A historic milestone in neurology: After more than two decades without therapeutic progress, doctors in Austria and Germany once again have new treatment options for Alzheimer's disease. What does this mean for practice?
Reading time: 8 minutes | Target audience: Neurologists, psychiatrists, geriatricians, general practitioners
The end of a 23-year drought
As a physician with intensive care experience at the Innsbruck University Hospital, I have accompanied numerous Alzheimer's patients and their families. The helplessness in the face of unstoppable cognitive decline was burdensome for all involved. Since 2002 – the year of the last Alzheimer approval – we have had to rely on purely symptomatic therapies that could not halt the progression of the disease.
2025 marks a turning point: With the approval of Lecanemab (Leqembi®) in November 2024, the first antibody was approved that not only alleviates symptoms but also intervenes in the disease process itself. Shortly thereafter, Donanemab followed, whose approval process has also been completed.
The stark numbers
Currently, about 130,000 people with dementia live in Austria, of which around 60-70% have Alzheimer's dementia. In Germany, there are about 1.8 million affected individuals. By 2050, this number is expected to double – a demographic challenge that will place massive strain on our healthcare system.
The economic costs of Alzheimer's disease in Austria amount to approximately 2.5 billion euros annually, while in Germany it exceeds 40 billion euros – for care, medical treatment, and productivity loss.
The scientific breakthrough: Amyloid-beta in focus
The amyloid hypothesis – finally confirmed?
For decades, neurology has discussed the amyloid cascade hypothesis: According to this, beta-amyloid plaques accumulate between nerve cells and trigger a cascade that ultimately leads to the death of neurons. Despite intensive research, all previous attempts to therapeutically combat these plaques have failed.
Lecanemab is different: The humanized monoclonal IgG1 antibody selectively binds to soluble amyloid-beta protofibrils – that is, to those intermediate forms that are particularly toxic to nerve cells. Unlike previous approaches, Lecanemab does not primarily target the already deposited plaques but rather the pathogenic precursor forms.
Study data from the Clarity-AD study
The approval-relevant Clarity-AD study included 1,795 patients with early Alzheimer's disease and mild cognitive impairment (MCI) or mild dementia. Participants received 10 mg/kg Lecanemab intravenously every two weeks for 18 months.
Primary endpoint: The change in CDR-SB (Clinical Dementia Rating-Sum of Boxes) was:
- Lecanemab: +1.21 points
- Placebo: +1.66 points
- Difference: -0.45 points (p<0.001)
In practice, this means: Disease progression was slowed by about 27% – statistically highly significant, but clinically moderate. The difference corresponds to approximately 5-7 months of delayed cognitive decline.
Secondary endpoints showed:
- Reduction of amyloid plaque burden by 68% (PET imaging)
- Less decline in daily functions (ADCS-ADL)
- Better results in ADAS-Cog14 (cognitive test)
Who is eligible for therapy? Clear inclusion criteria
The enthusiasm over the breakthrough must be tempered by realistic assessment. Lecanemab is not a therapy for all Alzheimer's patients.
Indication: Only early stage
Lecanemab is approved exclusively for:
- Early stage of Alzheimer's disease
- Confirmed amyloid pathology in the brain
- Mild cognitive impairment (MCI) or
- Mild dementia (MMSE ≥ 20 points)
Exclusion criteria:
- Advanced dementia (MMSE < 20)
- Microbleeds (> 4 on MRI)
- Superficial siderosis
- Anticoagulation (relative risk)
- APOE4 homozygosity (increased ARIA risk)
The diagnostic hurdle: Biomarker detection required
Unlike previous Alzheimer's diagnostics, which were primarily clinical, the Lecanemab therapy requires objective evidence of amyloid pathology. This poses challenges for practices.
Three detection options:
1. Amyloid-PET (Positron Emission Tomography)
- Visualization of amyloid plaques
- Cost: approx. 1,500-2,500 euros
- Availability: Only in university centers (Vienna, Graz, Innsbruck, Salzburg)
- Radiation exposure: Yes
- Duration: approx. 90 minutes
2. Lumbar puncture (CSF analysis)
- Determination of Aβ42/Aβ40 ratio, tau protein, phospho-tau
- Cost: approx. 300-500 euros
- Availability: Neurological departments, specialized practices
- Invasive: Lumbar puncture required
- Sensitivity/Specificity: > 90%
3. Blood biomarkers (experimental)
- Phospho-tau217, Aβ42/40 ratio
- Not yet standard, but promising
- Possibly soon available as screening
Genetic testing (APOE status): Recommended for risk assessment for ARIA (Amyloid-Related Imaging Abnormalities). APOE4 homozygotes have a significantly higher risk of cerebral microbleeds and edema under therapy.
