CYP24A1: the pivotal regulator of vitamin D homeostasis, pathophysiology in metabolic and genetic disease, and emerging target for precision medicine.

CYP24A1 (25-hydroxyvitamin D3 24-hydroxylase) functions as the essential catabolic 'off-switch' of the vitamin D endocrine axis. As a mitochondrial cytochrome P450 enzyme, it tightly regulates calcitriol (1,25(OH)2D3) levels through a remarkably sensitive negative feedback mechanism, capable of a 20,000-fold transcriptional response-by converting biologically active vitamin D metabolites into the inactive end-product calcitroic acid. Its expression is governed by opposing endocrine cues from Parathyroid Hormone (PTH) and Fibroblast Growth Factor 23 (FGF23), with FGF23-mediated induction of CYP24A1 playing a key role in lowering calcitriol during states of phosphate excess. Pathogenic loss-of-function variants in CYP24A1 underlie Idiopathic Infantile Hypercalcemia (IIH) type 1, whereas acquired dysregulation contributes significantly to chronic kidney disease (CKD). In CKD, sustained FGF23 elevation drives aberrant CYP24A1 activation, promoting functional vitamin D deficiency and secondary hyperparathyroidism. Emerging studies also implicate inflammation-induced CYP24A1 upregulation in metabolic diseases and cancer, establishing it as a molecular basis for vitamin D resistance. The advent of selective CYP24A1 inhibitors represents a promising therapeutic strategy to optimize vitamin D signaling and control hypercalcemia. Incorporating pharmacogenetic markers (e.g. rs2248359) and functional indices such as 24,25(OH)2D measurements supports individualized vitamin D dosing and advances precision medicine for vitamin D-related disorders.