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{{Short description|Enzyme that metabolizes substances by oxidation}}{{Use dmy dates|date=December 2023}}{{cs1 config|name-list-style=vanc|display-authors=}}{{Use American English|date=February 2024}}

factoids

factoids

Cytochrome P450 3A4 (abbreviated CYP3A4) ({{EC number|1.14.13.97}}) is an important enzyme in the body, mainly found in the liver and in the intestine, which in humans is encoded by CYP3A4 gene. It oxidizes small foreign organic molecules (xenobiotics), such as toxins or drugs, so that they can be removed from the body. It is highly homologous to CYP3A5, another important CYP3A enzyme.While many drugs are deactivated by CYP3A4, there are also some drugs that are activated by the enzyme. Some substances, such as some drugs and furanocoumarins present in grapefruit juice, interfere with the action of CYP3A4. These substances will, therefore, either amplify or weaken the action of those drugs that are modified by CYP3A4.CYP3A4 is a member of the cytochrome P450 family of oxidizing enzymes. Several other members of this family are also involved in drug metabolism, but CYP3A4 is the most common and the most versatile one. Like all members of this family, it is a hemoprotein, i.e. a protein containing a heme group with an iron atom. In humans, the CYP3A4 protein is encoded by the CYP3A4 gene.JOURNAL, Hashimoto H, Toide K, Kitamura R, Fujita M, Tagawa S, Itoh S, Kamataki T, Gene structure of CYP3A4, an adult-specific form of cytochrome P450 in human livers, and its transcriptional control, European Journal of Biochemistry, 218, 2, 585–95, December 1993, 8269949, 10.1111/j.1432-1033.1993.tb18412.x, free, This gene is part of a cluster of cytochrome P450 genes on chromosome 7q22.1.JOURNAL, Inoue K, Inazawa J, Nakagawa H, Shimada T, Yamazaki H, Guengerich FP, Abe T, Assignment of the human cytochrome P-450 nifedipine oxidase gene (CYP3A4) to chromosome 7 at band q22.1 by fluorescence in situ hybridization, The Japanese Journal of Human Genetics, 37, 2, 133–8, June 1992, 1391968, 10.1007/BF01899734, free, Previously another CYP3A gene, CYP3A3, was thought to exist; however, it is now thought that this sequence represents a transcript variant of CYP3A4. Alternatively-spliced transcript variants encoding different isoforms have been identified.

Function

CYP3A4 is a member of the cytochrome P450 superfamily of enzymes. The cytochrome P450 proteins are monooxygenases that catalyze many reactions involved in drug metabolism and synthesis of steroids (including cholesterol), and other lipids.{{NCBI RefSeq|title=CYP3A4 cytochrome P450 family 3 subfamily A member 4 [ Homo sapiens (human) ]|url=https://www.ncbi.nlm.nih.gov/gene/1576}}The CYP3A4 protein localizes to the endoplasmic reticulum, and its expression is induced by glucocorticoids and some pharmacological agents. Cytochrome P450 enzymes metabolize approximately 60% of prescribed drugs, with CYP3A4 responsible for about half of this metabolism;JOURNAL, Zanger UM, Schwab M, Cytochrome P450 enzymes in drug metabolism: regulation of gene expression, enzyme activities, and impact of genetic variation, Pharmacology & Therapeutics, 138, 1, 103–41, April 2013, 23333322, 10.1016/j.pharmthera.2012.12.007, free, substrates include acetaminophen (paracetamol), codeine, ciclosporin (cyclosporin), diazepam, erythromycin, and chloroquine. The enzyme also metabolizes some steroids and carcinogens.{{EntrezGene|1576}} Most drugs undergo deactivation by CYP3A4, either directly or by facilitated excretion from the body. Also, many substances are bioactivated by CYP3A4 to form their active compounds, and many protoxins are toxicated into their toxic forms (see table below for examples).CYP3A4 also possesses epoxygenase activity in that it metabolizes arachidonic acid to epoxyeicosatrienoic acids (EETs), i.e. (±)-8,9-, (±)-11,12-, and (±)-14,15-epoxyeicosatrienoic acids.JOURNAL, Bishop-Bailey D, Thomson S, Askari A, Faulkner A, Wheeler-Jones C, Lipid-metabolizing CYPs in the regulation and dysregulation of metabolism, Annual Review of Nutrition, 34, 261–79, 24819323, 10.1146/annurev-nutr-071813-105747, 2014,rvc-repository.worktribe.com/preview/1659487/kura-et-al-2023-can-mass-drug-administration-of-moxidectin-accelerate-onchocerciasis-elimination-in-africa.pdf, 2 February 2024, 18 January 2024,web.archive.org/web/20240118040330/https://rvc-repository.worktribe.com/preview/1659487/kura-et-al-2023-can-mass-drug-administration-of-moxidectin-accelerate-onchocerciasis-elimination-in-africa.pdf, live, EETs have a wide range of activities including the promotion of certain types of cancers (see epoxyeicosatetraenoic acid). CYP3A4 promotes the growth of various types of human cancer cell lines in culture by producing (±)-14,15-epoxyeicosatrienoic acids, which stimulate these cells to grow.JOURNAL, Fleming I, The pharmacology of the cytochrome P450 epoxygenase/soluble epoxide hydrolase axis in the vasculature and cardiovascular disease, Pharmacological Reviews, 66, 4, 1106–40, October 2014, 25244930, 10.1124/pr.113.007781, The CYP3A4 enzyme is also reported to have fatty acid monooxgenase activity for metabolizing arachidonic acid to 20-Hydroxyeicosatetraenoic acid (20-HETE).JOURNAL, Miyata N, Taniguchi K, Seki T, Ishimoto T, Sato-Watanabe M, Yasuda Y, Doi M, Kametani S, Tomishima Y, Ueki T, Sato M, Kameo K, HET0016, a potent and selective inhibitor of 20-HETE synthesizing enzyme, British Journal of Pharmacology, 133, 3, 325–9, June 2001, 11375247, 1572803, 10.1038/sj.bjp.0704101, 20-HETE has a wide range of activities that include growth stimulation in breast and other types of cancers (see 12-hydroxyeicosatetraenoic acid).

Evolution

The CYP3A4 gene exhibits a much more complicated upstream regulatory region in comparison with its paralogs.JOURNAL, Qiu H, Mathäs M, Nestler S, Bengel C, Nem D, Gödtel-Armbrust U, Lang T, Taudien S, Burk O, Wojnowski L, 205602787, The unique complexity of the CYP3A4 upstream region suggests a nongenetic explanation of its expression variability, Pharmacogenetics and Genomics, 20, 3, 167–78, March 2010, 20147837, 10.1097/FPC.0b013e328336bbeb, This increased complexity renders the CYP3A4 gene more sensitive to endogenous and exogenous PXR and CAR ligands, instead of relying on gene variants for wider specificity. Chimpanzee and human CYP3A4 are highly conserved in metabolism of many ligands, although four amino acids positively selected in humans led to a 5-fold benzylation of 7-BFC in the presence of the hepatotoxic secondary bile acid lithocholic acid.JOURNAL, Kumar S, Qiu H, Oezguen N, Herlyn H, Halpert JR, Wojnowski L, Ligand diversity of human and chimpanzee CYP3A4: activation of human CYP3A4 by lithocholic acid results from positive selection, Drug Metabolism and Disposition, 37, 6, 1328–33, June 2009, 19299527, 2683693, 10.1124/dmd.108.024372, This change in consequence contributes to an increased human defense against cholestasis.

