Access to new Alzheimer’s disease treatments

A group of 16 clinicians working in dementia care across Ireland have written to the Minister for Health expressing concern about access to new treatments for Alzheimer’s disease in Ireland

Dear Minister,

We are writing as clinicians who support the care of people living with dementia and cognitive disorders across Ireland to express our deep concern regarding the recent recommendation by the National Centre for Pharmacoeconomics (NCPE) against reimbursement of lecanemab, the first disease-modifying treatment licensed in Europe for Alzheimer’s disease.

For the approximately 64,000 people living with dementia in Ireland, the majority with Alzheimer’s disease, the arrival of disease-modifying therapies, which alter the clinical trajectory of the condition, represents a fundamental shift in what we can offer patients and families, with treatments until now largely limited to managing symptoms. While the benefits of these first-generation treatments are modest, our clinical experience and discussions with patients and families tell us they are worthwhile, offering appropriately selected patients an opportunity to delay decline and to preserve independence and quality-of-life for longer.

This is a watershed moment for dementia care in Ireland. Our concern is that the NCPE recommendation, if translated into a decision against public reimbursement, risks perpetuating, and deepening existing inequities in access to care.

We fully recognise the importance of rigorous health economic assessment. However, the NCPE’s conclusion that lecanemab is not cost-effective reflects, at least in part, the substantial costs of delivering treatment within a healthcare system that remains under-resourced in specialist cognitive services and diagnostic infrastructure. Importantly, the NCPE itself acknowledges considerable uncertainty in the economic modelling underpinning its recommendation, describing its preferred analysis as exploratory. We believe this assessment needs to be considered in a broader context, particularly as other healthcare systems, including Canada, Germany, and Austria, have moved towards publicly funded access under controlled arrangements. Irish patients should not be denied access to potentially beneficial treatments because our health system has not yet developed the capacity to deliver them efficiently.

Of particular concern is that, in the absence of a publicly funded pathway, access to these treatments will ultimately be determined by an individual’s ability to pay. This will exacerbate a two-tier system in which patients with identical clinical needs have very different opportunities for treatment, fundamentally at odds with the principles of Sláintecare. Without addressing the underlying gaps in our services, we also risk facing the same barriers with future disease-modifying therapies.

We therefore urge you to ensure that the NCPE recommendation does not become the end of the discussion on access to disease-modifying treatments for Alzheimer’s disease in Ireland. We believe there is an opportunity to explore alternative approaches, including managed access arrangements with prospective collection of clinical outcomes, while addressing longstanding gaps in dementia services. This would represent an important step towards ensuring that Irish patients can benefit equitably from advances in Alzheimer’s treatment.

Yours faithfully,

Dr Antoinette O’Connor, Consultant Neurologist, Tallaght University Hospital, Dublin;
Prof Seán Kennelly, Consultant Physician in Geriatric Medicine and Director of Institute of Memory and Cognition, Tallaght University Hospital;
Prof Iracema Leroi, Professor of Geriatric Psychiatry and Site Director of Global Brain Health Institute, Trinity College Dublin;
Prof Tony Foley, Professor of General Practice, University College Cork;
Prof Ronan Killeen, Consultant Radiologist, St Vincent’s University Hospital, Dublin;
Dr Seán O’Dowd, Consultant Neurologist, Tallaght University Hospital, Dublin;
Dr Aoife Fallon, Consultant Physician in Geriatric Medicine, Tallaght University Hospital;
Dr Siobhán Hutchinson, Consultant Neurologist, St James’s Hospital, Dublin;
Dr Rónán O’Caoimh, Consultant Physician in Geriatric Medicine, Mercy University Hospital, Cork;
Dr Tim Dukelow, Consultant Physician in Geriatric Medicine, Cork University Hospital;
Dr Justin Kinsella, Consultant Neurologist, St Vincent’s University Hospital;
Dr Laura Morrison, Consultant Physician in Geriatric Medicine, Tallaght University Hospital;
Dr Mary Buckley, Consultant Physician in Geriatric Medicine, University Hospital Kerry;
Dr Catherine Dolan, Consultant Psychiatrist in Old Age Psychiatry, Sligo Leitrim Mental Health Service;
Prof Marwa Ismail Elamin, Consultant Neurologist, University Hospital Galway; and
Dr Rob Durcan, Consultant Neurologist, Mayo University Hospital