RE, Pasricha PJ. Tetrahydrobiopterin (BH4), a cofactor for nNOS, restores gastric emptying and nNOS expression in female diabetic rats. Am J Physiol Gastrointest Liver Physiol 298: G692-G699, 2010. First published February 25, 2010 doi:10.1152/ajpgi.00450.2009.-Gastroparesis is a debilitating disease predominantly affecting young women. Recently, dysregulation of neuronal nitric oxide synthase (nNOS) in myenteric plexus neurons has been implicated for delayed solid gastric emptying/gastroparesis in diabetic patients. In this study, we have explored the role of tetrahydrobiopterin (BH4), a major cofactor for nNOS activity and NO synthesis in diabetic gastroparesis. Diabetes was induced with single injection of streptozotocin (55 mg/kg body wt, ip) in female rats, with experiments performed on week 3 or 9 following induction, with or without 3-wk BH4 supplementation. Gastric pyloric BH4 levels were significantly decreased in diabetic female rats compared with control (18.6 Ϯ 1.45 vs. 31.0 Ϯ 2.31 pmol/mg protein). In vitro studies showed that 2,4-diamino-6-hydroxypyrimidine (DAHP), an inhibitor of BH4 synthesis, significantly decreased gastric NO release and nitrergic relaxation. Three-week dietary supplementation of BH4 either from day 1 or week 6 significantly attenuated diabetes-induced delayed gastric emptying for solids (3 wk: BH4, 67 Ϯ 6.7 vs. diabetic, 36.05 Ϯ 7.09; 9 wk: BH4, 57 Ϯ 8.45 vs. diabetic, 33 Ϯ 9.91) and diabetes-induced reduction in pyloric nNOS-␣ protein expression in female rats. Supplementation of BH4 significantly restored gastric nNOS-␣ dimerization in 9-wk-old diabetic female rats. In addition, BH4 treatment reversed (17.23 Ϯ 5.81 vs. 42.0 Ϯ 2.70 mmHg ϫ s) the diabetes-induced changes in intragastric pressures (IGP) and gastric pyloric nitrergic relaxation (Ϫ0.62 Ϯ 0.01 vs. Ϫ0.22 Ϯ 0.07). BH4 deficiency plays a critical role in diabetes-induced alterations including delayed solid gastric emptying, increased IGP, reduced pyloric nitrergic relaxation, and nNOS-␣ expression in female rats. Supplementation of BH4 accelerates gastric emptying by restoring nitrergic system in diabetic female rats. Therefore, BH4 supplementation is a potential therapeutic option for female patients of diabetic gastroparesis. nitrergic relaxation; diabetes; female rat; streptozotocin GASTROPARESIS IS A CLINICAL DISORDER characterized by delayed gastric emptying and symptoms such as nausea, vomiting, pain, and discomfort. A recent increase in prevalence of gastroparesis has been indicated, which may be an outcome of increased prevalence of diabetes (38). The most common known cause of this syndrome is diabetes, and it is estimated to affect 20 -55% of patients with type 1 (insulin-dependent) and up to 30% of patients with type 2 (noninsulin-dependent) diabetes (31). There is a striking sex bias in gastroparetic patients, with women outnumbering men by a 4:1 ratio (18,19,34). Recent findings from our laboratory demonstrate that the reduction in gastric emptying is greater in female rats compared with males after dia...