Quote · The Peter Attia Drive
#399 ‒ The evolution of Alzheimer's disease and dementia care: how early detection, personalized treatment, new therapies, and a multimodal approach are changing the landscape | Gayatri Devi, M.D.
Where this was said
Anti-amyloid therapies and slow titration
At 52:03 · chapter starts 51:45
The three FDA-approved anti-amyloid monoclonal antibodies — aducanumab (withdrawn), lecanemab, and donanemab — all clear amyloid plaques from the brain, but their clinical benefit on the 18-point CDR Sum of Boxes scale is only 0.3–0.4 points compared to placebo, a small but potentially meaningful effect that Gayatri Devi believes is larger when treatment is earlier [1] — Gayatri Devi "Anti-amyloid monoclonal antibodies like lecanemab and donanemab can clear amyloid from the brain, but carry a greater than 40% risk of ARIA…" 52:58 . The most serious risk is ARIA — brain edema and hemorrhage caused by the antibodies disrupting amyloid-laden artery walls — which exceeds 40% in standard protocols for APOE4 homozygotes. Her ultra-slow titration protocol reduces ARIA to roughly 4% in published data from her practice. However, insurance companies refuse to reimburse off-protocol dosing for lecanemab, meaning patients who want the safer protocol must pay out of pocket — a systemic barrier she describes with visible frustration. Donanemab's approved titration schedule is more flexible, allowing her to implement slow escalation without insurance conflict.
Aducanumab was approved in 2021 against its FDA advisory board's recommendation because clearing amyloid didn't translate to clear clinical benefit in the trials. Gayatri Devi prescribed it anyway, applying a simple personal test: would she want it herself if she had Alzheimer's? Her answer was yes.
Anti-amyloid monoclonal antibodies like lecanemab and donanemab can clear amyloid from the brain, but carry a greater than 40% risk of ARIA in standard protocols for APOE4 carriers. Gayatri Devi developed an ultra-slow titration protocol that reduces this risk to approximately 4%, allowing even high-risk APOE4 homozygotes to access potentially life-changing therapy.
Aducanumab carried a greater than 40% incidence of abnormal brain bleeding and swelling (ARIA), driving Gayatri Devi to develop her slow-titration protocol.
Anti-amyloid therapies like lecanemab and donanemab show only 0.3–0.4 point improvements on the 18-point CDR Sum of Boxes scale, a modest but potentially meaningful shift.
Gayatri Devi's slow-titration protocol for APOE4 carriers on anti-amyloid monoclonal antibodies yields only a 4% rate of ARIA, far below standard protocols.