Tissue distribution

Fetuses do not express CYP3A4 in their liver tissue, but rather CYP3A7 ({{EC number|1.14.14.1}}), which acts on a similar range of substrates. CYP3A4 increases to approximately 40% of adult levels in the fourth month of life and 72% at 12 months.JOURNAL, Johnson TN, Rostami-Hodjegan A, Tucker GT, 25596506, Prediction of the clearance of eleven drugs and associated variability in neonates, infants and children, Clinical Pharmacokinetics, 45, 9, 931–56, 2006, 16928154, 10.2165/00003088-200645090-00005, JOURNAL, Johnson TN, Tucker GT, Rostami-Hodjegan A, Development of CYP2D6 and CYP3A4 in the first year of life, Clinical Pharmacology and Therapeutics, 83, 5, 670–1, May 2008, 18043691, 10.1038/sj.clpt.6100327, 9714442, Although CYP3A4 is predominantly found in the liver, it is also present in other organs and tissues of the body, where it may play an important role in metabolism. CYP3A4 in the intestine plays an important role in the metabolism of certain drugs. Often this allows prodrugs to be activated and absorbed, as in the case of the histamine H1-receptor antagonist terfenadine.Recently CYP3A4 has also been identified in the brain, but its role in the central nervous system is still unknown.JOURNAL, Robertson GR, Field J, Goodwin B, Bierach S, Tran M, Lehnert A, Liddle C, 17209434, Transgenic mouse models of human CYP3A4 gene regulation, Molecular Pharmacology, 64, 1, 42–50, July 2003, 12815159, 10.1124/mol.64.1.42,

Mechanisms

Cytochrome P450 enzymes perform an assortment of modifications on a variety of ligands, utilizing its large active site and its ability to bind more than one substrate at a time to perform complicated chemical alterations in the metabolism of endogenous and exogenous compounds. These include hydroxylation, epoxidation of olefins, aromatic oxidation, heteroatom oxidations, N- and O- dealkylation reactions, aldehyde oxidations, dehydrogenation reactions, and aromatase activity.JOURNAL, Schmiedlin-Ren P, Edwards DJ, Fitzsimmons ME, He K, Lown KS, Woster PM, Rahman A, Thummel KE, Fisher JM, Hollenberg PF, Watkins PB, Mechanisms of enhanced oral availability of CYP3A4 substrates by grapefruit constituents. Decreased enterocyte CYP3A4 concentration and mechanism-based inactivation by furanocoumarins, Drug Metabolism and Disposition, 25, 11, 1228–33, November 1997, 9351897, JOURNAL, Shahrokh K, Cheatham TE, Yost GS, Conformational dynamics of CYP3A4 demonstrate the important role of Arg212 coupled with the opening of ingress, egress and solvent channels to dehydrogenation of 4-hydroxy-tamoxifen, Biochimica et Biophysica Acta (BBA) - General Subjects, 1820, 10, 1605–17, October 2012, 22677141, 3404218, 10.1016/j.bbagen.2012.05.011, Hydroxylation of an sp3 C-H bond is one of the ways in which CYP3A4 (and cytochrome P450 oxygenases) affects its ligand.JOURNAL, Meunier B, de Visser SP, Shaik S, 33927145, Mechanism of oxidation reactions catalyzed by cytochrome p450 enzymes, Chemical Reviews, 104, 9, 3947–80, September 2004, 15352783, 10.1021/cr020443g, In fact, hydroxylation is sometimes followed by dehydrogenation, leading to more complex metabolites. An example of a molecule that undergoes more than one reaction due to CYP3A4 includes tamoxifen, which is hydroxylated to 4-hydroxy-tamoxifen and then dehydrated to 4-hydroxy-tamoxifen quinone methide.Two mechanisms have been proposed as the primary pathway of hydroxylation in P450 enzymes. (File:Hydroxylation Mechanisms of Cytochrome P450 Enzymes.png|thumb|Two of the most commonly proposed mechanisms used for the hydroxylation of an sp3 C–H bond) The first pathway suggested is a cage-controlled radical method (“oxygen rebound“), and the second involves a concerted mechanism that does not utilize a radical intermediate but instead acts very quickly via a “radical clock”.

Inhibition through fruit ingestion

In 1998, various researchers showed that grapefruit juice, and grapefruit in general, is a potent inhibitor of CYP3A4, which can affect the metabolism of a variety of drugs, increasing their bioavailability.JOURNAL, He K, Iyer KR, Hayes RN, Sinz MW, Woolf TF, Hollenberg PF, Inactivation of cytochrome P450 3A4 by bergamottin, a component of grapefruit juice, Chemical Research in Toxicology, 11, 4, 252–9, April 1998, 9548795, 10.1021/tx970192k, JOURNAL, Bailey DG, Malcolm J, Arnold O, Spence JD, Grapefruit juice-drug interactions, British Journal of Clinical Pharmacology, 46, 2, 101–10, August 1998, 9723817, 1873672, 10.1046/j.1365-2125.1998.00764.x, JOURNAL, Garg SK, Kumar N, Bhargava VK, Prabhakar SK, Effect of grapefruit juice on carbamazepine bioavailability in patients with epilepsy, Clinical Pharmacology and Therapeutics, 64, 3, 286–8, September 1998, 9757152, 10.1016/S0009-9236(98)90177-1, 27490726, free, JOURNAL, Bailey DG, Dresser GK, 11525439, Interactions between grapefruit juice and cardiovascular drugs, American Journal of Cardiovascular Drugs, 4, 5, 281–97, 2004, 15449971, 10.2165/00129784-200404050-00002, JOURNAL, Bressler R, Grapefruit juice and drug interactions. Exploring mechanisms of this interaction and potential toxicity for certain drugs, Geriatrics, 61, 11, 12–8, November 2006, 17112309, In some cases, this can lead to a fatal interaction with drugs like astemizole or terfenadine. The effect of grapefruit juice with regard to drug absorption was originally discovered in 1989. The first published report on grapefruit drug interactions was in 1991 in the Lancet entitled “Interactions of Citrus Juices with Felodipine and Nifedipine”, and was the first reported food-drug interaction clinically. The effects of grapefruit last from 3–7 days, with the greatest effects when juice is taken an hour previous to administration of the drug.JOURNAL, Lilja JJ, Kivistö KT, Neuvonen PJ, Duration of effect of grapefruit juice on the pharmacokinetics of the CYP3A4 substrate simvastatin, Clinical Pharmacology and Therapeutics, 68, 4, 384–90, October 2000, 11061578, 10.1067/mcp.2000.110216, 29029956, In addition to grapefruit, other fruits have similar effects. Noni (Morinda citrifolia), for example, is a dietary supplement typically consumed as a juice and also inhibits CYP3A4.WEB,www.mskcc.org/cancer-care/herb/noni, Integrative Medicine, Noni, Memorial Sloan-Kettering Cancer Center, 27 June 2013, 20 August 2013,www.mskcc.org/cancer-care/herb/noni," title="web.archive.org/web/20130820052559www.mskcc.org/cancer-care/herb/noni,">web.archive.org/web/20130820052559www.mskcc.org/cancer-care/herb/noni, live, Pomegranate juice has shown some inhibition in limited studies, but has not yet demonstrated the effect in humans.JOURNAL, Hidaka M, Okumura M, Fujita K, Ogikubo T, Yamasaki K, Iwakiri T, Setoguchi N, Arimori K, 7997718, Effects of pomegranate juice on human cytochrome p450 3A (CYP3A) and carbamazepine pharmacokinetics in rats, Drug Metabolism and Disposition, 33, 5, 644–8, May 2005, 15673597, 10.1124/dmd.104.002824, JOURNAL, Anlamlert W, Sermsappasuk P, Pomegranate Juice does not Affect the Bioavailability of Cyclosporine in Healthy Thai Volunteers, Curr Clin Pharmacol, 15, 2, 145–151, 2020, 31924158, 7579232, 10.2174/1574884715666200110153125,

