The role of Neuroimaging in Patient Selection and Safety Monitoring during Lecanemab Treatment

Abstract

AbstractBackgroundLecanemab (Leqembi) is a monoclonal antibody therapy approved in the United States for the treatment of Alzheimer’s disease (AD). Administration of lecanemab in community settings will be guided by the appropriate use recommendations (AURs) that are soon to be published.MethodThe lecanemab AUR’s use clinical trial data as well as evidence from research and clinical practice regarding AD to inform clinicians how to administer lecanemab with optimal safety and opportunity for efficacy. Neuroimaging will play a significant role in selecting the appropriate patients for administration of lecanemab as well as in safety monitoring for adverse events such as amyloid related imaging abnormalities (ARIA). In this presentation we will review the selection and monitoring guidelines for lecanemab as detailed in the AURs.ResultMost ARIA are asymptomatic, but a few cases are serious or fatal. While micro‐ and macrohemorrhages are rare, they can occur in patients receiving lecanemab. Patients who are apolipoprotein E4 (APOE4) gene carriers, and especially those that are APOE4 homozygotes, are at higher risk for ARIA than APOE4 non‐carriers. The AURs recommends genotyping to better inform risk discussions with patients who are candidates for lecanemab therapy. The AURs recommends a screening MRI and periodic along with symptom‐triggered MRI surveillance to detect asymptomatic and symptomatic ARIA and address it appropriately.ConclusionClinician and institutional preparedness are mandatory for the use of lecanemab. This includes training of neurologists, geriatric psychiatrists, radiologists, primary care, emergency room and intensive care physicians, and stroke neurologists in safety monitoring and treatment of symptomatic ARIA.