NASH in patients with major overweight. After an episode of bile duct obstruction, owing to sepsis, liver surgery or drug exposure, it might take days to weeks before the jaundice improves. The term severe persistent hepatocellular secretory failure has been introduced for this situation. A short treatment with the
2013 Macmillan Publishers Limited. All rights reserved Bile acid Nutrients Liver Insulin sensitivity Lipogenesis Gluconeogenesis
Alimentary loop
FGFR4
Bilio-pancreatic loop
FGF19 FGF19? VDR GLP-1 TGR5 FXR
Figure 5 | Bile acid receptor activation after Roux-enY gastric bypass surgery. After Roux-enY gastric bypass surgery, partially digested food (red filled circles) and bile acids (green filled circles) mix at a distal site in the small intestine. Because of incomplete admixture of chyme and bilepancreatic juice, bile acids spill into the large intestine where they activate TGR5 and VDR. As a result, secreted factors are produced that signal to the liver (FGF19) and pancreas (GLP1) to reduce hepatic lipogenesis and improve insulin sensitivity and insulin secretion. Abbreviations: FGF19, fibroblast growth factor 19; FXR, farnesoid X receptor; GLP1, glucagon-like peptide 1; TGR5, transmembrane G protein-coupled receptor TGR5 (also known as GPBAR1); VDR, vitaminD receptor.
PXR agonist rifampicin greatly shortened the time to recovery.155 Moreover, PXR and CAR agonists have been widely used in the treatment of unconjugated hyperbilirubinaemia as occurring in Gilbert syndrome and type2 CriglerNajjarsyndrome.156158
Conclusions
The endocrine-like signalling function of bile acids and insight into the 3D structure of bile acid receptors have given momentum to a new field of pharmacology with the promise of new drugs for difficult-to-treat metabolic and liver disorders. Some of these new drugs are already the subject of randomized controlled trials. New mol ecules are in the pipeline and these factors might undergo clinical testing in the near future. Many of the concepts discussed in this Review are based on invitro studies and work with knockout mice. The bridge from basic studies to clinical medicine still needs to be crossed.
Review criteria
This Review is based on a PubMed search of relevant topics without time constraints. Key references are cited for original data. This Review is obviously a selection of available literature and we apologize for not citing other relevant work. For more general statements we cite reviews published in high-impact, peer-reviewed journals. This Review is not meant to be a systematic review.
REVIEWS
1. Hagey, L.R. etal. Ursodeoxycholic acid in the Ursidae: biliary bile acids of bears, pandas, and related carnivores. J. Lipid Res. 34, 19111917 (1993). Maton, P .N., Murphy, G.M. & Dowling, R.H. Ursodeoxycholic acid treatment of gallstones. Dose-response study and possible mechanism of action. Lancet 2, 12971301 (1977). Poupon, R. etal. Is ursodeoxycholic acid an effective treatment for primary biliary cirrhosis? Lancet 1, 834836 (1987). Salen, G., Meriwether, T.W. & Nicolau, G. Chenodeoxycholic acid inhibits increased cholesterol and cholestanol synthesis in patients with cerebrotendinous xanthomatosis. Biochem. Med. 14, 5774 (1975). Hench, P .S. Effect of jaundice on rheumatoid arthritis. Br. Med. J. 2, 394398 (1938). Russell, D.W. The enzymes, regulation, and genetics of bile acid synthesis. Annu. Rev. Biochem. 72, 137174 (2003). Ridlon, J.M., Kang, D.J. & Hylemon, P .B. Bile salt biotransformations by human intestinal bacteria. J. Lipid Res. 47, 241259 (2006). Dawson, P .A., Lan, T. & Rao, A. Bile acid transporters. J. Lipid Res. 50, 23402357 (2009). Hofmann, A.F. Biliary secretion and excretion inhealth and disease: current concepts. Ann.Hepatol. 6, 1527 (2007). Borgstrom, B., Dahlqvist, A., Lundh, G. &Sjovall,J. Studies of intestinal digestion and absorption in the human. J. Clin. Invest. 36, 15211536 (1957). Forman, B.M. etal. Identification of a nuclear receptor that is activated by farnesol metabolites. Cell 81, 687693 (1995). Seol, W., Choi, H.S. & Moore, D.D. Isolation ofproteins that interact specifically with the retinoid X receptor: two novel orphan receptors. Mol. Endocrinol. 9, 7285 (1995). Shefer, S., Hauser, S., Bekersky, I. &Mosbach,E.H. Feedback regulation of bile acid biosynthesis in the rat. J. Lipid Res. 10, 646655 (1969). Goodwin, B. etal. A regulatory cascade of the nuclear receptors FXR, SHP1, and LRH1 represses bile acid biosynthesis. Mol. Cell 6, 517526 (2000). Seol, W., Choi, H.S. & Moore, D.D. An orphan nuclear hormone receptor that lacks a DNA binding domain and heterodimerizes with other receptors. Science 272, 13361339 (1996). Inagaki, T. etal. Fibroblast growth factor 15 functions as an enterohepatic signal to regulate bile acid homeostasis. Cell. Metab. 2, 217225 (2005). Houten, S.M., Watanabe, M. & Auwerx, J. Endocrine functions of bile acids. EMBO J. 25, 14191425 (2006). Huang, W. etal. Nuclear receptor-dependent bile acid signaling is required for normal liver regeneration. Science 312, 233236 (2006). Inagaki, T. etal. Regulation of antibacterial defense in the small intestine by the nuclear bile acid receptor. Proc. Natl Acad. Sci. USA 103, 39203925 (2006). Alemi, F. etal. The receptor TGR5 mediates the prokinetic actions of intestinal bile acids and isrequired for normal defecation in mice. Gastroenterology 144, 145154 (2013). Higuchi, H., Grambihler, A., Canbay, A., Bronk,S.F. & Gores, G.J. Bile acids up-regulate death receptor 5/TRAIL-receptor 2 expression via a cJun N.terminal kinase-dependent pathway involving Sp1. J. Biol. Chem. 279, 5160 (2004). Allen, K., Jaeschke, H. & Copple, B.L. Bile acidsinduce inflammatory genes in hepatocytes: a novel mechanism of inflammation during obstructive cholestasis. Am. J. Pathol. 178, 175186 (2011). Baes, M. etal. A new orphan member of the nuclear hormone receptor superfamily that interacts with a subset of retinoic acid response elements. Mol. Cell Biol. 14, 15441552 (1994). Makishima, M. etal. Vitamin D receptor as anintestinal bile acid sensor. Science 296, 13131316 (2002). Choi, H.S. etal. Differential transactivation by two isoforms of the orphan nuclear hormone receptor CAR. J. Biol. Chem. 272, 2356523571 (1997). Maruyama, T. etal. Identification of membranetype receptor for bile acids (M-BAR). Biochem. Biophys. Res. Commun. 