:
Tetrahydrobipterin (BH4) is a pivotal enzymatic cofactor required for the synthesis of serotonin, dopamine and
nitric oxide. BH4 is essential for numerous physiological processes at periphery and central level, such as vascularization,
inflammation, glucose homeostasis, regulation of oxidative stress and neurotransmission. BH4 de novo synthesis involves
the sequential activation of three enzymes, the major controlling point being GTP cyclohydrolase I (GCH1). Complementary salvage and recycling pathways ensure that BH4 levels are tightly kept within a physiological range in the body. Even if
the way of transport of BH4 and its ability to enter the brain after peripheral administration is still controversial, data
showed increased levels in the brain after BH4 treatment. Available evidence shows that GCH1 expression and BH4 synthesis are stimulated by immunological factors, notably pro-inflammatory cytokines. Once produced, BH4 can act as antiinflammatory molecule and scavenger of free radicals protecting against oxidative stress. At the same time,
BH4 is prone to autoxidation, leading to release of superoxide radicals contributing to inflammatory processes,
and to production of BH2, an inactive form of BH4, reducing its bioavailability. Alterations in BH4 levels have
been documented in many pathological situations, including Alzheimer's disease, Parkinson's disease and depression, in
which increased oxidative stress, inflammation and alterations in monoaminergic function are described. This review aims
at providing an update of the knowledge about metabolism and role of BH4 in brain function, from preclinical to clinical
studies, addressing some therapeutic implications.