Primary sclerosing cholangitis (PSC) is a rare chronic liver disease characterized by inflammation and fibrosis of the biliary ducts, resulting in cholestasis and eventually liver failure. No effective treatment is currently available and most patients ultimately require liver transplantation in order to survive. The underlying mechanisms of the disease is poorly understood but a range of hypotheses exist, many of which recognize and grapple with PSC's close relationship with inflammatory bowel disease. Most agree genetics is involved, predisposing for an imbalance in 1) bile acid metabolism, 2) immune response and/or 3) gut microbiota. This literature study aims to describe and elucidate recent progress in the field of pharmacotherapy, as it relates to PSC and our current understanding of the disease. Covered in this study is a total of seven randomized, controlled trials, published between 2015-2022, and available through the medical database/search engine PubMed. Endpoints of particular note are ALP and ELF. ALP, or alkaline phosphatase, is an enzyme found in the liver. Rising levels of ALP in the blood stream is indicative of liver damage. ELF, or Enhanced Liver Fibrosis, is a blood test measuring markers of fibrosis, useful in assessing and staging fibrosis in chronic liver disease. Drugs included in this literature study are aldafermin, cilofexor, fenofibrate, norUrsodeoxicholic acid, obeticholic acid, simtuzumab and vancomycin. With the exception of aldafermin and simtuzumab, all showed promise as ALP reducing agents, in general lowering levels with 15-40 percent. In the case of fenofibrate, a reduction of 65 percent was observed. Of the drugs measured against ELF, only aldafermin produced a statistically significant reduction in fibrosis markers. At the time being it is not entirely clear what to make of the results, due to uncertainties surrounding ALP as a prognostic marker. To what extent ALP predicts transplantation free survival is still a matter of debate. Although considerable efforts have been made to further our understanding of PSC, much is yet to be solved. With regards to pharmacotherapy, the field is experiencing somewhat of a renaissance, showcased by the dozen on-going randomized, controlled trials on a plethora of potential PSC substances. Thus, the search for an effective therapy against PSC goes on.

Les acides biliaires sont des composants naturels du tractus gastro-intestinal. La hausse du taux d’acides biliaires dans l’intestin est associée à une carcinogenèse de l’appareil digestif. L’homéostasie des acides biliaires est maintenue par le contrôle de l’expression des gènes impliqués dans le métabolisme tels que SHP, FGF19 et CYP-7A1 par le récepteur nucléaire FXRα. FXRα agit comme facteur de transcription en réponse à l’interaction directe des acides biliaires. Par contre, plusieurs évidences tendent à démontrer le rôle central de FXRα dans la carcinogenèse hépatique. Les récepteurs de la famille EGFR/ErbB sont des récepteurs tyrosine kinase également activés par les acides biliaires, dont la surexpression est associée au développement de plusieurs cancers. Ainsi, le projet vise à déterminer l’impact de la signalisation des récepteurs EGFR/ErbB sur la réponse transcriptionnelle de FXRα. Nous avons identifié un mécanisme d’inhibition de l’activité transcriptionnelle de FXRα et de l’expression de ses gènes cibles par l’activation des récepteurs EGFR/ErbB par leur ligands HRG et EGF et par l’expression du mutant constitutivement actif ErbB2-V659E dans les cellules hépatiques. Nous avons montré que ce processus dépend de la signalisation par la voie MAPK. On observe également que l’activation de FXRα diminue la prolifération des cellules cancéreuses du foie alors que celle du récepteur ErbB2 augmente cette prolifération. Ainsi, cette étude nous a permis d’établir un nouveau mécanisme de l’impact délétère de la suractivation des récepteurs EGFR/ErbB sur la prolifération des cellules cancéreuses du foie qui implique une inhibition du potentiel transcriptionnel du récepteur aux acides biliaires FXRα. / Bile acids are natural components of the gastrointestinal tract. An increase of bile acid levels in the intestine is associated with the carcinogenesis of the digestive system. Bile acid homeostasis is maintained by the nuclear receptor FXRα which regulates the expression of specific genes involved in metabolism such as SHP, FGF19 and CYP-7A1. In this way, FXRα acts as a transcription factor following bile acids binding, allowing its transcriptional activation. On the other hand, several studies established the central role of FXRα activation in liver carcinogenesis. EGFR/ErbB receptors are a family of tyrosine kinase receptors that can be regulated by bile acids. Overexpression of EGFR/ErbB receptors is associated with several cancers. Thus, the project aims to examine the impact of EGFR/ErbB receptors signaling on FXR transcriptional potential. We identify that EGFR/ErbB activation by their ligands HRG and EGF and by the expression of the constitutively active mutant ErbB2-V659E inhibits FXR transcriptional activity and expression of its target genes in liver cells. We demonstrate that this process is dependent on the MAPK signaling pathway. We also show that FXR activation decreases proliferation of liver cancer cells while activation of ErbB2 increases this cellular response. Thus, this study identifies a new mechanism of the deleterious impact of EGFR/ErbB receptors overactivation on liver cancer cells proliferation, involving the inhibition of the transcriptional potential of the bile acid receptor FXRα.