298, 714719 (2002). Kawamata, Y. etal. A G protein-coupled receptor responsive to bile acids. J. Biol. Chem. 278, 94359440 (2003). Otte, K. etal. Identification of farnesoid X receptor beta as a novel mammalian nuclear receptor sensing lanosterol. Mol. Cell Biol. 23, 864872 (2003). Zhang, Y., Kast-Woelbern, H.R. & Edwards, P .A. Natural structural variants of the nuclear receptor farnesoid X receptor affect transcriptional activation. J. Biol. Chem. 278, 104110 (2003). Bookout, A.L. etal. Anatomical profiling of nuclear receptor expression reveals a hierarchical transcriptional network. Cell 126, 789799 (2006). Li, Z., Kruijt, J.K., van der Sluis, R.J., VanBerkel,T.J. & Hoekstra, M. Nuclear receptor atlas of female mouse liver parenchymal, endothelial, and Kupffer cells. Physiol. Genomics 45, 268275 (2013). Fickert, P . etal. Farnesoid X receptor critically determines the fibrotic response in mice but isexpressed to a low extent in human hepatic stellate cells and periductal myofibroblasts. Am.J. Pathol. 175, 23922405 (2009). Bishop-Bailey, D., Walsh, D.T. & Warner, T.D. Expression and activation of the farnesoid X receptor in the vasculature. Proc. Natl Acad. Sci. USA 101, 36683673 (2004). Lee, H. etal. FXR regulates organic solute transporters and in the adrenal gland, kidney, and intestine. J. Lipid Res. 47, 201214 (2006). Cariou, B. etal. The farnesoid X receptor modulates adiposity and peripheral insulin sensitivity in mice. J. Biol. Chem. 281, 1103911049 (2006). Jiang, T. etal. Farnesoid X receptor modulates renal lipid metabolism, fibrosis, and diabetic nephropathy. Diabetes 56, 24852493 (2007). Abel, U. etal. Synthesis and pharmacological validation of a novel series of non-steroidal FXRagonists. Bioorg. Med. Chem. Lett. 20, 49114917 (2010). Sayin, S.I. etal. Gut microbiota regulates bile acid metabolism by reducing the levels of tauromuricholic acid, a naturally occurring FXR antagonist. Cell. Metab. 17, 225235 (2013). Beraza, N. etal. Nor-ursodeoxycholic acid reverses hepatocyte-specific nemo-dependent steatohepatitis. Gut 60, 387396 (2011). Gardmo, C., Tamburro, A., Modica, S. &Moschetta, A. Proteomics for the discovery ofnuclear bile acid receptor FXR targets. Biochim. Biophys. Acta 1812, 836841 (2011). Jung, D. & Kullak-Ublick, G.A. Hepatocyte nuclear factor 1 : a key mediator of the effect ofbile acids on gene expression. Hepatology 37, 622631 (2003). Jung, D., Mangelsdorf, D.J. & Meyer, U.A. Pregnane X receptor is a target of farnesoid X receptor. J. Biol. Chem. 281, 1908119091 (2006). Inoue, J. etal. PPAR gene expression is upregulated by LXR and PXR activators in the small intestine. Biochem. Biophys. Res. Commun. 371, 675678 (2008). Renga, B. etal. Farnesoid X receptor suppresses constitutive androstane receptor activity at the multidrug resistance protein4 promoter. Biochim. Biophys. Acta 1809, 157165 (2011). Beilke, L.D. etal. Constitutive androstane receptor-mediated changes in bile acid composition contributes to hepatoprotection from lithocholic acid-induced liver injury in mice. Drug Metab. Dispos. 37, 10351045 (2009). Claudel, T., Staels, B. & Kuipers, F. The Farnesoid X receptor: a molecular link between bile acid and lipid and glucose metabolism. Arterioscler. Thromb. Vasc. Biol. 25, 20202030 (2005). Wang, Y.D., Chen, W.D., Moore, D.D. &Huang,W. FXR: a metabolic regulator and cell protector. Cell Res. 18, 10871095 (2008). Pircher, P .C. etal. Farnesoid X receptor regulates bile acid-amino acid conjugation. J. Biol. Chem. 278, 2770327711 (2003). Ananthanarayanan, M., Balasubramanian, N., Makishima, M., Mangelsdorf, D.J. & Suchy, F.J. Human bile salt export pump promoter is transactivated by the farnesoid X receptor/bile acid receptor. J. Biol. Chem. 276, 2885728865 (2001). Boyer, J.L. etal. Upregulation of a basolateral FXR-dependent bile acid efflux transporter OSTOST in cholestasis in humans and rodents. Am.J. Physiol. Gastrointest. Liver Physiol. 290, G1124G1130 (2006). Fiorucci, S. etal. The nuclear receptor SHP mediates inhibition of hepatic stellate cells by FXR and protects against liver fibrosis. Gastroenterology 127, 14971512 (2004). Kim, I. etal. Spontaneous hepatocarcinogenesis in farnesoid X receptor-null mice. Carcinogenesis 28, 940946 (2007). Deuschle, U. etal. FXR controls the tumor suppressor NDRG2 and FXR agonists reduce liver tumor growth and metastasis in an orthotopic mouse xenograft model. PLoS ONE 7, e43044 (2012). Jiang, Y. etal. Farnesoid X receptor inhibits gankyrin in mouse livers and prevents development of liver cancer. Hepatology 57, 10981106 (2013). Wistuba, W., Gnewuch, C., Liebisch, G., Schmitz,G. & Langmann, T. Lithocholic acid induction of the FGF19 promoter in intestinal cells is mediated by PXR. World J. Gastroenterol. 13, 42304235 (2007). Schmidt, D.R. etal. Regulation of bile acid synthesis by fat-soluble vitamins A and D. J. Biol. Chem. 285, 1448614494 (2010). Schreuder, T.C. etal. The hepatic response to FGF19 is impaired in patients with nonalcoholic fatty liver disease and insulin resistance. Am.J.Physiol. Gastrointest Liver Physiol. 298, G440G445 (2010). Triantis, V., Saeland, E., Bijl, N., OudeElferink,R.P . & Jansen, P .L. Glycosylation of fibroblast growth factor receptor 4 is a key regulator of fibroblast growth factor 19-mediated down-regulation of cytochrome P450 7A1. Hepatology 52, 656666 (2010). Wu, X. etal. Co-receptor requirements for fibroblast growth factor19 signaling. J. Biol. Chem. 282, 2906929072 (2007). Kir, S., Zhang, Y., Gerard, R.D., Kliewer, S.A. &Mangelsdorf, D.J. Nuclear receptors HNF4 and LRH1 cooperate in regulating Cyp7a1 invivo. J. Biol. Chem. 287, 4133441341 (2012).
43.
23.
2.
44.
24.
3.
25.
45.
4.
26.
46.
5. 6.
27.
47.
28.
7.
48.
8.
29.
49.
9.
30.
10.
50.
31.
11.
51.
12.
32.
52.
13.
33.
53.
14.
34.
54.
15.
35.
55.
16.
36.
17.
37.
56.
18.
57.
38.
19.
39.
58.
20.
40.
21.
59.
41.
60.
22.
42.

