The identification of apolipoprotein E (APOE) as a genetic risk factor modifying the chances of developing Alzheimer's disease (AD) has opened the possibility that other susceptibility genes exist that either independently modify the risk of developing AD or alter the risk imparted by APOE. We have identified alpha-1-antichymotrypsin (ACT) as a potential risk gene, by virtue of the interactive effect of either of its two alleles (A and T) on the risk of AD associated with the APOE epsilon 4 allele. In a large population of AD (n = 308) and control (n = 579) cohorts, we found the expected elevation in the APOE epsilon 4 allele frequency in the AD cases compared to controls, with threefold and sevenfold increases in the risk of AD for APOE epsilon 4/X and APOE epsilon 4/epsilon 4, respectively. Of the three ACT genotypes, the ACT A/T genotype did not affect the risk of AD beyond that which is conferred by the APOE epsilon 4 allele. However, the ACT A/A genotype greatly increased the risk associated with APOE epsilon 4 homozygosity. On the other hand, the ACT T/T genotype suppressed the gene dosage effect of the APOE epsilon 4 allele; the risk of AD in APOE epsilon 4/epsilon 4, ACT T/T cases was the same as that of APOE epsilon 4/X. A variety of potential mechanisms for interactions of ACT and APOE are discussed.