Variability

While over 28 single nucleotide polymorphisms (SNPs) have been identified in the CYP3A4 gene, it has been found that this does not translate into significant interindividual variability . It can be supposed that this may be due to the induction of CYP3A4 on exposure to substrates.CYP3A4 alleles that have been reported to have minimal function compared to wild-type include CYP3A4*6 (an A17776 insertion) and CYP3A4*17 (F189S). Both of these SNPs led to decreased catalytic activity with certain ligands, including testosterone and nifedipine in comparison to wild-type metabolism.JOURNAL, Lee SJ, Goldstein JA, Functionally defective or altered CYP3A4 and CYP3A5 single nucleotide polymorphisms and their detection with genotyping tests, Pharmacogenomics, 6, 4, 357–71, June 2005, 16004554, 10.1517/14622416.6.4.357,zenodo.org/record/1236271, 25 May 2020, 29 July 2020,web.archive.org/web/20200729005806/https://zenodo.org/record/1236271, live, By contrast, CYP3A4*1G allele has more potent enzymatic activity compared to CYP3A4*1A (the wild-type allele).Alkattan A, Alsalameen E. Polymorphisms of genes related to phase-I metabolic enzymes affecting the clinical efficacy and safety of clopidogrel treatment. Expert Opin Drug Metab Toxicol. 2021 Apr 30. doi: 10.1080/17425255.2021.1925249. Epub ahead of print. PMID 33931001.Variability in CYP3A4 function can be determined noninvasively by the erythromycin breath test (ERMBT). The ERMBT estimates CYP3A4 activity by measuring the radiolabelled carbon dioxide exhaled after an intravenous dose of (14C-N-methyl)-erythromycin.JOURNAL, Watkins PB, Noninvasive tests of CYP3A enzymes, Pharmacogenetics, 4, 4, 171–84, August 1994, 7987401, 10.1097/00008571-199408000-00001,cdr.lib.unc.edu/record/uuid:8d5c6276-d350-4216-b108-276f2be1d59d,

Induction

CYP3A4 is induced by a wide variety of ligands. These ligands bind to the pregnane X receptor (PXR). The activated PXR complex forms a heterodimer with the retinoid X receptor (RXR), which binds to the XREM region of the CYP3A4 gene. XREM is a regulatory region of the CYP3A4 gene, and binding causes a cooperative interaction with proximal promoter regions of the gene, resulting in increased transcription and expression of CYP3A4. Activation of the PXR/RXR heterodimer initiates transcription of the CYP3A4 promoter region and gene. Ligand binding increases when in the presence of CYP3A4 ligands, such as in the presence of aflatoxin B1, M1, and G1. Indeed, due to the enzyme’s large and malleable active site, it is possible for the enzyme to bind multiple ligands at once, leading to potentially detrimental side effects.JOURNAL, Ratajewski M, Walczak-Drzewiecka A, SaÅ‚kowska A, Dastych J, Aflatoxins upregulate CYP3A4 mRNA expression in a process that involves the PXR transcription factor, Toxicology Letters, 205, 2, 146–53, August 2011, 21641981, 10.1016/j.toxlet.2011.05.1034, Induction of CYP3A4 has been shown to vary in humans depending on sex. Evidence shows an increased drug clearance by CYP3A4 in women, even when accounting for differences in body weight. A study by Wolbold et al. (2003) found that the median CYP3A4 levels measured from surgically removed liver samples of a random sample of women exceeded CYP3A4 levels in the livers of men by 129%. CYP3A4 mRNA transcripts were found in similar proportions, suggesting a pre-translational mechanism for the up-regulation of CYP3A4 in women. The exact cause of this elevated level of enzyme in women is still under speculation, however studies have elucidated other mechanisms (such as CYP3A5 or CYP3A7 compensation for lowered levels of CYP3A4) that affect drug clearance in both men and women.JOURNAL, Wolbold R, Klein K, Burk O, Nüssler AK, Neuhaus P, Eichelbaum M, Schwab M, Zanger UM, Sex is a major determinant of CYP3A4 expression in human liver, Hepatology, 38, 4, 978–88, October 2003, 14512885, 10.1053/jhep.2003.50393, CYP3A4 substrate activation varies amongst different animal species. Certain ligands activate human PXR, which promotes CYP3A4 transcription, while showing no activation in other species. For instance, mouse PXR is not activated by rifampicin and human PXR is not activated by pregnenolone 16α-carbonitrileJOURNAL, Gonzalez FJ, CYP3A4 and pregnane X receptor humanized mice, Journal of Biochemical and Molecular Toxicology, 21, 4, 158–62, 2007, 17936928, 10.1002/jbt.20173, 21501739,zenodo.org/record/1229206, 6 September 2019, 29 July 2020,web.archive.org/web/20200729031129/https://zenodo.org/record/1229206, live, In order to facilitate study of CYP3A4 functional pathways in vivo, mouse strains have been developed using transgenes in order to produce null/human CYP3A4 and PXR crosses. Although humanized hCYP3A4 mice successfully expressed the enzyme in their intestinal tract, low levels of hCYP3A4 were found in the liver. This effect has been attributed to CYP3A4 regulation by the growth hormone signal transduction pathway. In addition to providing an in vivo model, humanized CYP3A4 mice (hCYP3A4) have been used to further emphasize gender differences in CYP3A4 activity.CYP3A4 activity levels have also been linked to diet and environmental factors, such as duration of exposure to xenobiotic substances.JOURNAL, Crago J, Klaper RD, Influence of gender, feeding regimen, and exposure duration on gene expression associated with xenobiotic metabolism in fathead minnows (), Comparative Biochemistry and Physiology. Toxicology & Pharmacology, 154, 3, 208–12, September 2011, 21664292, 10.1016/j.cbpc.2011.05.016, Due to the enzyme’s extensive presence in the intestinal mucosa, the enzyme has shown sensitivity to starvation symptoms and is upregulated in defense of adverse effects. Indeed, in fatheaded minnows, unfed female fish were shown to have increased PXR and CYP3A4 expression, and displayed a more pronounced response to xenobiotic factors after exposure after several days of starvation. By studying animal models and keeping in mind the innate differences in CYP3A4 activation, investigators can better predict drug metabolism and side effects in human CYP3A4 pathways.

Turnover

Estimates of the turnover rate of human CYP3A4 vary widely. For hepatic CYP3A4, in vivo methods yield estimates of the enzyme half-life mainly in the range of 70 to 140 hours, whereas in vitro methods give estimates from 26 to 79 hours. Turnover of gut CYP3A4 is likely to be a function of the rate of enterocyte renewal; an indirect approach based on the recovery of activity following exposure to grapefruit juice yields measurements in the 12- to 33-hour range.JOURNAL, Yang J, Liao M, Shou M, Jamei M, Yeo KR, Tucker GT, Rostami-Hodjegan A, Cytochrome p450 turnover: regulation of synthesis and degradation, methods for determining rates, and implications for the prediction of drug interactions, Current Drug Metabolism, 9, 5, 384–94, June 2008, 18537575, 10.2174/138920008784746382,

Technology

Due to membrane-bound CYP3A4’s natural propensity to conglomerate, it has historically been difficult to study drug binding in both solution and on surfaces. Co-crystallization is difficult since the substrates tend to have a low KD (between 5–150 Î¼M) and low solubility in aqueous solutions.JOURNAL, Sevrioukova IF, Poulos TL, Structural and mechanistic insights into the interaction of cytochrome P4503A4 with bromoergocryptine, a type I ligand, The Journal of Biological Chemistry, 287, 5, 3510–7, January 2012, 22157006, 3271004, 10.1074/jbc.M111.317081, free, A successful strategy in isolating the bound enzyme is the functional stabilization of monomeric CYP3A4 on silver nanoparticles produced from nanosphere lithography and analyzed via localized surface plasmon resonance spectroscopy (LSPR).JOURNAL, Das A, Zhao J, Schatz GC, Sligar SG, Van Duyne RP, Screening of type I and II drug binding to human cytochrome P450-3A4 in nanodiscs by localized surface plasmon resonance spectroscopy, Analytical Chemistry, 81, 10, 3754–9, May 2009, 19364136, 4757437, 10.1021/ac802612z, These analyses can be used as a high-sensitivity assay of drug binding, and may become integral in further high-throughput assays utilized in initial drug discovery testing. In addition to LSPR, CYP3A4-Nanodisc complexes have been found helpful in other applications including solid-state NMR, redox potentiometry, and steady-state enzyme kinetics.