REVIEWS
61. Kim, I. etal. Differential regulation of bile acid homeostasis by the farnesoid X receptor in liver and intestine. J. Lipid Res. 48, 26642672 (2007). 62. Potthoff, M.J. etal. FGF15/19 regulates hepatic glucose metabolism by inhibiting the CREBPGC1 pathway. Cell. Metab. 13, 729738 (2011). 63. Kir, S. etal. FGF19 as a postprandial, insulinindependent activator of hepatic protein and glycogen synthesis. Science 331, 16211624 (2011). 64. Miyata, M., Sakaida, Y., Matsuzawa, H., Yoshinari, K. & Yamazoe, Y. Fibroblast growth factor 19 treatment ameliorates disruption of hepatic lipid metabolism in farnesoid X receptor (Fxr)-null mice. Biol. Pharm. Bull. 34, 18851889 (2011). 65. Choi, M. etal. Identification of a hormonal basis for gallbladder filling. Nat. Med. 12, 12531255 (2006). 66. Drafahl, K.A., McAndrew, C.W., Meyer, A.N., Haas, M. & Donoghue, D.J. The receptor tyrosine kinase FGFR4 negatively regulates NFB signaling. PLoS ONE 5, e14412 (2010). 67. Uriarte, I. etal. Identification of fibroblast growth factor 15 as a novel mediator of liver regeneration and its application in the prevention of post-resection liver failure in mice. Gut 62 , 899910 (2013). 68. Zweers, S.J. etal. The human gallbladder secretes fibroblast growth factor 19 into bile: towards defining the role of fibroblast growth factor 19 in the enterobiliary tract. Hepatology 55, 575583 (2012). 69. Nicholes, K. etal. A mouse model of hepatocellular carcinoma: ectopic expression offibroblast growth factor 19 in skeletal muscle of transgenic mice. Am. J. Pathol. 160, 22952307 (2002). 70. Lin, B.C. & Desnoyers, L.R. FGF19 and cancer. Adv. Exp. Med. Biol. 728, 183194 (2012). 71. Wu, X. etal. Separating mitogenic and metabolic activities of fibroblast growth factor 19 (FGF19). Proc. Natl Acad. Sci. USA 107, 1415814163 (2010). 72. Keitel, V. etal. The membrane-bound bile acid receptor TGR5 is localized in the epithelium of human gallbladders. Hepatology 50, 861870 (2009). 73. Keitel, V. etal. The bile acid receptor TGR5 (Gpbar1) acts as a neurosteroid receptor in brain. Glia 58, 17941805 (2010). 74. Keitel, V. etal. The G.protein coupled bile salt receptor TGR5 is expressed in liver sinusoidal endothelial cells. Hepatology 45, 695704 (2007). 75. Sato, H. etal. Anti-hyperglycemic activity of aTGR5 agonist isolated from Olea europaea. Biochem. Biophys. Res. Commun. 362, 793798 (2007). 76. Sato, H. etal. Novel potent and selective bile acid derivatives as TGR5 agonists: biological screening, structure-activity relationships, and molecular modeling studies. J. Med. Chem. 51, 18311841 (2008). 77. Pols, T.W., Noriega, L.G., Nomura, M., Auwerx,J. & Schoonjans, K. The bile acid membrane receptor TGR5 as an emerging target in metabolism and inflammation. J. Hepatol. 54, 12631272 (2011). 78. Pols, T.W. etal. TGR5 activation inhibits atherosclerosis by reducing macrophage inflammation and lipid loading. Cell. Metab. 14, 747757 (2011). 79. Wang, Y.D., Chen, W.D., Yu, D., Forman, B.M. &Huang, W. The Gproteincoupled bile acid receptor, Gpbar1 (TGR5), negatively regulates hepatic inflammatory response through antagonizing nuclear factor light-chain enhancer of activated Bcells (NF-B) in mice. Hepatology 54, 14211432 (2011). Katsuma, S., Hirasawa, A. & Tsujimoto, G. Bile acids promote glucagon-like peptide1 secretion through TGR5 in a murine enteroendocrine cell line STC1. Biochem. Biophys. Res. Commun. 329, 386390 (2005). Thomas, C. etal. TGR5-mediated bile acid sensing controls glucose homeostasis. Cell. Metab. 10, 167177 (2009). Watanabe, M. etal. Bile acids induce energy expenditure by promoting intracellular thyroid hormone activation. Nature 439, 484489 (2006). Jansen, P.L. etal. Alterations of hormonally active fibroblast growth factors after RouxenY gastric bypass surgery. Dig. Dis. 29, 4851 (2011). Li, T. etal. The G protein-coupled bile acid receptor, TGR5, stimulates gallbladder filling. Mol. Endocrinol. 25, 10661071 (2011). Beuers, U. etal. The biliary HCO3 umbrella: aunifying hypothesis on pathogenetic and therapeutic aspects of fibrosing cholangiopathies. Hepatology 52, 14891496 (2010). Zhang, H. etal. Rat pregnane X receptor: molecular cloning, tissue distribution, and xenobiotic regulation. Arch. Biochem. Biophys. 368, 1422 (1999). Kliewer, S.A. etal. An orphan nuclear receptor activated by pregnanes defines a novel steroid signaling pathway. Cell 92, 7382 (1998). Lehmann, J.M. etal. The human orphan nuclearreceptor PXR is activated by compounds that regulate CYP3A4 gene expression and cause drug interactions. J. Clin. Invest. 