Practical NeurologyA Practical Approach to Selecting Patients for Amyloid-Targeting Treatments

🎓 Expert Commentary / Peer Perspective

A clinician review distills lecanemab and donanemab appropriate use recommendations into a practical patient-selection framework. The authors share their center’s approach to diagnostic confidence, staging, ARIA risk, and off-trial contexts.

Clinical Considerations

• ATT eligibility requires biomarker-confirmed AD plus a matching clinical syndrome, since positive biomarkers alone do not establish AD as the symptom driver.
• APOE ε4 homozygotes face the highest ARIA risk; ARIA-E reached 32.6% in homozygotes versus 5.4% in noncarriers in Clarity AD.
• Treatment is limited to MCI or mild dementia; baseline MRI excludes patients with microhemorrhages, siderosis, or severe small-vessel disease.
• Full-strength anticoagulation and recent stroke, TIA, or seizure raise hemorrhagic concerns and generally preclude treatment.

Practice Applications

• Integrate clinical syndrome with biomarker confirmation before prescribing.
• Recognize APOE genotyping as central to ARIA risk counseling.
• Monitor baseline and on-treatment MRI for ARIA development.
• Avoid treating patients lacking a reliable care partner or consent capacity.