Mouse double minute 4 (MDM4), also known as MDMX or HDMX (human MDMX), is a critical negative regulator of the tumor suppressor p53. Under normal growth conditions, MDM4 contributes to the repression of p53 activity. Upon DNA damage, it becomes important to down-regulate MDM4 to allow a full p53 response. Here, the mechanisms by which MDM4 activity is controlled are reviewed and discussed, starting with alterations in copy number, then control of transcription, mRNA stability, translation, and finally post-translational interactions, modifications, localization, and targeting by recently developed drugs.