102, 10161023 (1998). Bertilsson, G. etal. Identification of a human nuclear receptor defines a new signaling pathway for CYP3A induction. Proc. Natl Acad. Sci. USA 95, 1220812213 (1998). Lamba, V. etal. PXR (NR1I2): splice variants inhuman tissues, including brain, and identification of neurosteroids and nicotine as PXR activators. Toxicol. Appl. Pharmacol. 199, 251265 (2004). Vogel, S.M. etal. Lithocholic acid is an endogenous inhibitor of MDM4 and MDM2. Proc. Natl Acad. Sci. USA 109, 1690616910 (2012). Wang, Y.M., Ong, S.S., Chai, S.C. & Chen, T. Role of CAR and PXR in xenobiotic sensing and metabolism. Expert Opin. Drug Metab. Toxicol. 8, 803817 (2012). Kast, H.R. etal. Regulation of multidrug resistance-associated protein 2 (ABCC2) by thenuclear receptors pregnane X receptor, farnesoid Xactivated receptor, and constitutive androstane receptor. J. Biol. Chem. 277, 29082915 (2002). Ihunnah, C.A., Jiang, M. & Xie, W. Nuclear receptor PXR, transcriptional circuits and metabolic relevance. Biochim. Biophys. Acta 1812, 956963 (2011). Wallace, K. etal. The PXR is a drug target for chronic inflammatory liver disease. J. Steroid Biochem. Mol. Biol. 120, 137148 (2010). Li, T. & Chiang, J.Y. Mechanism of rifampicin and pregnane X receptor inhibition of human cholesterol 7 -hydroxylase gene transcription. Am. J. Physiol. Gastrointest. Liver Physiol. 288, G74G84 (2005). Cheng, J., Shah, Y.M. & Gonzalez, F.J. PregnaneX receptor as a target for treatment ofinflammatory bowel disorders. Trends Pharmacol. Sci. 33, 323330 (2012). 98. Zhou, J. etal. Hepatic fatty acid transporter Cd36 is a common target of LXR, PXR, and PPAR in promoting steatosis. Gastroenterology 134, 556567 (2008). 99. Jonker, J.W., Liddle, C. & Downes, M. FXR andPXR: potential therapeutic targets in cholestasis. J. Steroid Biochem. Mol. Biol. 130, 147158 (2012). 100. Norman, A.W. Minireview: vitamin D receptor: new assignments for an already busy receptor. Endocrinology 147, 55425548 (2006). 101. Han, S. & Chiang, J.Y. Mechanism of vitamin D receptor inhibition of cholesterol 7-hydroxylase gene transcription in human hepatocytes. Drug Metab. Dispos. 37, 469478 (2009). 102. Adachi, R. etal. Structural determinants for vitamin D receptor response to endocrine and xenobiotic signals. Mol. Endocrinol. 18, 4352 (2004). 103. Huhtakangas, J.A., Olivera, C.J., Bishop, J.E., Zanello, L.P . & Norman, A.W. The vitamin D receptor is present in caveolae-enriched plasma membranes and binds 1,25(OH)2-vitamin D3 invivo and invitro. Mol. Endocrinol. 18, 26602671 (2004). 104. Han, S., Li, T., Ellis, E., Strom, S. & Chiang, J.Y. Anovel bile acid-activated vitamin D receptor signaling in human hepatocytes. Mol. Endocrinol. 24, 11511164 (2010). 105. DAldebert, E. etal. Bile salts control the antimicrobial peptide cathelicidin through nuclear receptors in the human biliary epithelium. Gastroenterology 136, 14351443 (2009). 106. Saini, S.P . etal. A novel constitutive androstanereceptor-mediated and CYP3Aindependent pathway of bile acid detoxification. Mol.Pharmacol. 65, 292300 (2004). 107. Chang, T.K. Activation of pregnane X receptor (PXR) and constitutive androstane receptor (CAR) by herbal medicines. AAPS J. 11, 590601 (2009). 108. Moore, L.B. etal. Pregnane X receptor (PXR), constitutive androstane receptor (CAR), and benzoate X receptor (BXR) define three pharmacologically distinct classes of nuclear receptors. Mol. Endocrinol. 16, 977986 (2002). 109. Miao, J., Fang, S., Bae, Y. & Kemper, J.K. Functional inhibitory cross-talk between constitutive androstane receptor and hepatic nuclear factor4 in hepatic lipid/glucose metabolism is mediated by competition for binding to the DR1 motif and to the common coactivators, GRIP1 and PGC-1. J. Biol. Chem. 281, 1453714546 (2006). 110. Uppal, H. etal. Combined loss of orphan receptors PXR and CAR heightens sensitivity totoxic bile acids in mice. Hepatology 41, 168176 (2005). 111. Pellicciari, R. etal. 6ethylchenodeoxycholic acid (6-ECDCA), a potent and selective FXR agonist endowed with anticholestatic activity. J.Med. Chem. 45, 35693572 (2002). 112. Pellicciari, R. etal. Discovery of 6ethyl23(S)methylcholic acid (S-EMCA, INT777) as a potent and selective agonist for the TGR5 receptor, a novel target for diabesity. J. Med. Chem. 52, 79587961 (2009). 113. Rizzo, G. etal. Functional characterization of thesemisynthetic bile acid derivative INT767, adual farnesoid X receptor and TGR5 agonist. Mol. Pharmacol. 78, 617630 (2010). 114. Baghdasaryan, A. etal. Dual farnesoid X receptor/TGR5 agonist INT767 reduces liver injury in the Mdr2/ (Abcb4/) mouse cholangiopathy model by promoting biliary HCO3 output. Hepatology 54, 13031312 (2011).
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.

