The P-glycoprotein efflux pump: how does it transport drugs?

Pgp is an atypical translocating ATPase, with low affinity for ATP and high constitutive ATPase activity. Pgp also has an unusually broad specificity for hydrophobic substrates, including many chemotherapeutic drugs. Transport studies in reconstituted systems indicate that drug transport requires ATP hydrolysis and is active, generating a drug concentration gradient. Binding of drugs and ATP to Pgp induces conformational changes in the protein, and the drug binding site is conformationally coupled to the NBDs. Evidence accumulated to date suggests that the transporter interacts directly with nonpolar substrates within the membrane environment, and may act as a drug flippase, moving drugs from the inner to the outer leaflet of the bilayer. Chemosensitizers that block the action of Pgp are proposed to act as alternative substrates, but their high rate of spontaneous flip-flop across the membrane results in futile cycling of the transporter.