What ED Physicians Need to Know About New Amyloid Targeting Treatments: Side Effects and Treatment Cautions Part 1

with Richard Isaacson and Kevin Biese

In 2024, dementia care costs are projected at 360 billion dollars, anticipated to rise to 1 trillion by 2050. Currently, 7 million people in the US have Alzheimer’s Disease (AD). AD not only affects individuals but also their families, with 11 million unpaid family caregivers providing essential support for those living with AD. New Amyloid Targeting Treatments (ATTs) have the potential to offer some therapeutic benefits for AD. However, there are some side effects and risks associated with them, particularly the use of one of the more controversial drugs in Emergency Medicine, tPA.

In this series, Dr. Shenvi is joined by two guests: Dr. Richard Isaacson, a neurologist and Director of Research at the Institute for Neurodegenerative Diseases in Florida, and Dr. Kevin Biese, an associate professor at UNC Chapel Hill and director of the Geriatric ED Collaborative and Geriatric ED accreditation programs. In part 1, they delve into how ATTs work, which patients are good candidates for them, complications that may arise, and the financial implications of these new drugs. They tie these insights back to what this all means for ED physicians, focusing on how these patients present, what ED physicians need to know, and the actions they need to take to provide the appropriate care.

Key Points

  • Alzheimer’s disease begins silently in the brain decades before memory loss symptoms appear. It starts with the buildup of amyloid protein that may be associated with or trigger tau tangles and through either neuroinflammation or a combination of amyloid and tau, results in neurodegeneration.
  • Amyloid Targeting Treatments (ATTs) target beta-amyloid in the brain to slow neurodegenerative disease progression.
  • Patients in the early stages of AD or with mild cognitive impairment are ideal candidates for ATTs.
    • In ED settings, we need a shift in perspective to recognize which patients might be on ATTs.
  • About 30% of individuals taking ATTs will develop amyloid-related imaging abnormalities (ARIA) but only about 6% of cases are symptomatic.
    • The two main patterns of imaging abnormalities are ARIA-H (microhemorrhages) and ARIA-E (edema).
    • Symptoms may be nonspecific (headache, confusion, vomiting, visual disturbance, and weakness) but can also mimic a stroke.
  • Patients with the APOE4 gene, especially those with two copies, are at increased risk of both Alzheimer’s disease and side effects from ATTs.
  • The high cost of ATTs, which can exceed $20,000 annually, and their evolving insurance coverage present significant financial challenges.

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