REVIEWS
115. Adorini, L., Pruzanski, M. & Shapiro, D. Farnesoid X receptor targeting to treat nonalcoholic steatohepatitis. Drug Discov. Today 17, 988997 (2012). 116. Hartman, H.B. etal. Activation of farnesoid X receptor prevents atherosclerotic lesion formation in LDLR / and apoE/ mice. J. Lipid Res. 50, 10901100 (2009). 117. Mencarelli, A., Renga, B., Distrutti, E. &Fiorucci,S. Antiatherosclerotic effect of farnesoid X receptor. Am. J. Physiol. Heart Circ. Physiol. 296, H272H281 (2009). 118. Urizar, N.L. etal. A natural product that lowers cholesterol as an antagonist ligand for FXR. Science 296, 17031706 (2002). 119. Zhang, Y. etal. FXR deficiency causes reduced atherosclerosis in Ldlr / mice. Arterioscler Thromb. Vasc Biol. 26, 23162321 (2006). 120. Guo, G.L. etal. Effects of FXR in foam-cell formation and atherosclerosis development. Biochim. Biophys. Acta 1761, 14011409 (2006). 121. Bennett, B.J. etal. TrimethylamineNoxide, ametabolite associated with atherosclerosis, exhibits complex genetic and dietary regulation. Cell. Metab. 17, 4960 (2013). 122. Marinozzi, M. etal. Pyrazole[3,4e][1 4] thiazepin7one derivatives as a novel class of farnesoid X receptor (FXR) agonists. Bioorg. Med. Chem. 20, 34293445 (2012). 123. Herbert, M.R. etal. Synthesis and SAR of 2aryl3-aminomethylquinolines as agonists of the bile acid receptor TGR5. Bioorg. Med. Chem. Lett. 20, 57185721 (2010). 124. Sakamoto, S. etal. Glucuronidation converting methyl 1(3,4-dimethoxyphenyl)3(3ethylvaleryl)4hydroxy6, 7,8trimethoxy2naphthoat e (S8921) to a potent apical sodium-dependent bile acid transporter inhibitor, resulting in a hypocholesterolemic action. J.Pharmacol. Exp. Ther. 322, 610618 (2007). 125. Kobayashi, M. etal. Prevention and treatment ofobesity, insulin resistance, and diabetes by bile acid-binding resin. Diabetes 56, 239247 (2007). 126. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of cholestatic liver diseases. J. Hepatol. 51, 237267 (2009). 127. Beuers, U. etal. Tauroursodeoxycholic acid inserts the apical conjugate export pump, Mrp2, into canalicular membranes and stimulates organic anion secretion by protein kinase Cdependent mechanisms in cholestatic rat liver. Hepatology 33, 12061216 (2001). 128. Garcia-Marin, J.J., Dumont, M., Corbic, M., deCouet, G. & Erlinger, S. Effect of acidbasebalance and acetazolamide onursodeoxycholate-induced biliary bicarbonatesecretion. Am. J. Physiol. 248, G20G27 (1985). 129. Kurz, A.K., Graf, D., Schmitt, M., Vom Dahl, S. &Haussinger, D. Tauroursodesoxycholateinduced choleresis involves p38(MAPK) activation and translocation of the bile salt export pump in rats. Gastroenterology 121, 407419 (2001). 130. Gohlke, H., Schmitz, B., Sommerfeld, A., Reinehr,R. & Haussinger, D. 5 1-integrins aresensors for tauroursodeoxycholic acid in hepatocytes. Hepatology 57, 11171129 (2013). 131. Bouscarel, B., Fromm, H. & Nussbaum, R. Ursodeoxycholate mobilizes intracellular Ca2+ and activates phosphorylase a in isolated hepatocytes. Am. J. Physiol. 264, G243G251 (1993). 132. Wong, M.H., Oelkers, P ., Craddock, A.L. &Dawson, P .A. Expression cloning and characterization of the hamster ileal sodiumdependent bile acid transporter. J. Biol. Chem. 269, 13401347 (1994). 133. Mekjian, H.S., Phillips, S.F. & Hofmann, A.F. Colonic secretion of water and electrolytes induced by bile acids: perfusion studies in man. J. Clin. Invest. 50, 15691577 (1971). 134. Harach, T. etal. TGR5 potentiates GLP1 secretion in response to anionic exchange resins. Sci. Rep. 2, 430 (2012). 135. Chen, L. etal. Inhibition of apical sodiumdependent bile acid transporter as a novel treatment for diabetes. Am. J. Physiol. Endocrinol. Metab. 302, E68E76 (2012). 136. Bhat, B.G. etal. Inhibition of ileal bile acid transport and reduced atherosclerosis in apoE/ mice by SC435. J. Lipid Res. 44, 16141621 (2003). 137. Li, H. etal. Inhibition of ileal bile acid transport lowers plasma cholesterol levels by inactivating hepatic farnesoid X receptor and stimulating cholesterol 7 -hydroxylase. Metabolism 53, 927932 (2004). 138. Insull, W. Jr etal. Effectiveness of colesevelam hydrochloride in decreasing LDL cholesterol in patients with primary hypercholesterolemia: a 24-week randomized controlled trial. Mayo Clin. Proc. 76, 971982 (2001). 139. Hansen, M. etal. Effect of bile acid sequestrants on glycaemic control: protocol for a systematic review with meta-analysis of randomised controlled trials. BMJ Open 2, e001803 (2012). 140. US National Library of Medicine. ClinicalTrials.gov [online], http://www.clinicaltrials.gov/ct2/ show/NCT01473524?term=NCT01473524 &rank=1 (2012). 