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.
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.
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:
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
Nurse who oversees the workup of prequalified patients, including:
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.” (Newswise/AM)