Practical implementation: From diagnosis to infusion
The therapy path in Austrian practice
Step 1: Clinical suspicion diagnosis
- Detailed medical history (patient + relatives)
- Neuropsychological testing (MMSE, MoCA, CERAD)
- Exclusion of other causes of dementia
- Basic lab tests, thyroid, vitamin B12
Step 2: Imaging
- MRI of the skull (exclusion of vascular dementia, tumors, NPH)
- Assessment of microbleeds, siderosis
- Baseline for later ARIA monitoring
Step 3: Biomarker diagnostics
- Lumbar puncture or amyloid-PET
- APOE genotyping
Step 4: Education and shared decision making
- Communicate realistic expectations
- Discuss side effect profile
- Explain infusion schedule
- Clarify costs (not yet covered by insurance!)
Step 5: Start of therapy
- Intravenous infusion every 2 weeks
- Dose: 10 mg/kg body weight
- Duration per infusion: approx. 1 hour
- Setting: Neurology outpatient clinic or day clinic
Step 6: Monitoring
- MRI after 3, 6, 9, 12 months (ARIA monitoring)
- Clinical check-ups every 3 months
- Neuropsychological retesting every 6 months
The side effect profile: ARIA as the main risk
Amyloid-Related Imaging Abnormalities (ARIA)
The most important and potentially dangerous side effect is ARIA – radiologically detectable changes associated with amyloid elimination:
ARIA-E (Edema/Effusion):
- Vasogenic edema, mostly temporal
- Frequency: ~13% under Lecanemab
- Mostly asymptomatic
- In case of symptoms: headaches, confusion, gait disturbance
- Management: Pause, possibly corticosteroids
ARIA-H (Hemorrhage):
- Microbleeds, superficial siderosis
- Frequency: ~17% under Lecanemab
- Mostly asymptomatic
- Risk increased in APOE4 homozygotes (up to 30%)
Other side effects:
- Infusion reactions: ~26% (mostly mild)
- Headaches: ~11%
- Nausea: ~7%
- Falls: Increased vigilance required
Important for practice: APOE4/4 carriers have a 3-4 times higher ARIA risk. Close MRI monitoring is particularly required for these patients.
The cost question: Who pays for the therapy?
Pricing and reimbursement
Therapy costs for Lecanemab:
- Annual costs: approx. 26,500 euros per patient
- Not included: Diagnostics, monitoring MRIs, infusion costs
- Total costs per patient/year: approx. 35,000-40,000 euros
Status in Austria (as of January 2025):
- No inclusion in the reimbursement code yet
- No insurance coverage
- Individual cost coverage by social insurances possible in exceptional cases
- Private health insurances: Clarification on a case-by-case basis
Status in Germany:
- AMNOG procedure (early benefit assessment) ongoing
- G-BA must assess additional benefits
- Reimbursement expected from mid-2025
Ethical dimension: The high price with moderate clinical benefit leads to intense debates. Cost-effectiveness analyses from the USA show an unfavorable cost-benefit ratio. The question of whether health systems should bear these costs for a delay in progression of months remains controversial.
Second preparation: Donanemab as an alternative
Shortly after Lecanemab, Donanemab (Eli Lilly) also received approval. Some differences:
Mechanism of action: Targets aggregated, insoluble amyloid-beta (N3pG-modified)
Dosing: Intravenously every 4 weeks (more practical for patients)
Special feature: Therapy discontinuation possible upon plaque clearance (amyloid-PET negative)
Studies (TRAILBLAZER-ALZ2):
- 35% slowing of progression (vs. 27% with Lecanemab)
- Similar ARIA risk
- Possibly stronger effect, but also more side effects
Practical consideration: Donanemab could offer advantages in everyday practice due to the monthly administration and the possibility of therapy discontinuation.
Outlook: What comes next?
Further antibodies in the pipeline
Remternetug: Subcutaneous administration possible – significant improvement in practicality
Gantenerumab: In advanced studies, subcutaneous self-injection
Solanezumab: Focus on soluble amyloid-beta
Combination therapies
Future-oriented could be multi-target approaches:
- Amyloid antibodies + tau inhibitors
- Neuroprotection + amyloid reduction
- Anti-inflammatory components
Preventive approaches
The most exciting question: Can we prevent Alzheimer's? Studies are investigating antibodies in asymptomatic individuals with amyloid positivity. If successful, this could revolutionize dementia epidemiology.
Oral therapies
Several pharmaceutical companies are developing oral small molecules that:
- Inhibit amyloid aggregation
- Reduce tau phosphorylation
- Mitigate neuroinflammation
These would be significantly easier to apply than infusion therapies.
Practical recommendations for doctors in Austria and Tyrol
Who should be screened for early Alzheimer's diagnosis?