141. US National Library of Medicine. ClinicalTrials.gov [online], http://www.clinicaltrials.gov/ct2/ show/NCT01265498?term=NCT01265498 &rank=1 (2013). 142. US National Library of Medicine. ClinicalTrials.gov [online], http://www.clinicaltrials.gov/ct2/ show/NCT00550862?term=NCT00550862 &rank=1 (2012). 143. Schaap, F.G., van der Gaag, N.A., Gouma, D.J. & Jansen, P .L. High expression of the bile salthomeostatic hormone fibroblast growth factor 19 in the liver of patients with extrahepatic cholestasis. Hepatology 49, 12281235 (2009). 144. Fickert, P . etal. Regurgitation of bile acids from leaky bile ducts causes sclerosing cholangitis in Mdr2 (Abcb4) knockout mice. Gastroenterology 127, 261274 (2004). 145. Fiorucci, S. etal. Farnesoid X receptor agonist for the treatment of liver and metabolic disorders: focus on 6ethylCDCA. Mini Rev. Med. Chem. 11, 753762 (2011). 146. Kremer, A.E. etal. Lysophosphatidic acid is apotential mediator of cholestatic pruritus. Gastroenterology 139, 10081018 (2010). 147. Kremer, A.E. etal. Serum autotaxin is increasedin pruritus of cholestasis, but not ofother origin, and responds to therapeutic interventions. Hepatology 56, 13911400 (2012). 148. Alemi, F. etal. The TGR5 receptor mediates bile acid-induced itch and analgesia. J. Clin. Invest. 123, 15131530 (2013). 149. Gadaleta, R.M. etal. Farnesoid X receptor activation inhibits inflammation and preserves the intestinal barrier in inflammatory bowel disease. Gut 60, 463472 (2011). 150. Terjung, B. etal. pANCAs in autoimmune liver disorders recognise human -tubulin isotype 5 and cross-react with microbial protein FtsZ. Gut59, 808816 (2010). 151. Wong, B.S. etal. Increased bile acid biosynthesis is associated with irritable bowel syndrome with diarrhea. Clin. Gastroenterol. Hepatol. 10, 10091015 e3 (2012). 152. Mudaliar, S. etal. Efficacy and safety of thefarnesoid X receptor agonist obeticholic acidin patients with type2 diabetes andnonalcoholic fatty liver disease. Gastroenterology http://dx.doi.org/10.1053/ j.gastro.2013.05.042. 153. Wang, X.X. etal. Diabetic nephropathy is accelerated by farnesoid X receptor deficiency and inhibited by farnesoid X receptor activation in a type1 diabetes model. Diabetes 59, 29162927 (2010). 154. Peterli, R. etal. Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic RouxenY gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial. Ann. Surg. 250, 234241 (2009). 155. van Dijk, R., Kremer, A.F., Enemuo, V., Jansen,P .L., Beuers, U. Clinical and molecular aspects of rifampicin-mediated attenuation of severe persistent hepatocellular secretory failure. Hepatology 56, 549A (2012). 156. Ohkubo, H., Okuda, K. & Iida, S. Effects of corticosteroids on bilirubin metabolism in patients with Gilberts syndrome. Hepatology 1, 168172 (1981). 157. Arias, I.M., Gartner, L.M., Cohen, M., Ezzer, J.B. & Levi, A.J. Chronic nonhemolytic unconjugated hyperbilirubinemia with glucuronyl transferase deficiency. Clinical, biochemical, pharmacologic and genetic evidence for heterogeneity. Am. J. Med. 47, 395409 (1969). 158. Ellis, E. etal. Successful treatment of severe unconjugated hyperbilirubinemia via induction ofUGT1A1 by rifampicin. J. Hepatol. 44, 243245 (2006). 159. Makishima, M. etal. Identification of a nuclearreceptor for bile acids. Science 284, 13621365 (1999). 160. Downes, M. etal. A chemical, genetic, and structural analysis of the nuclear bile acid receptor FXR. Mol. Cell 11, 10791092 (2003). 161. Hambruch, E. etal. Synthetic farnesoid X receptor agonists induce high-density lipoproteinmediated transhepatic cholesterol efflux in mice and monkeys and prevent atherosclerosis in cholesteryl ester transfer protein transgenic lowdensity lipoprotein receptor(/) mice. J.Pharmacol. Exp. Ther. 343, 556567 (2012). 162. Flatt, B. etal. Discovery of XL335 (WAY362450), a highly potent, selective, and orally active agonist of the farnesoid X receptor (FXR). J. Med. Chem. 52, 904907 (2009). 163. Soisson, S.M. etal. Identification of a potent synthetic FXR agonist with an unexpected mode of binding and activation. Proc. Natl Acad. Sci. USA 105, 53375342 (2008). 164. Bass, J.Y. etal. Conformationally constrained farnesoid X receptor (FXR) agonists: heteroaryl replacements of the naphthalene. Bioorg. Med. Chem. Lett. 21, 12061213 (2011). 165. Chen, W.D. etal. Farnesoid X receptor alleviatesage-related proliferation defects in regenerating mouse livers by activating forkhead box m1b transcription. Hepatology 51, 953962 (2010). 166. Hollman, D.A., Milona, A., van Erpecum, K.J. &van Mil, S.W. Anti-inflammatory and metabolic actions of FXR: insights into molecular mechanisms. Biochim. Biophys. Acta 1821, 14431452 (2012).

