More and more healthcare organizations are prescribing the new anti-amyloid (sometimes called amyloid-targeting) therapies lecanemab and donanemab. As these drugs aim to slow progression, identifying Alzheimer’s patients in the earliest stages of disease is critical, and eliminating organizational barriers and bottlenecks that get in the way is key. Patients who slip through the cracks or linger on waitlists may progress to a point where they’ve missed the window of efficacy.
This is one reason that care teams everywhere are streamlining their dementia screening workflows, building infrastructure, and training providers on how to evaluate good candidates for treatment without delay. Here’s a quick guide to these treatments, their indications, and a few helpful talking points to support provider discussions with patients and their loved ones.
Examples: lecanemab, donanemab
Mechanism: Target and clear β-amyloid plaques in the brain
Indication: MCI and (early) mild dementia stage of Alzheimer’s disease with confirmed amyloid pathology and without contraindications (i.e. bleeding risk)
Delivery: Intravenous infusion at regular intervals during treatment phase (lecanemab is now approved for subcutaneous injection during a post-treatment maintenance phase)
Check for cognitive impairment with objective cognitive screening
Evaluate functional status
Confirm patient is in the MCI or mild dementia stages of Alzheimer’s disease
Demonstrate presence of amyloid pathology with biomarker testing (blood tests, lumbar puncture, and/or PET scan)
Consider ruling out patients with bleeding risks via medication review (e.g. anticoagulants), MRI, and genetic testing
Get a baseline MRI to check for evidence of previous brain bleeds, scarring from strokes, or preexisting brain damage
Order genetic testing to check for APOE ε4 (carriers may have a high risk of ARIA side effects)
During your general evaluation check for use of blood thinners (e.g., DOACs, warfarin) or other drugs that may interfere with treatment, bleeding disorders, contraindications for regular MRIs and/or infusions, and advanced frailty
You’re in the early stages of Alzheimer’s disease or mild cognitive impairment (MCI) due to Alzheimer's disease. This means a protein called amyloid is building up in your brain. There are two new medicines that may help slow down memory loss by targeting that protein.
In studies, symptoms in people taking the medicine stayed the same for about 5 extra months over a year and a half. (That’s the average, some people see more benefit, some less.)
It’s important to understand that these drugs won’t restore memory. The disease still moves forward, just a little slower.
You’ll get treatment through an IV every two weeks. Each visit takes about an hour.
You will also get MRI brain scans to check for side effects. The main side effect is called ARIA. This means swelling or tiny spots of bleeding in the brain. Most people don’t notice any symptoms when this is happening, so we keep a close watch with regular MRIs to be safe.
This medicine is expensive, but your insurance may cover most of the cost.
Before you decide, let’s talk about your goals, and see if the treatment fits your life:
What do you hope this treatment could help you do?
Would you have help getting to the appointments?
Based on your brain scans and health, this medicine isn’t the right choice for you right now.
[If the patient is in later stages] It’s unlikely to be effective at your stage of disease.
[If the patient has contraindications] The risks of this treatment may be too high for you.
But there are still many ways we can help. We can talk about other treatments and lifestyle changes that could benefit you. These things may help you keep doing things that you enjoy.
Let’s talk about what’s most important to you. Then we can make a care plan that fits your needs.
The main side effect we watch for is called ARIA. This means swelling or small bleeding spots in the brain. About 1 in 8 people have swelling. About 1 in 6 have tiny bleeds. Most people don’t feel anything when this happens. A few people—about 1 in 30—may get headaches, feel confused, or dizzy.
A gene test can tell us how likely you are to have this side effect. We also do MRI scans regularly to monitor for ARIA.
If we find ARIA on a scan, we usually stop the medicine for a few weeks. It often goes away, and we can start again later. Very rarely, we may need to stop treatment for good.
Recently neurologist Armen J. Moughamian, MD, PhD, Medical Director of the Ray Dolby Brain Health Center and Chief of Memory with our partner Sutter Health, appeared on a BrightFocus Foundation webinar to clarify what these new Alzheimer's therapies can realistically do. In the video, Dr. Moughamian covers the latest information on efficacy, safety, eligibility, the logistics of managing an infusion-delivered drug, costs, and access.
Watch a complete recording of the event HERE.