High-risk groups:
- Subjective cognitive impairment + positive family history
- MCI with amnestic profile
- Atypical presentations (< 65 years)
- Rapid progressive courses
Screening tools in practice:
- MoCA (Montreal Cognitive Assessment): More sensitive than MMSE
- DemTect: Validated in German, 10 minutes
- CERAD test battery: Gold standard, approx. 30 minutes
Referral criteria
When to refer to a memory clinic?:
- MoCA < 26 points with university degree
- MoCA < 23 points in general
- Functional impairment in daily life (IADL)
- Discrepancy between self-assessment and external assessment
- Rapid decline (< 1 year)
Memory clinics in Austria:
- Innsbruck University Hospital: Neurology outpatient clinic
- Vienna: AKH, SMZ-Ost
- Graz: LKH University Hospital
- Salzburg: PMU/University Hospital
Education of patients and relatives
What do I tell my patients?
"The new antibody therapies are an important advance, but not a miracle cure. They can slow the disease, not stop it. At best, we gain several months in which daily abilities are preserved. The therapy is complex, costly, and not without risks. Whether it is personally meaningful for you, we need to discuss together with neurologists and your family."
Realistic expectations are crucial. Media coverage of the "breakthrough" can raise exaggerated hopes.
Non-medication measures remain indispensable
The foundation: Lifestyle interventions
Despite new medications, primary prevention remains central:
Cardiovascular risk factors:
- Hypertension control (target < 130/80 mmHg)
- Diabetes management (HbA1c < 7%)
- Cholesterol management
- Smoking cessation
Lifestyle:
- Mediterranean diet: Omega-3 fatty acids, antioxidants
- Physical activity: 150 min/week moderate, even in old age
- Cognitive stimulation: Reading, making music, social interaction
- Sleep hygiene: 7-9 hours, treat sleep apnea
Studies show: Lifestyle interventions can reduce dementia risk by 30-40% – an effect that has not yet been achieved with medications.
Ethical considerations: Hope vs. realism
As a physician, I face a dilemma: On one hand, I want to give patients and families hope. On the other hand, I must not raise false expectations.
The critical questions
1. Does the moderate benefit justify the high costs?
- 27% slowing = approx. 5-7 months
- 35,000 euros/year
- Cost per gained life year: > 200,000 euros
2. Who makes the decision in the early stages of dementia?
- Capacity to consent often borderline
- Role of relatives
- Advance care planning important
3. Social justice
- Access only in urban centers
- Private cost coverage → two-tier medicine
- Resource allocation in the healthcare system
My personal assessment
After 23 years of stagnation, Lecanemab and Donanemab are important milestones that show: Alzheimer's is treatable. The clinical benefit is currently still modest, but it is a start. The next generation of medications will be more effective.
For selected patients in the early stage with realistic expectations, therapy can be valuable – especially if it delays the need for nursing home care.
Conclusion for practice
What changes concretely for doctors in Austria?
- Early detection will become more important: Actively address and clarify mild cognitive impairments
- Biomarker diagnostics: Lumbar puncture or PET will become standard for MCI
- Interdisciplinary collaboration: Close cooperation with neurology/memory clinics
- Patient education: Communicate realistic expectations
- Prioritize prevention: Lifestyle interventions remain first-line
The new Alzheimer's therapy is not a game changer, but a paradigm shift: For the first time, we can intervene in the disease process. The coming years will show whether this approach can be further developed.
Further resources for doctors
Austrian Alzheimer Society: www.alzheimer-gesellschaft.at
Overview of memory clinics: www.neurodemenzen.at
European guidelines: www.ean.org (European Academy of Neurology)
Continuing education:
- ÖGN Congress (Austrian Society for Neurology)
- ÖGGG Annual Conference (Geriatrics)
- Tyrolean Dementia Symposium, Innsbruck
Your partner for medical diagnostics: MeinArztbedarf
The new Alzheimer's diagnostics require high-quality neurological examination instruments. At MeinArztbedarf.at, doctors and medical facilities in Austria can find:
- Neuropsychological test materials (MMSE, MoCA, CERAD)
- Reflex hammers and neurological examination sets
- Diagnostic systems for memory clinics
- Point-of-care laboratory devices for biomarker screening
As a physician-led company, we understand the requirements of modern dementia diagnostics. All products are MDR-compliant and are professionally reviewed by us.
Consultation for practices and clinics: Contact our team for individual solutions in neurological diagnostics.
Author: Dr. Daniel Pehböck, Physician | MeinArztbedarf GmbH, Hall in Tyrol Expertise: Emergency and intensive care medicine, Innsbruck University Hospital
Disclaimer: This article serves for medical education and does not replace individual medical advice. All information is without guarantee. Status: January 2025.
Meta-Description (160 characters): Alzheimer's breakthrough 2025: Lecanemab and Donanemab – first disease-modifying therapies. Everything about efficacy, costs, and practical implementation in Austria.
Keywords: Alzheimer therapy 2025, Lecanemab Austria, new Alzheimer medication, amyloid antibodies, memory clinic Innsbruck, dementia treatment, Alzheimer early diagnosis, ARIA side effects, Alzheimer costs, neurology Tyrol
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