REVIEWS
167. Staudinger, J.L. etal. The nuclear receptor PXR is a lithocholic acid sensor that protects against liver toxicity. Proc. Natl Acad. Sci. USA 98, 33693374 (2001). 168. Jones, S.A. etal. The pregnane X receptor: apromiscuous xenobiotic receptor that has diverged during evolution. Mol. Endocrinol. 14, 2739 (2000). 169. Moore, L.B. etal. St. Johns wort induces hepatic drug metabolism through activation of the pregnane X receptor. Proc. Natl Acad. Sci. USA 97, 75007502 (2000). 170. Ogura, M. etal. Vitamin D3 modulates the expression of bile acid regulatory genes and represses inflammation in bile duct-ligated mice.J. Pharmacol. Exp. Ther. 328, 564570 (2009). 171. Ma, Y. etal. Identification and characterization of noncalcemic, tissue-selective, nonsecosteroidal vitamin D receptor modulators. J. Clin. Invest. 116, 892904 (2006). 172. Maglich, J.M. etal. Nuclear pregnane x receptor and constitutive androstane receptor regulate overlapping but distinct sets of genes involved in xenobiotic detoxification. Mol. Pharmacol. 62, 638646 (2002). 173. Gao, J. & Xie, W. Targeting xenobiotic receptors PXR and CAR for metabolic diseases. Trends Pharmacol. Sci. 33, 552558 (2012). Acknowledgements The authors of this Review are supported by grantsP19118B05, F3008 and F3517-B20 from theAustrian Science Foundation and European Communitys Seventh Framework Program (FP7/20072013) under grant agreement HEALTHF22009241762 for the project FLIP (M.Trauner) and the Dutch Digestive Diseases Foundation (MLDS WO 0869; to P.L.M. Jansen andF.G. Schaap). Author contributions P.L.M. Jansen and F.G. Schaap wrote the article. M.Trauner reviewed and edited the manuscript beforesubmission.