Ligands

Following are lists of selected substrates, inducers and inhibitors of CYP3A4. Where classes of agents are listed, there may be exceptions within the class.

Substrates

The substrates of CYP3A4 are:

• some immunosuppressants:
  • ciclosporin (cyclosporin),FASS (drug formulary): Swedish environmental classification of pharmaceuticals {{Webarchive|url=https://web.archive.org/web/20020611044953www.fass.se/LIF/produktfakta/fakta_lakare_artikel.jsp?articleID=18352 |date=11 June 2002 }} Facts for prescribers (Fakta för förskrivare). Retrieved July 2011
  • tacrolimus,
  • sirolimus,
  • upadacitinib;“Rinvoq: EPAR – Public assessment report {{Webarchive|url=https://web.archive.org/web/20200721125405www.ema.europa.eu/en/documents/assessment-report/rinvoq-epar-public-assessment-report_en.pdf |date=21 July 2020 }}” (PDF). European Medicines Agency. 5 March 2020. Archived (PDF) from the original on 21 July 2020. Retrieved 21 July 2020.Austria-Codex (in German). Vienna: Österreichischer Apothekerverlag. 2020. Rinvoq 15 mg Retardtabletten.
• many chemotherapeutics:
  • docetaxel,
  • tamoxifen,
  • paclitaxel,
  • cyclophosphamide,
  • doxorubicin,
  • erlotinib,WEB, Erlotinib,www.drugs.com/ppa/erlotinib.html, Metabolized primarily by CYP3A4 and, to a lesser degree, by CYP1A2 and the extrahepatic isoform CYP1A1, 10 April 2018, 24 December 2019,web.archive.org/web/20191224052924/https://www.drugs.com/ppa/erlotinib.html, live,
  • etoposide,
  • ifosfamide,
  • teniposide,
  • vinblastine,
  • vincristine,
  • vindesine,
  • imatinib,
  • irinotecan,
  • sorafenib,
  • sunitinib,
  • vemurafenib,
  • temsirolimus,
  • anastrozole,
  • gefitinib;
• azole antifungals:
  • ketoconazole
  • itraconazole
• macrolides (except azithromycin):
  • clarithromycin,
  • erythromycin,
  • telithromycin;
• dapsone (in leprosy),
• tricyclic antidepressants:
  • amitriptyline,
  • clomipramine,
  • imipramine,
  • cyclobenzaprine;WEB,www.drugbank.ca/drugs/DB00924, Cyclobenzaprine, DrugBank, 10 April 2018, 27 October 2018,web.archive.org/web/20181027220500/https://www.drugbank.ca/drugs/DB00924, live,
• SSRI antidepressants :
  • citalopram
  • norfluoxetine
  • sertraline
• some other antidepressants:
  • mirtazapine (NaSSA),
  • nefazodone (atypical),
  • reboxetine (NRI),
  • venlafaxine (SNRI),
  • trazodone (SARI),
  • vilazodone (serotonin modulator),
• buspirone (anxiolytic),
• antipsychotics:
  • haloperidol,
  • aripiprazole,
  • risperidone,
  • ziprasidone,
  • pimozide,
  • quetiapine,
  • lurasidone;BOOK, Azhar Y, Shaban K, Lurasidone, 2022,www.ncbi.nlm.nih.gov/books/NBK541057/, StatPearls, Treasure Island (FL), StatPearls Publishing, 31082101, 14 October 2022, 18 May 2023,web.archive.org/web/20230518045845/https://www.ncbi.nlm.nih.gov/books/NBK541057/, live,
• opioids (mainly analgesics):
  • alfentanil,
  • buprenorphineJOURNAL, Moody DE, Fang WB, Lin SN, Weyant DM, Strom SC, Omiecinski CJ, Effect of rifampin and nelfinavir on the metabolism of methadone and buprenorphine in primary cultures of human hepatocytes, Drug Metabolism and Disposition, 37, 12, 2323–9, December 2009, 19773542, 2784702, 10.1124/dmd.109.028605, (analgesic, addiction maintenance treatment),
  • codeine (analgesic, antitussive, antidiarrheal),
  • fentanyl,
  • hydrocodoneJOURNAL, British Journal of Clinical Pharmacology, CYP2D6 and CYP3A4 involvement in the primary oxidative metabolism of hydrocodone by human liver microsomes, Hutchinson MR, Menelaou A, Foster DJ, Coller JK, Somogyi AA, 14998425, 57, 3, Mar 2004, 287–97, 10.1046/j.1365-2125.2003.02002.x, 1884456, (partial involvement, not the bioactivation factor),
  • methadone (analgesic, addiction maintenance treatment),
  • levacetylmethadol,
  • tramadol (to inactive metabolites, do not confuse with metabolism via CYP2D6);
• benzodiazepines:
  • alprazolam,
  • midazolam,
  • triazolam,
  • diazepam, (bioactivation to desmethyldiazepam)
  • clonazepam;JOURNAL, Tanaka E, Clinically significant pharmacokinetic drug interactions with benzodiazepines, Journal of Clinical Pharmacy and Therapeutics, 24, 5, 347–355, October 1999, 10583697, 10.1046/j.1365-2710.1999.00247.x, 22229823, free,
• some hypnotics:
  • zopiclone,
  • zaleplon,
  • zolpidem,
• donepezil (acetylcholinesterase inhibitor),
• statins (except pravastatin and rosuvastatin):
  • atorvastatin,
  • lovastatin,
  • simvastatin,
  • cerivastatin;
• calcium channel blockers:
  • diltiazem (sensitive substrateJOURNAL, Sutton D, Butler AM, Nadin L, Murray M, Role of CYP3A4 in human hepatic diltiazem N-demethylation: inhibition of CYP3A4 activity by oxidized diltiazem metabolites, The Journal of Pharmacology and Experimental Therapeutics, 282, 1, 294–300, July 1997, 9223567, ),
