Speaker: Sophia Wang, MD, Associate Professor of Clinical Psychiatry, IUSM
Introduced By: Russell Judd
Attendance: NESC: 88, Zoom: 48
Guest(s): Josh Matthews, Marinelle Morgan, Rich Peine
Scribe: Benny Ko
Editor: Carl Warner
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Today's Program 022624
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With the recent FDA approval of the new drug Lecanemab (Lequembi), we are on the verge of a new era in the treatment of Alzheimer's disease. While the drug does not cure the disease, it has been shown to slow its progression by about 20-30% while the patients were on an 18-month therapy. The drug is given intravenously every two weeks in a 45-60 minute session. The mechanism of action of Lecanemab is thought to be its binding with protofibrils and preventing the latter from becoming fibrils, the main component of amyloid plaques. Currently, the treatment is recommended for patients with very mild to mild symptoms of Alzheimer's disease. A similar class of therapeutic agents is currently on trial.
Before this new drug, Alzheimer's disease treatment was palliative, i.e., moderating symptoms. Such symptom reducing drugs include acetylcholinesterase inhibitors, rivastigmine, and donepezil. Other drugs such as memantine target NMDA receptors at the neuronal level. Unlike Lecanemab, they do not slow disease progression.
In Alzheimer's disease, early detection is important. CSF biomarkers, APOE genetic testing, amyloid PET scans, cognitive testing, and clinical history are all important diagnostic tools.
Lecanemab has to be intravenous-delivered because it has to cross the blood-brain barrier. The therapy is not without some known complications such as allergic reactions. ARIA stands for amyloid-related imaging abnormalities observed in patients' serial imaging studies during their therapy period. These observed abnormalities are sometimes asymptomatic and transient while at other times they are not. ARIA with severe symptoms and complications occurs in less than 1%.
ARIA-E represents brain edema and ARIA-H represents hemosiderin, a sign of hemorrhage. These vascular pathologies happen because the drug removes the amyloid accumulated in an infiltrated blood vessel and hence compromises its integrity. The drug should not be given in conjunction with anticoagulative and TPA therapy.
The cost is substantial but Medicare will pay for the major portion.
What is DICE in non-drug management of behavioral symptoms? The DICE approach includes describe, investigate, create, and evaluate. Behavioral symptoms include aggression, agitation, anxiety, apathy, delusions, hallucinations, disinhibition, irritability, motor disturbances, and nighttime behaviors. A "behavioral triad" involves three components: the caregiver, the environment, and the person with dementia. Together, they have a role in the behavioral status of the patient. To establish a routine and a safe environment are important for the patient.
Sophia Wang