Bile Acid Receptors As Targets For Drug

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Bile Acid Receptors As Targets For Drug

Hochgeladen von

Copyright:

Verfügbare Formate

REVIEWS

Bile acid receptors as targets for drug development

NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY

ADVANCE ONLINE PUBLICATION | 1

Bile acid receptors

2013 Macmillan Publishers Limited. All rights reserved

Hepatocyte FXR CYP7A1

Bile canalicus CDCA NTCP CDCA BSEP

Ileal epithelial cell OST/ CDCA FXR FGF19

ASBT CDCA FXR agonist

Affected pathways and/or processes

Liver, intestine, gallbladder, muscle, brain Liver, intestine

Cholestatic liver disease,pruritus, IBD

Intestine, kidney, bone

Cholestatic liver disease, pruritus

2013 Macmillan Publishers Limited. All rights reserved

cAMP TGR5 TGR5

Enteroendocrine cells in intestine

Energy expenditure Insulin secretion and/or sensitivity Inflammation

2013 Macmillan Publishers Limited. All rights reserved

O Pfizer WAY-362450 (FXR450, XL335)

2013 Macmillan Publishers Limited. All rights reserved

Bile acid receptors as drug targets

UDCA and bile salt sequestrants

2013 Macmillan Publishers Limited. All rights reserved

2013 Macmillan Publishers Limited. All rights reserved

FGF19 FGF19? VDR GLP-1 TGR5 FXR

ADVANCE ONLINE PUBLICATION | 9

10 | ADVANCE ONLINE PUBLICATION

NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY

ADVANCE ONLINE PUBLICATION | 11

12 | ADVANCE ONLINE PUBLICATION

NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY

ADVANCE ONLINE PUBLICATION | 13

Das könnte Ihnen auch gefallen

10 | ADVANCE ONLINE PUBLICATION

12 | ADVANCE ONLINE PUBLICATION