  • felodipine (sensitive substrateWEB, Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers, U S Food and Drug Administration Home Page, 25 June 2009,www.fda.gov/drugs/developmentapprovalprocess/developmentresources/druginteractionslabeling/ucm093664.htmtable2-2, 1 February 2019, 23 April 2019,web.archive.org/web/20190423033345/https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm093664.htmtable2-2, live, JOURNAL, Lown KS, Bailey DG, Fontana RJ, Janardan SK, Adair CH, Fortlage LA, Brown MB, Guo W, Watkins PB, Grapefruit juice increases felodipine oral availability in humans by decreasing intestinal CYP3A protein expression, The Journal of Clinical Investigation, 99, 10, 2545–53, May 1997, 9153299, 508096, 10.1172/jci119439, American Society for Clinical Investigation, JOURNAL, Bailey DG, Bend JR, Arnold JM, Tran LT, Spence JD, Erythromycin-felodipine interaction: magnitude, mechanism, and comparison with grapefruit juice, Clinical Pharmacology and Therapeutics, 60, 1, 25–33, July 1996, 8689808, 10.1016/s0009-9236(96)90163-0, Springer Nature, 1246705, JOURNAL, Guengerich FP, Brian WR, Iwasaki M, Sari MA, Bäärnhielm C, Berntsson P, Oxidation of dihydropyridine calcium channel blockers and analogues by human liver cytochrome P-450 IIIA4, Journal of Medicinal Chemistry, 34, 6, 1838–44, June 1991, 2061924, 10.1021/jm00110a012, ),
  • nifedipine (sensitive substrateJOURNAL, Katoh M, Nakajima M, Yamazaki H, Yokoi T, Inhibitory effects of CYP3A4 substrates and their metabolites on P-glycoprotein-mediated transport, European Journal of Pharmaceutical Sciences, 12, 4, 505–13, February 2001, 11231118, 10.1016/s0928-0987(00)00215-3, JOURNAL, Foti RS, Rock DA, Wienkers LC, Wahlstrom JL, 6823063, Selection of alternative CYP3A4 probe substrates for clinical drug interaction studies using in vitro data and in vivo simulation, Drug Metabolism and Disposition, 38, 6, 981–7, June 2010, 20203109, 10.1124/dmd.110.032094, American Society for Pharmacology & Experimental Therapeutics (ASPET), JOURNAL, Odou P, Ferrari N, Barthélémy C, Brique S, Lhermitte M, Vincent A, Libersa C, Robert H, Grapefruit juice-nifedipine interaction: possible involvement of several mechanisms, Journal of Clinical Pharmacy and Therapeutics, 30, 2, 153–8, April 2005, 15811168, 10.1111/j.1365-2710.2004.00618.x, 30463290, free, WEB, NIFEDIPINE EXTENDED RELEASE- nifedipine tablet, extended release, DailyMed, 29 November 2012,dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4617417a-08df-4417-a944-dfc30de183db, 1 February 2019, Drug Interactions: Nifedipine is mainly eliminated by metabolism and is a substrate of CYP3A. Inhibitors and inducers of CYP3A can impact the exposure to nifedipine and, consequently, its desirable and undesirable effects. In vitro and in vivo data indicate that nifedipine can inhibit the metabolism of drugs that are substrates of CYP3A, thereby increasing the exposure to other drugs. Nifedipine is a vasodilator, and coadministration of other drugs affecting blood pressure may result in pharmacodynamic interactions., 31 January 2022,web.archive.org/web/20220131061535/https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4617417a-08df-4417-a944-dfc30de183db, live, ),
  • verapamil (sensitive substrateJOURNAL, Zhang Y, Guo X, Lin ET, Benet LZ, Overlapping substrate specificities of cytochrome P450 3A and P-glycoprotein for a novel cysteine protease inhibitor, Drug Metabolism and Disposition, 26, 4, 360–6, April 1998, 9531525, JOURNAL, Stringer KA, Mallet J, Clarke M, Lindenfeld JA, The effect of three different oral doses of verapamil on the disposition of theophylline, European Journal of Clinical Pharmacology, 43, 1, 35–8, 1992, 1505606, 10.1007/bf02280751, 8942097, JOURNAL, Nielsen-Kudsk JE, Buhl JS, Johannessen AC, Verapamil-induced inhibition of theophylline elimination in healthy humans, Pharmacology & Toxicology, 66, 2, 101–3, February 1990, 2315261, 10.1111/j.1600-0773.1990.tb00713.x, JOURNAL, Gin AS, Stringer KA, Welage LS, Wilton JH, Matthews GE, The effect of verapamil on the pharmacokinetic disposition of theophylline in cigarette smokers, Journal of Clinical Pharmacology, 29, 8, 728–32, August 1989, 2778093, 10.1002/j.1552-4604.1989.tb03407.x, 20446675, JOURNAL, Sirmans SM, Pieper JA, Lalonde RL, Smith DG, Self TH, Effect of calcium channel blockers on theophylline disposition, Clinical Pharmacology and Therapeutics, 44, 1, 29–34, July 1988, 3391002, 10.1038/clpt.1988.108, 39570845, JOURNAL, Robson RA, Miners JO, Birkett DJ, Selective inhibitory effects of nifedipine and verapamil on oxidative metabolism: effects on theophylline, British Journal of Clinical Pharmacology, 25, 3, 397–400, March 1988, 3358901, 1386365, 10.1111/j.1365-2125.1988.tb03319.x, JOURNAL, Abernethy DR, Egan JM, Dickinson TH, Carrum G, Substrate-selective inhibition by verapamil and diltiazem: differential disposition of antipyrine and theophylline in humans, The Journal of Pharmacology and Experimental Therapeutics, 244, 3, 994–9, March 1988, 3252045, ),
  • amlodipine (sensitive substrateJOURNAL, Katoh M, Nakajima M, Yamazaki H, Yokoi T, Inhibitory potencies of 1,4-dihydropyridine calcium antagonists to P-glycoprotein-mediated transport: comparison with the effects on CYP3A4, Pharmaceutical Research, 17, 10, 1189–97, October 2000, 11145223, 10.1023/a:1007568811691, 24304693, ),
  • lercanidipine,
  • nitrendipine,
  • nisoldipine,
• amiodarone (class III antiarrhythmic),
• dronedarone (class III antiarrhythmic),
• quinidine (class I antiarrhythmic),
• PDE5 inhibitors:
  • sildenafil,
  • tadalafil,WEB, Active ingredient: Tadalafil - Brands, Medical Use, Clinical Data,www.druglib.com/activeingredient/tadalafil/, Druglib.com, 13 March 2022, 28 November 2022,www.druglib.com/activeingredient/tadalafil/," title="web.archive.org/web/20221128145825www.druglib.com/activeingredient/tadalafil/,">web.archive.org/web/20221128145825www.druglib.com/activeingredient/tadalafil/, live,
• kinins (vasodilators, smooth muscle contractors),
• steroids:
  • sex hormones (agonists and antagonists):
