by Isabella Colonna
Commentary on the recently published position paper Filippi M, Cecchetti G, Spinelli et al, Anti-amyloid therapies and the transformation of Alzheimer’s care pathways: early lessons from the frontline. Lancet Reg Health Eur. 2026 Feb 12;64:101609. doi: 10.1016/j.lanepe.2026.101609. PMID: 41732200; PMCID: PMC12925121.
The approval of anti-amyloid monoclonal antibodies for early symptomatic Alzheimer’s disease represents a major step toward disease-modifying therapy. Following authorisation by the European Medicines Agency in 2025, these treatments have begun to transition from research settings into routine clinical practice across Europe. This transition raises important practical questions regarding feasibility, safety monitoring, and the organisation of diagnostic pathways. Real-world experience from early-adopting centres can therefore provide valuable operational insights into how these therapies can be integrated into everyday care.
This paper describes the experience of the IRCCS San Raffaele Center for Alzheimer’s and Related Diseases (Milan, Italy), among the first European centres to introduce anti-amyloid monoclonal antibodies into routine care.
To facilitate timely access to treatment, the centre developed an accelerated pathway integrated within the standard diagnostic workflow and reserved for patients potentially eligible for anti-amyloid therapy. Initial access may occur either through traditional referral or through a dedicated telemedicine pre-screening process. Patients subsequently undergo an in-person cognitive and neurological evaluation, providing the clinical context necessary for biomarker interpretation. Diagnostic assessment includes structural MRI to identify potential exclusion criteria, such as microbleeds or cortical superficial siderosis, together with plasma biomarker testing.
Apolipoprotein E (ApoE) genotyping is systematically performed for risk stratification, while cerebrospinal fluid analysis is obtained when available and not contraindicated. A shared decision-making consultation follows, during which clinicians discuss expected benefits, potential risks related to amyloid-related imaging abnormalities (ARIA), treatment logistics, and the anticipated trajectory of care. After informed consent, baseline amyloid PET imaging is performed in patients who decide to proceed with therapy, providing a quantitative measure of amyloid burden before treatment initiation.
Once treatment has begun, patients enter a structured program of biological and clinical follow-up. Amyloid PET imaging, plasma biomarkers, and cognitive evaluations are repeated every six months. Between September 2024 and 12 November 2025, 32 patients were treated. Supported by a multidisciplinary team, the mean interval between initial screening and treatment initiation was 10.3 weeks (SD 5.0; range 3.9–27.1), demonstrating the feasibility of an accelerated diagnostic-therapeutic pathway within a tertiary memory clinic.
The introduction of anti-amyloid therapies has also reshaped safety monitoring in Alzheimer’s disease. Amyloid-related imaging abnormalities (ARIA), particularly oedema (ARIA-E) and haemorrhagic manifestations such as microhaemorrhages or superficial siderosis (ARIA-H), represent the main safety concern and require systematic MRI surveillance together with careful clinical oversight. At IRCCS San Raffaele Center, ARIA risk management is adapted according to ApoE genotype, leading to individualised MRI monitoring schedules. Before treatment initiation, monitoring protocols, ARIA management algorithms, and communication pathways are shared with referring neurologists and local clinics.
Despite the rapid clinical adoption of anti-amyloid therapies, several aspects of long-term management remain uncertain, including treatment duration, criteria for discontinuation, and the possibility of switching between different anti-amyloid antibodies.
In conclusion, the approval of anti-amyloid monoclonal antibodies marks a turning point in Alzheimer’s disease management, shifting the focus from symptomatic care toward biological disease modification. Early real-world experience suggests that implementation is feasible but highlights the complexity of translating trial-based protocols into heterogeneous healthcare systems. Three key elements appear essential: timely diagnosis supported by biological markers, monitoring strategies that integrate both safety and treatment response, and continuous communication with shared decision-making throughout the care pathway. Together, these factors illustrate the multidimensional transformation currently reshaping Alzheimer’s disease care.