Nuclear receptors play significant roles in the regulation of transporters and enzymes to balance the level of endogenous molecules and to protect the body from foreign molecules. The vitamin D receptor (VDR) and its natural ligand, 1alpha,25-dihydroxyvitamin D3 [1,25(OH)2D3], was shown to upregulate rat ileal apical sodium dependent bile acid transporter (Asbt) to increase the reclamation of bile acids, ligands of the farnesoid X receptor (FXR). FXR is considered to be an important, negative regulator of the cholesterol metabolizing enzyme, Cyp7a1, which metabolizes cholesterol to bile acids in the liver. In rats, decreased Cyp7a1 and increased P-glycoprotein/multidrug resistance protein 1 (P-gp/Mdr1) expressions pursuant to 1,25(OH)2D3 treatment was viewed as FXR effects in which hepatic VDR protein is poorly expressed. In contrast, changes in rat intestinal and renal transporters such as multidrug resistance associated proteins (Mrp2, Mrp3, and Mrp4), Asbt, and P-gp after administration of 1,25(OH)2D3 were attributed directly as VDR effects due to higher VDR levels expressed in these tissues. Higher VDR expressions were found among mouse hepatocytes compared to those in rats. Hence, fxr(-/-) and fxr(+/+) mouse models were used to discriminate between VDR vs. FXR effects in murine livers. Hepatic Cyp7a1 in mice was found to be upregulated with 1,25(OH)2D3 treatment, via the derepression of the short heterodimer partner (SHP). Putative VDREs, identified in mouse and human SHP promoters, were responsible for the inhibitory effect on SHP. The increase in hepatic Cyp7a1 expression and decreased plasma and liver cholesterol were observed in mice prefed with a Western diet. A strong correlation was found between tissue Cyp7a1 and P-gp changes and 1,25(OH)2D3 plasma and tissue concentrations, confirming that VDR plays an important role in the disposition of xenobiotics and cholesterol metabolism. Moreover, renal and brain Mdr1a/P-gp were found to be directly upregulated by the VDR in mice, and concomitantly, increased renal and brain secretion of digoxin, a P-gp substrate, in vivo. The important observations: the cholesterol lowering and increased brain P-gp efflux activity properties suggest that VDR is a therapeutic target for treatment of hypercholesterolemia and Alzheimer’s diseases, since beta amyloid, precursors of plague, are P-gp substrates.

Nuclear receptors play significant roles in the regulation of transporters and enzymes to balance the level of endogenous molecules and to protect the body from foreign molecules. The vitamin D receptor (VDR) and its natural ligand, 1alpha,25-dihydroxyvitamin D3 [1,25(OH)2D3], was shown to upregulate rat ileal apical sodium dependent bile acid transporter (Asbt) to increase the reclamation of bile acids, ligands of the farnesoid X receptor (FXR). FXR is considered to be an important, negative regulator of the cholesterol metabolizing enzyme, Cyp7a1, which metabolizes cholesterol to bile acids in the liver. In rats, decreased Cyp7a1 and increased P-glycoprotein/multidrug resistance protein 1 (P-gp/Mdr1) expressions pursuant to 1,25(OH)2D3 treatment was viewed as FXR effects in which hepatic VDR protein is poorly expressed. In contrast, changes in rat intestinal and renal transporters such as multidrug resistance associated proteins (Mrp2, Mrp3, and Mrp4), Asbt, and P-gp after administration of 1,25(OH)2D3 were attributed directly as VDR effects due to higher VDR levels expressed in these tissues. Higher VDR expressions were found among mouse hepatocytes compared to those in rats. Hence, fxr(-/-) and fxr(+/+) mouse models were used to discriminate between VDR vs. FXR effects in murine livers. Hepatic Cyp7a1 in mice was found to be upregulated with 1,25(OH)2D3 treatment, via the derepression of the short heterodimer partner (SHP). Putative VDREs, identified in mouse and human SHP promoters, were responsible for the inhibitory effect on SHP. The increase in hepatic Cyp7a1 expression and decreased plasma and liver cholesterol were observed in mice prefed with a Western diet. A strong correlation was found between tissue Cyp7a1 and P-gp changes and 1,25(OH)2D3 plasma and tissue concentrations, confirming that VDR plays an important role in the disposition of xenobiotics and cholesterol metabolism. Moreover, renal and brain Mdr1a/P-gp were found to be directly upregulated by the VDR in mice, and concomitantly, increased renal and brain secretion of digoxin, a P-gp substrate, in vivo. The important observations: the cholesterol lowering and increased brain P-gp efflux activity properties suggest that VDR is a therapeutic target for treatment of hypercholesterolemia and Alzheimer’s diseases, since beta amyloid, precursors of plague, are P-gp substrates.