    • finasteride (antiandrogen),
    • estradiol (estrogen),
    • progesterone,
    • ethinylestradiol (hormonal contraceptive),
    • testosterone (androgen),
    • toremifene (SERM),
    • bicalutamide;JOURNAL, Cockshott ID, Bicalutamide: clinical pharmacokinetics and metabolism, Clinical Pharmacokinetics, 43, 13, 855–78, 2004, 15509184, 10.2165/00003088-200443130-00003, 29912565,
  • glucocorticoids:
    • budesonide,
    • hydrocortisone (cortisol),JOURNAL, Aquinos BM, García Arabehety J, Canteros TM, de Miguel V, Scibona P, Fainstein-Day P, [Adrenal crisis associated with modafinil use], es, Medicina, 81, 5, 846–849, 2021, 34633961,
    • dexamethasone,
    • fluticasone;JOURNAL, Ledger T, Tong W, Rimmer J, Iatrogenic Cushing’s syndrome with inhaled fluticasone, Australian Prescriber, 42, 4, 139–140, August 2019, 31427846, 6698236, 10.18773/austprescr.2019.040,
• some H1-receptor antagonists (H1 antihistamines):
  • ketotifen,JOURNAL, 10.1016/j.ancr.2014.11.003, Analysis for commonly prescribed non-sedating antihistamines, 2015, Analytical Chemistry Research, 3, 1–12, El-Kommos ME, El-Gizawy SM, Atia NN, Hosny NM, free, JOURNAL, Jáuregui I, Mullol J, Bartra J, del Cuvillo A, Dávila I, Montoro J, Sastre J, Valero AL, H1 antihistamines: psychomotor performance and driving, J Investig Allergol Clin Immunol, 16, Suppl 1, 37–44, 2006, 17357376, JOURNAL, Li L, Liu R, Peng C, Chen X, Li J, Pharmacogenomics for the efficacy and side effects of antihistamines, Exp Dermatol, 31, 7, 993–1004, July 2022, 35538735, 10.1111/exd.14602, JOURNAL, Merk HF, Standard treatment: the role of antihistamines, J Investig Dermatol Symp Proc, 6, 2, 153–6, November 2001, 11764306, 10.1046/j.0022-202x.2001.00032.x, free, doi,
  • terfenadine,
  • astemizole,JOURNAL, Matsumoto S, Yamazoe Y, Involvement of multiple human cytochromes P450 in the liver microsomal metabolism of astemizole and a comparison with terfenadine, British Journal of Clinical Pharmacology, 51, 2, 133–42, February 2001, 11259984, 2014443, 10.1111/j.1365-2125.2001.01292.x,
  • chlorphenamine;
• protease inhibitors:
  • indinavir,
  • ritonavir,
  • saquinavir,
  • nelfinavir;
• non-nucleoside reverse-transcriptase inhibitors (antiretroviral drugs):
  • nevirapineBOOK, Marzinke MA, Chapter 6 - Therapeutic Drug Monitoring of Antiretrovirals, Therapeutic Drug Monitoring of Antiretrovirals, 2016-01-01, Clinical Challenges in Therapeutic Drug Monitoring, 135–163, Clarke W, Dasgupta A,www.sciencedirect.com/science/article/pii/B9780128020258000064, 2024-02-06, San Diego, Elsevier, 10.1016/B978-0-12-802025-8.00006-4, 978-0-12-802025-8, 2 May 2024,web.archive.org/web/20240502101129/https://www.sciencedirect.com/science/article/abs/pii/B9780128020258000064, live,
  • delavirdine,
  • efavirenz,
  • etravirine,
  • rilpivirine;
• albendazoleEnzyme 1.14.13.32 {{Webarchive|url=https://web.archive.org/web/20170327070920www.genome.jp/dbget-bin/www_bget?enzyme+1.14.13.32 |date=27 March 2017 }} at KEGGWEB, Showing Protein Cytochrome P450 3A4 (HMDBP01018), Human Metabolome Database, 5 August 2017,www.hmdb.ca/proteins/HMDBP01018, 2 May 2024,web.archive.org/web/20240502101115/https://hmdb.ca/proteins/HMDBP01018, live, (antihelminthic)
• cisapride, (5-HT4 receptor agonist)
• aprepitant, (antiemetic)
• caffeine, (stimulant)
• cocaine, (stimulant)
• cilostazol, (phosphodiesterase inhibitor)
• dextromethorphan, (antitussive)
• domperidone, (antidopaminergic)
• eplerenone, (aldosterone antagonist)
• lidocaine, (local anesthetic, antiarrhythmic)
• ondansetron, (5-HT3 antagonist)
• propranolol, (beta blocker)
• salmeterol, (beta agonist)
• warfarin,JOURNAL, Daly AK, King BP, Pharmacogenetics of oral anticoagulants, Pharmacogenetics, 13, 5, 247–52, May 2003, 12724615, 10.1097/00008571-200305000-00002, (anticoagulant)
• clopidogrel becoming bioactivatedJOURNAL, Lau WC, Waskell LA, Watkins PB, Neer CJ, Horowitz K, Hopp AS, Tait AR, Carville DG, Guyer KE, Bates ER, Atorvastatin reduces the ability of clopidogrel to inhibit platelet aggregation: a new drug-drug interaction, Circulation, 107, 1, 32–7, January 2003, 12515739, 10.1161/01.CIR.0000047060.60595.CC, free, (antiplatelet),
• 2-oxo-clopidogrel,
• omeprazole, (proton pump inhibitor)
• nateglinide, (antidiabetic)
• methoxetamine,JOURNAL, Meyer MR, Bach M, Welter J, Bovens M, Turcant A, Maurer HH, 27966043, Ketamine-derived designer drug methoxetamine: metabolism including isoenzyme kinetics and toxicological detectability using GC-MS and LC-(HR-)MSn, Analytical and Bioanalytical Chemistry, 405, 19, 6307–21, July 2013, 23774830, 10.1007/s00216-013-7051-6,
• montelukast (leukotriene receptor antagonist),
• vilaprisan (selective progesterone receptor modulator),
• certain angiotensin II receptor blockers:
  • losartan, (sensitive substrates)WEB, LOSARTAN- losartan potassium tablet, film coated, DailyMed, 26 December 2018,dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a98a821c-7b81-4f9b-9801-1a16d71871ce, 6 February 2019, 7 February 2019,web.archive.org/web/20190207015904/https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a98a821c-7b81-4f9b-9801-1a16d71871ce, live, JOURNAL, Taavitsainen P, Kiukaanniemi K, Pelkonen O, In vitro inhibition screening of human hepatic P450 enzymes by five angiotensin-II receptor antagonists, Eur J Clin Pharmacol, 56, 2, 135–40, May 2000, 10877007, 10.1007/s002280050731, 26865251,
  • irbesartan.

