Navigating Treatment Options

There is exciting progress in Alzheimer’s and dementia research that is creating promising new treatments for people living with the disease. It is important to learn as much as you can about which drugs are available. Talk about your options with your doctor.

The U.S. Food and Drug Administration (FDA) has approved medications for Alzheimer’s. These fall into two categories:

• Drugs that temporarily ease some symptoms of Alzheimer’s disease.

• Drugs that change disease progression in people living with Alzheimer’s.

When thinking about any treatment, it is important to have a conversation with a health care professional to determine whether it is appropriate. A doctor who is experienced in using these medications should monitor people who are taking them and provide information that can help people make informed decisions about their usage and care. 

Drugs that treat symptoms

As Alzheimer’s progresses, brain cells die and connections among cells are lost. This causes cognitive (memory and thinking) and noncognitive (behavioral and psychological) symptoms to worsen. While these medications do not stop the damage Alzheimer’s causes to brain cells, they may help lessen or stabilize symptoms for a limited time. 

• Learn about medications for memory, cognition and dementia-related behaviors.
• Learn about treatments for behavior.
• Learn about treatments for sleep changes.

Drugs that change disease progression

Drugs in this category slow disease progression. They slow the decline of memory and thinking, as well as function, in people living with Alzheimer’s disease.

Aducanumab (Aduhelm™)

Aducanumab (Aduhelm™) is an anti-amyloid antibody intravenous (IV) infusion therapy approved for Alzheimer's disease. Aducanumab works by targeting beta-amyloid, a protein that forms in the brain and makes plaques. 

• This drug is approved for people with early Alzheimer’s disease: mild cognitive impairment (MCI) or mild dementia due to Alzheimer's disease. 
• Doctors should confirm the presence of elevated beta-amyloid in the brain prior to starting treatment.
• The most common side effects are amyloid-related imaging abnormalities (ARIA), headache and fall. ARIA does not usually cause symptoms but can be serious. It is typically a temporary swelling of the brain or small areas of bleeding in the brain. It usually resolves over time.

Lecanemab (Leqembi™)

Lecanemab (Leqembi™) is an anti-amyloid antibody intravenous (IV) infusion therapy approved for Alzheimer's with confirmation of elevated beta-amyloid. Lecanemab works by targeting beta-amyloid, a protein that forms in the brain and makes plaques. Although lecanemab also targets beta-amyloid, it works in a different way than aducanumab.

• This drug is approved for people with early Alzheimer’s disease: mild cognitive impairment (MCI) or mild dementia due to Alzheimer's disease. 
• Doctors should confirm the presence of elevated beta-amyloid in the brain prior to starting treatment.
• The most common reported side effects were infusion-related reactions, headache and amyloid-related imaging abnormalities (ARIA). ARIA does not usually cause symptoms but can be serious. It is typically a temporary swelling of the brain or small areas of bleeding in the brain. It usually resolves over time.

Importance of early diagnosis

It is important to seek a diagnosis as early as possible. The earlier you are diagnosed, the more treatment options will be available to you. Some medications are only effective in the early stages of the disease. 
 
To determine if you can take a specific treatment, your doctor will need to consider the which stage of the disease you are in. Some treatments are only approved for people in a specific stage.

Alzheimer’s is a progressive brain disease. This means the disease and resulting symptoms worsen over time. The disease often progresses in the following stages:

• Asymptomatic: No cognitive symptoms but possible biological changes in the brain.
• Mild cognitive impairment (MCI) due to Alzheimer’s disease: Symptoms of cognitive ability loss begin to appear.
• Early stage (mild): Typically involves symptoms that interfere with some daily activities.
• Middle stage (moderate): More pronounced symptoms that interfere with many daily activities.
• Late stage (severe): Symptoms interfere with most daily activities.

Treatment benefits and side effects

Your doctor may have a conversation with you about how well some of the Alzheimer’s treatments work. They may discuss if the potential benefits outweigh the risk of any side effects. Taking a drug is a personal decision that each individual must make on their own with the help of doctors. You may want to ask your doctor:

• How will we decide if this medication is right for me?
• How common are side effects? How will you watch for them?
• If I do experience side effects, how will we manage them? Will I need to stop taking the drug?
• What is the benefit I might receive from this drug? How would that change daily life?

Insurance coverage

If your doctor says you are medically able to take a treatment, your next questions may be about cost and insurance coverage. Because drugs that treat the progression of the disease are newer, coverage is an evolving issue. You should talk to your doctor about coverage and if they can help with appeals. 

Currently, the Centers for Medicare & Medicaid Services (CMS) will not cover FDA-approved treatments that target amyloid for Alzheimer’s disease, like aducanumab and lecanemab, unless the person is enrolled in an approved clinical trial. Many private insurers have followed this example. There are exceptions. If you have insurance other than Medicare, contact your insurance provider to determine if coverage is available.

The Alzheimer’s Association is asking CMS to reconsider this decision. The current decision limits the number of people who could benefit from treatments today. On Dec. 19, 2022, the Alzheimer’s Association filed a formal request asking CMS to provide full and unrestricted coverage for FDA-approved Alzheimer’s treatments.

Insurance appeals

If you are denied coverage of an Alzheimer’s treatment, there are actions you can take. You may want to file an appeal with your health insurance provider. This can be difficult. You should think about your needs and your medical history before you begin. 

All insurance companies and Medicare have a formal appeal process.

1. Call the number on the back of your insurance card. Ask for instructions for how to make a formal appeal. Provide all the information requested on the appeal form.
2. There is often a time limit on appeals. Don’t delay taking action.
3. Keep records/copies of all conversations with the insurance provider.
4. Your doctor may be able to help you with the appeal. Ask them about your options during a visit.