Clear empathetic conversations can help patients with an Alzheimer’s disease (AD) diagnosis weigh the use of amyloid-targeting therapy (ATT). Framing the risks and benefits of ATT realistically, explaining the required monitoring, and outlining insurance and infusion logistics can reduce fear and support informed choices, opening the door to a practical discussion for clinicians and patients.

Once I confirm an AD diagnosis, I use shared decision making and inform my patients that they have 3 treatment options: symptomatic drugs only, symptomatic drugs plus ATTs (if they are eligible), or enrollment in a clinical trial. I explain that symptomatic drugs improve the AD symptom of memory loss but do not fundamentally alter the disease, whereas ATTs make you less worse off but do not make you better. Then I define what that means.

I talk about the risks and benefits of ATTs. They are infusions, they require frequent magnetic resonance imaging (MRI) scans, and they are a big commitment. This is important because many patients are often reading about these treatments and want to discuss what they have read. Since I am always in the room with my electronic medical records on my laptop, I love to pull up one of my lectures and show my patients what positive and negative amyloid positron emission tomography/computed tomography scans look like, along with some of the data on ATTs. Some patients may be scared by what they hear about ATTs and think that a symptomatic drug is good enough for them, and some people want a clinical trial option. However, after our discussions, patients usually understand that, with good vigilance, monitoring, and surveillance, an ATT may be an appropriate choice.

Our practice has many patients with AD who are on an ATT, so I am familiar with the process, and I can tell them about other patients’ general experience with ATTs. Over the past 2 years, I have found that there is a good amount of patients who objectively self-report doing well on these drugs and tolerating the treatment. In my experience, I would say that one-third of patients do well, one-third of patients really do not get any clinical benefit at all, and one-third of patients are somewhere in between. Fairly consistently, we see patients on ATTs getting to amyloid-negative positron emission tomography/computed tomography scans by 18 months.

A discussion regarding the safety of ATTs is also important. During my meeting with the patient, I talk about the risk of amyloid-related imaging abnormalities (ARIA) with ATTs and related brain swelling and bleeding. I tell them about how we need aggressive surveillance with frequent MRIs to ensure that we identify ARIA if it occurs and about how ARIA is most commonly asymptomatic and only identified on an MRI scan. More rarely, it can be symptomatic and requires action.

I also talk to my patients with AD about other practical aspects of treatment with ATTs. For example, people often ask about insurance coverage, and I assure them that we do not order ATT without receiving authorization. If the patient agrees to being treated with an ATT, then they move to our infusion clinic. Once there, they speak with the nurse practitioner, who completes the required documentation, arranges MRI preordering, sets up the infusion services, and takes care of any other necessary logistics.

After the initial appointment during which we discuss treatment options, patients often still do not fully understand the treatments, and they request a follow-up visit to discuss them further. I want to be very clear, and I never push a certain therapeutic option. I use shared decision making with patients to discuss their treatment options, including the risks, benefits, advantages, disadvantages, and potential consequences of each option.