Inhibitors

Inhibitors of CYP3A4 are classified by potency:

• a Strong inhibitor causes at least a 5-fold increase in the plasma AUC values, or more than 80% decrease in clearance.
• a Moderate inhibitor causes at least a 2-fold increase in the plasma AUC values, or 50–80% decrease in clearance.
• a Weak inhibitor causes at least a 1.25-fold but less than 2-fold increase in the plasma AUC values, or 20–50% decrease in clearance.WEB, Flockhart DA, Drug Interactions: Cytochrome P450 Drug Interaction Table, Indiana University School of Medicine, 2007,medicine.iupui.edu/flockhart/table.htm, 25 December 2008, 10 October 2007,medicine.iupui.edu/flockhart/table.htm," title="web.archive.org/web/20071010053126medicine.iupui.edu/flockhart/table.htm,">web.archive.org/web/20071010053126medicine.iupui.edu/flockhart/table.htm, live, Retrieved on 25 December 2008.

The inhibitors of CYP3A4 are the following substances.

Strong inhibitors

• boceprevir,JOURNAL, Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers, FDA, 6 May 2023,www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-inducers, US Food and Drug Administration, 21 June 2020, 4 November 2020,web.archive.org/web/20201104173036/https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-inducers, live,
• protease inhibitors:
  • ritonavir,
  • indinavir,
  • nelfinavir,
  • saquinavir;
• some macrolide antibiotics:
  • clarithromycin,JOURNAL, Kapetas AJ, Abuhelwa AY, Sorich MJ, McKinnon RA, Rodrigues AD, Rowland A, Hopkins AM, Evidence-Based Guidelines for Drug Interaction Studies: Model-Informed Time Course of Intestinal and Hepatic CYP3A4 Inhibition by Clarithromycin, AAPS J, 23, 5, 104, August 2021, 34467456, 10.1208/s12248-021-00632-7, 237373341, JOURNAL, Ushiama H, Echizen H, Nachi S, Ohnishi A, Dose-dependent inhibition of CYP3A activity by clarithromycin during Helicobacter pylori eradication therapy assessed by changes in plasma lansoprazole levels and partial cortisol clearance to 6beta-hydroxycortisol, Clin Pharmacol Ther, 72, 1, 33–43, July 2002, 12152002, 10.1067/mcp.2002.125559, free, JOURNAL, Herdegen T, Cascorbi I, Drug Interactions of Tetrahydrocannabinol and Cannabidiol in Cannabinoid Drugs: Recommendations for Clinical Practice, Dtsch Arztebl Int, 120, 49, 833–840, December 2023, 37874128, 10.3238/arztebl.m2023.0223, 10824494, December 1, 2024, 264438050,
  • erythromycinJOURNAL, Hougaard Christensen MM, Bruun Haastrup M, Øhlenschlaeger T, Esbech P, Arnspang Pedersen S, Bach Dunvald AC, Bjerregaard Stage T, Pilsgaard Henriksen D, Thestrup Pedersen AJ, Interaction potential between clarithromycin and individual statins-A systematic review, Basic Clin Pharmacol Toxicol, 126, 4, 307–317, April 2020, 31628882, 10.1111/bcpt.13343, Erythromycin 500 mg three-four times daily for 6-7 days markedly increased lovastatin exposure (≈6-fold increase in AUC),findresearcher.sdu.dk/ws/files/158846448/Interaction_Potential_between_Clarithromycin_and_Individual_Statins_a_Systematic_Review.pdf, 2 February 2024, 2 February 2024,web.archive.org/web/20240202140200/https://findresearcher.sdu.dk/ws/files/158846448/Interaction_Potential_between_Clarithromycin_and_Individual_Statins_a_Systematic_Review.pdf, live, (although FDA lists it as a moderate inhibitor, and inhibitor of P-glycoprotein, defined as those increasing the AUC of digoxin to ≥1.25-fold);
  • telithromycin
• ceritinib
• mibefradil (used for the treatment of hypertension and chronic angina pectoris)
• nefazodone (antidepressant)
• ribociclib
• tucatinib
• chloramphenicol (antibiotic)JOURNAL, Park JY, Kim KA, Kim SL, Chloramphenicol is a potent inhibitor of cytochrome P450 isoforms CYP2C19 and CYP3A4 in human liver microsomes, Antimicrobial Agents and Chemotherapy, 47, 11, 3464–9, November 2003, 14576103, 253795, 10.1128/AAC.47.11.3464-3469.2003,
• some azole antifungals:
  • ketoconazole,
  • itraconazole,
  • posaconazole,WEB,www.fda.gov/drugs/developmentapprovalprocess/developmentresources/druginteractionslabeling/ucm093664.htm, Drug Interactions & Labeling - Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers, Center for Drug Evaluation and Research, www.fda.gov, 6 August 2018, 23 April 2019,web.archive.org/web/20190423033345/https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm093664.htm, live,
  • voriconazole;
• cobicistat,
• green tea extract,
• grape seed extract,JOURNAL, Darweesh RS, El-Elimat T, Zayed A, Khamis TN, Babaresh WM, Arafat T, Al Sharie AH, The effect of grape seed and green tea extracts on the pharmacokinetics of imatinib and its main metabolite, N-desmethyl imatinib, in rats, BMC Pharmacology & Toxicology, 21, 1, 77, November 2020, 33198812, 7670682, 10.1186/s40360-020-00456-9, free, JOURNAL, Nishikawa M, Ariyoshi N, Kotani A, Ishii I, Nakamura H, Nakasa H, Ida M, Nakamura H, Kimura N, Kimura M, Hasegawa A, Kusu F, Ohmori S, Nakazawa K, Kitada M, 6, Effects of continuous ingestion of green tea or grape seed extracts on the pharmacokinetics of midazolam, Drug Metabolism and Pharmacokinetics, 19, 4, 280–289, August 2004, 15499196, 10.2133/dmpk.19.280, JOURNAL, Wanwimolruk S, Wong K, Wanwimolruk P, Variable inhibitory effect of different brands of commercial herbal supplements on human cytochrome P-450 CYP3A4, Drug Metabolism and Drug Interactions, 24, 1, 17–35, 2009, 19353999, 10.1515/dmdi.2009.24.1.17,pubmed.ncbi.nlm.nih.gov/19353999/, 14 October 2023, live, 27192663,web.archive.org/web/20231021225447/https://pubmed.ncbi.nlm.nih.gov/19353999/, 21 October 2023,
• dillapiole (compound present in dill plants),JOURNAL, Francis Carballo-Arce A, Raina V, Liu S, Liu R, Jackiewicz V, Carranza D, Arnason JT, Durst T, 6, Potent CYP3A4 Inhibitors Derived from Dillapiol and Sesamol, ACS Omega, 4, 6, 10915–10920, June 2019, 31460189, 6648837, 10.1021/acsomega.9b00897, JOURNAL, Briguglio M, Hrelia S, Malaguti M, Serpe L, Canaparo R, Dell’Osso B, Galentino R, De Michele S, Dina CZ, Porta M, Banfi G, 6, Food Bioactive Compounds and Their Interference in Drug Pharmacokinetic/Pharmacodynamic Profiles, Pharmaceutics, 10, 4, 277, December 2018, 30558213, 6321138, 10.3390/pharmaceutics10040277, free,
• apigenin (compound present in plants such as celery, parsley, and chamomile)JOURNAL, Kondža M, Bojić M, Tomić I, MaleÅ¡ Ž, Rezić V, Ćavar I, Characterization of the CYP3A4 Enzyme Inhibition Potential of Selected Flavonoids, Molecules, 26, 10, 3018, May 2021, 34069400, 8158701, 10.3390/molecules26103018, free,
• Artemisia annuaJOURNAL, Kondža M, Mandić M, Ivančić I, Vladimir-Knežević S, Brizić I, Artemisia annua L. Extracts Irreversibly Inhibit the Activity of CYP2B6 and CYP3A4 Enzymes, Biomedicines, 11, 1, 232, January 2023, 36672740, 9855681, 10.3390/biomedicines11010232, free,

Moderate inhibitors

• amiodarone (class III antiarrhythmic),
• aprepitant, (antiemetic)
• ciprofloxacin,
• conivaptan,
• crizotinib,
• rutin (in vitro)JOURNAL, Karakurt S, Modulatory effects of rutin on the expression of cytochrome P450s and antioxidant enzymes in human hepatoma cells, Acta Pharmaceutica, 66, 4, 491–502, December 2016, 27749250, 10.1515/acph-2016-0046, 20274417, free,hrcak.srce.hr/file/243341, 2 February 2024, 18 June 2022,web.archive.org/web/20220618102746/https://hrcak.srce.hr/file/243341, live, JOURNAL, Ashour ML, Youssef FS, Gad HA, Wink M, Inhibition of Cytochrome P450 (CYP3A4) Activity by Extracts from 57 Plants Used in Traditional Chinese Medicine (TCM), Pharmacognosy Magazine, 13, 50, 300–308, 2017, 28539725, 5421430, 10.4103/0973-1296.204561, free, (dietary flavonoid),
• tofisopam,
• some calcium channel blockers:
  • verapamil,
  • diltiazem;
• some azole antifungals:
  • fluconazole,
  • miconazole;Product Information: ORAVIG(R) buccal tablets, miconazole buccal tablets. Praelia Pharmaceuticals, Inc (per FDA), Cary, NC, 2013.
• bergamottinJOURNAL, Vetrichelvan O, Gorjala P, Goodman O, Mitra R, Bergamottin a CYP3A inhibitor found in grapefruit juice inhibits prostate cancer cell growth by downregulating androgen receptor signaling and promoting G0/G1 cell cycle block and apoptosis, PLOS ONE, 16, 9, e0257984, 2021, 34570813, 8476002, 10.1371/journal.pone.0257984, 2021PLoSO..1657984V, free, (constituent of grapefruit juice),
• cyclosporine,
• donedarone,
• fluvoxamine,
• imatinib,
• valerian.WEB,www.rxlist.com/valerian-page3/supplements.htmInteractions, Valerian: Health Benefits, Side Effects, Uses, Dose & Precautions, 10 April 2018, 16 January 2018,web.archive.org/web/20180116055514/https://www.rxlist.com/valerian-page3/supplements.htmInteractions, dead,

