New Anti-amyloid Drugs are Providing Hope for People with Alzheimer’s Disease – Now What?

Key Takeaways: 

• New anti-amyloid therapies can slow Alzheimer’s disease progression, but ensuring the treatment is provided safely and effectively is creating a huge challenge for health systems. 
• Because the treatments come with life-threatening side effects and are costly, health systems need to carefully think through and implement patient screening and care protocols. 
• Leading neurologists recommend creating a new infrastructure of multidisciplinary teams that include neurologists, primary care physicians, brain health navigators, nurses and other specialists.  

PHILADELPHIA, Sept. 12, 2023 – Newly approved anti-amyloid therapies that slow Alzheimer’s disease progression offer new hope for people with the disorder. The challenge for health systems is to implement them safely and effectively by creating an extensive new care infrastructure, from screening candidates to intravenous (IV) infusion of the medication, according to a presentation at the 148th Annual Meeting of the American Neurological Association (ANA). 

The first Food and Drug Administration-approved anti-amyloids (aducanumab and lecanemab) have been shown to slow the progression of Alzheimer’s disease and the Centers for Medicare & Medicaid Services announced they would be covered. Other anti-amyloid drugs are in various stages of the drug development pipeline. Because the therapies come with significant risks (brain bleeds, brain swelling and death) and are expensive, patients need to complete several steps and undergo numerous tests before they ultimately can receive the therapy.  

“We’re very excited about these new medications, but providing them safely and effectively will require an unprecedented coordination of care,” said Liana G. Apostolova, MD, MS, FAAN, associate dean of Alzheimer’s Disease Research and Indiana University distinguished professor in Alzheimer’s disease, who will discuss the challenges during a symposium on anti-amyloid therapies. “I’m not sure that patients and care partners truly understand how much needs to be done to serve them effectively.” 

Providing Timely Access to Treatment with an Influx of Patients   

The first challenge is determining how to ease the inevitable bottle neck when multitudes of patients try to make appointments with a limited number of neurologists (and even fewer who specialize in Alzheimer’s disease). It could take many months for patients to get an appointment, only to potentially learn they may no longer be appropriate candidates for therapy because their condition has advanced beyond the early stages. Ideally, every health system that plans to provide anti-amyloid therapies should establish a carefully developed protocol to handle the coming influx of patients, from evaluating their eligibility to safely administering the anti-amyloid infusions. Dr. Apostolova said one approach is to create and train a multidisciplinary team of health professionals, which could include: 

• Neurologist who oversees the team 
• Brain health navigator (a newly created role at most institutions), who takes the initial call from the patient and works with the primary care physician to ensure the right tests are conducted 
• Primary care physicians who get reimbursed to prequalify patients by: 

• Compiling the patient’s health history, including: 

• Dementia  
• Medications  
• Allergies 
• Flagging those on blood thinners or with terminal cancer or immunologic conditions 

• Ordering or conducting: 

• MRI brain scan 
• Neurological exam and cognitive testing of the six domains (from executive function to language), which can be performed by a psychology service or psychometrist 
• 12 blood tests for the dementia workup to rule out other conditions  
• Depression assessment 

• Nurse who oversees the workup of prequalified patients, including: 

• Amyloid PET  
• Genetic testing for APOE4, the strongest known Alzheimer’s disease risk gene 

• Radiologist to interpret brain imaging tests 
• Nurse to manage the infusion of the anti-amyloid, which must be done in the hospital or an infusion center 
• Emergency room, intensive care and stroke team specialists to treat patients experiencing side effects of the therapy 

Managing Infusion Treatment 

Another challenge is managing the infusion, including ensuring there are an adequate number of available infusion chairs. This may be a significant limitation for many hospitals because the chairs are also used for infusions to treat other conditions such as cancer, multiple sclerosis and rheumatological disorders. All patients need to be monitored for an allergic reaction throughout the treatment – for three hours after the first infusion, two hours after the second, one hour after the third and 30 minutes after subsequent infusions. The brain health navigator or nurse also needs to call the patient the next day to be sure they haven’t had a delayed reaction.  

“Developing a well-thought-out and implemented protocol will help ensure patient care is seamless,” said Dr. Apostolova. “It is a huge challenge, but it is absolutely essential to ensuring appropriate patients can safely benefit from this exciting new therapy. This coordinated care paradigm could even be the model for other common neurological health conditions, especially those that are treated with biologic therapies.” 

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About the American Neurological Association (ANA) 

From advances in stroke and dementia to movement disorders and epilepsy, the American Neurological Association has been the vanguard of research since 1875 as the premier professional society of academic neurologists and neuroscientists devoted to understanding and treating diseases of the nervous system. Its monthly Annals of Neurology is among the world’s most prestigious medical journals, and the ANA’s Annals of Clinical and Translational Neurology is an online-only, open access journal providing rapid dissemination of high-quality, peer-reviewed research related to all areas of neurology. The acclaimed ANA Annual Meeting draws faculty and trainees from the top academic departments across the U.S. and abroad for groundbreaking research, networking, and career development. For more information, visit www.myana.org or @TheNewANA1.