Reduced clearance of amyloid- (A) from brain partly underlies increased A brain accumulation in Alzheimer's disease (AD). The mechanistic basis for this pathology is unknown, but recent evidence suggests a neurovascular component in AD etiology. We show here that the ATP-driven pump, P-glycoprotein, specifically mediates efflux transport of A from mouse brain capillaries into the vascular space, thus identifying a critical component of the A brain efflux mechanism. We demonstrate in a transgenic mouse model of AD [human amyloid precursor protein (hAPP)-overexpressing mice; Tg2576 strain] that brain capillary P-glycoprotein expression and transport activity are substantially reduced compared with wild-type control mice, suggesting a mechanism by which A accumulates in the brain in AD. It is noteworthy that dosing 12-week-old, asymptomatic hAPP mice over 7 days with pregnenolone-16␣-carbonitrile to activate the nuclear receptor pregnane X receptor restores P-glycoprotein expression and transport activity in brain capillaries and significantly reduces brain A levels compared with untreated control mice. Thus, targeting intracellular signals that up-regulate blood-brain barrier P-glycoprotein in the early stages of AD has the potential to increase A clearance from the brain and reduce A brain accumulation. This mechanism suggests a new therapeutic strategy in AD.A hallmark of Alzheimer's disease (AD) is the accumulation of neurotoxic amyloid- (A) peptide within the brain. The A transport-clearance hypothesis of AD proposed by Zlokovic and coworkers (Zlokovic and Frangione, 2003;Deane et al., 2004b;Zlokovic, 2005) states that reduced A clearance (reduced A efflux transport) from the brain underlies A brain accumulation (see also Mooradian et al., 1997). This hypothesis suggests that the mechanism responsible for A brain clearance itself could be a therapeutic target in AD.A clearance from brain to blood has to be a two-step process. A must first pass through the abluminal (brain side) and then the luminal (blood side) plasma membranes of the brain capillary endothelial cells that comprise the bloodbrain barrier. Given that A is a peptide, both steps must be facilitated, involving receptors or transporters. At the abluminal membrane, the receptor low-density lipoprotein receptor-related protein 1 (LRP1) seems to be the major protein responsible for A uptake from brain into capillary endothelial cells (Shibata et al., 2000; Deane et al., 2004a,b). However, the luminal membrane protein mediating the critical second step, A efflux from the endothelial cells into the blood, has not been identified.One candidate is P-glycoprotein, an ATP-driven efflux transporter that under normal physiological conditions is highly expressed at the luminal membrane of the brain capillary endothelium. This transporter handles a wide spectrum of nonpolar, therapeutic drugs, some of which are small polypeptide derivatives .