Weak inhibitors

• berberineJOURNAL, Feng PF, Zhu LX, Jie J, Yang PX, Chen X, The Intracellular Mechanism of Berberine-Induced Inhibition of CYP3A4 Activity, Curr Pharm Des, 27, 40, 4179–4185, 2021, 34269665, 10.2174/1381612827666210715155809, 235960940, JOURNAL, Nguyen JT, Tian DD, Tanna RS, Arian CM, Calamia JC, Rettie AE, Thummel KE, Paine MF, An Integrative Approach to Elucidate Mechanisms Underlying the Pharmacokinetic Goldenseal-Midazolam Interaction: Application of In Vitro Assays and Physiologically Based Pharmacokinetic Models to Understand Clinical Observations, J Pharmacol Exp Ther, 387, 3, 252–264, December 2023, 37541764, 10658920, 10.1124/jpet.123.001681, JOURNAL, Hermann R, von Richter O, Clinical evidence of herbal drugs as perpetrators of pharmacokinetic drug interactions, Planta Medica, 78, 13, 1458–77, September 2012, 22855269, 10.1055/s-0032-1315117, free, JOURNAL, Feng P, Zhao L, Guo F, Zhang B, Fang L, Zhan G, Xu X, Fang Q, Liang Z, Li B, The enhancement of cardiotoxicity that results from inhibiton of CYP 3A4 activity and hERG channel by berberine in combination with statins, Chemico-Biological Interactions, 293, 115–123, September 2018, 30086269, 10.1016/j.cbi.2018.07.022, 2018CBI...293..115F, 206489481, (an alkaloid found in plants such as berberis or goldenseal),
• buprenorphine (analgesic),JOURNAL, Zhang W, Ramamoorthy Y, Tyndale RF, Sellers EM, 16229370, Interaction of buprenorphine and its metabolite norbuprenorphine with cytochromes p450 in vitro, Drug Metabolism and Disposition, 31, 6, 768–72, June 2003, 12756210, 10.1124/dmd.31.6.768,
• cafestol (in unfiltered coffee)JOURNAL, Interaction of coffee diterpenes, cafestol and kahweol, with human P-glycoprotein, Nabekura T, Yamaki T, Kitagawa S, 2009, AAPS Journal, The American Association of Pharmaceutical Scientists,www.aapsj.org/abstracts/AM_2009/AAPS2009-001235.PDF,www.aapsj.org/abstracts/AM_2009/AAPS2009-001235.PDF," title="web.archive.org/web/20110721141830www.aapsj.org/abstracts/AM_2009/AAPS2009-001235.PDF,">web.archive.org/web/20110721141830www.aapsj.org/abstracts/AM_2009/AAPS2009-001235.PDF, 21 July 2011,
• cilostazol,
• cimetidine,
• fosaprepitant,
• lomitapide,
• orphenadrine,
• omeprazole (proton pump inhibitor),
• quercetin,JOURNAL, Kheoane PS, Enslin GM, Tarirai C, Determination of effective concentrations of drug absorption enhancers using in vitro and ex vivo models, Eur J Pharm Sci, 167, 106028, December 2021, 34601070, 10.1016/j.ejps.2021.106028, 238257296,
• ranitidine,
• ranolazine,
• tacrolimus,
• ticagrelor,
• valproic acid,JOURNAL, 2014611, 11736863, 52, 5, In vitro evaluation of valproic acid as an inhibitor of human cytochrome P450 isoforms: preferential inhibition of cytochrome P450 2C9 (CYP2C9), Br J Clin Pharmacol, 547–53, Wen X, Wang JS, Kivistö KT, Neuvonen PJ, Backman JT, 10.1046/j.0306-5251.2001.01474.x, 2001,
• amlodipine,
• azithromycin (macrolide antibiotic).

Inhibitors of unspecified potency

• bergaptol (a furocoumarin in citrus),JOURNAL, Phucharoenrak P, Trachootham D, Bergaptol, a Major Furocoumarin in Citrus: Pharmacological Properties and Toxicity, Molecules, 29, 3, February 2024, 713, 38338457, 10856120, 10.3390/molecules29030713, free,
• cannabidiol,JOURNAL, Yamaori S, Ebisawa J, Okushima Y, Yamamoto I, Watanabe K, Potent inhibition of human cytochrome P450 3A isoforms by cannabidiol: role of phenolic hydroxyl groups in the resorcinol moiety, Life Sciences, 88, 15–16, 730–6, April 2011, 21356216, 10.1016/j.lfs.2011.02.017,
• dithiocarbamate (functional group),
• flavonoids,JOURNAL, Kondža M, Brizić I, Jokić S, Flavonoids as CYP3A4 Inhibitors In Vitro, Biomedicines, 12, 3, March 2024, 644, 38540257, 10968035, 10.3390/biomedicines12030644, free,
• mifepristone (abortifacient),
• norfloxacin (fluoroquinolone antibiotic),
• some non-nucleoside reverse-transcriptase inhibitors:Non-nucleoside reverse-transcriptase inhibitors have been shown to both induce and inhibit CYP3A4.
  • delavirdine;
• gestodene (hormonal contraceptive),
• star fruit,JOURNAL, Hidaka M, Fujita K, Ogikubo T, Yamasaki K, Iwakiri T, Okumura M, Kodama H, Arimori K, 17392051, Potent inhibition by star fruit of human cytochrome P450 3A (CYP3A) activity, Drug Metabolism and Disposition, 32, 6, 581–3, June 2004, 15155547, 10.1124/dmd.32.6.581,
• milk thistle,WEB,www.hcvadvocate.org/hepatitis/hepC/mthistle.html,www.hcvadvocate.org/hepatitis/hepC/mthistle.html," title="web.archive.org/web/20100305175124www.hcvadvocate.org/hepatitis/hepC/mthistle.html,">web.archive.org/web/20100305175124www.hcvadvocate.org/hepatitis/hepC/mthistle.html, dead, HCVadvocate.org, 5 March 2010,
• niacinJOURNAL, Gaudineau C, Auclair K, Inhibition of human P450 enzymes by nicotinic acid and nicotinamide, Biochemical and Biophysical Research Communications, 317, 3, 950–6, May 2004, 15081432, 10.1016/j.bbrc.2004.03.137, (nicotinic acid) and its form – niacinamide (nicotinamide), collectively called as Vitamin B3,
• ginkgo biloba,JOURNAL, Kimura Y, Ito H, Ohnishi R, Hatano T, Inhibitory effects of polyphenols on human cytochrome P450 3A4 and 2C9 activity, Food and Chemical Toxicology, 48, 1, 429–35, January 2010, 19883715, 10.1016/j.fct.2009.10.041, Ginko Biloba has been shown to contain the potent inhibitor amentoflavone,
• sesaminJOURNAL, Lim YP, Ma CY, Liu CL, Lin YH, Hu ML, Chen JJ, Hung DZ, Hsieh WT, Huang JD, Sesamin: A Naturally Occurring Lignan Inhibits CYP3A4 by Antagonizing the Pregnane X Receptor Activation, Evidence-Based Complementary and Alternative Medicine, 2012, 242810, 2012, 22645625, 3356939, 10.1155/2012/242810, free, (a lignan constituent in sesame seeds and oil),
• piperine,JOURNAL, Bhardwaj RK, Glaeser H, Becquemont L, Klotz U, Gupta SK, Fromm MF, 7398172, Piperine, a major constituent of black pepper, inhibits human P-glycoprotein and CYP3A4, The Journal of Pharmacology and Experimental Therapeutics, 302, 2, 645–50, August 2002, 12130727, 10.1124/jpet.102.034728,
• isoniazid,JOURNAL, Wen X, Wang JS, Neuvonen PJ, Backman JT, 19299097, Isoniazid is a mechanism-based inhibitor of cytochrome P450 1A2, 2A6, 2C19 and 3A4 isoforms in human liver microsomes, European Journal of Clinical Pharmacology, 57, 11, 799–804, January 2002, 11868802, 10.1007/s00228-001-0396-3,
• serenoa.JOURNAL, Ekstein D, Schachter SC, Natural Products in Epilepsy-the Present Situation and Perspectives for the Future, Pharmaceuticals, 3, 5, 1426–1445, May 2010, 27713311, 4033990, 10.3390/ph3051426, free,

Inducers

Strong and moderate CYP3A4 inducers are drugs that decrease the AUC of sensitive substrates of a given pathway where CYP3A4 is involved by ≥80 percent and ≥50 to